AAP Senior Members Look Back
Thoughts from a "Seasoned" Pediatrician
Ann Beach, MD, FAAP, FHM
I’ve now practiced 33 years and have loved almost every minute of it. I’ve been a small-town pediatrician, an HMO administrator, a hospital administrator involved in quality and patient safety, and for the last 15 years, a pediatric hospitalist in a big city pediatric tertiary referral hospital.
As a medical student and resident, I kept a list of all of my patients, and disciplined myself to write down one medical thing (the science of medicine) and one non-medical thing (the art of medicine) I learned from each patient. Today, I encourage all of the students and residents I teach to do the same thing.
I recently leafed through those old binders. Plenty of things have changed! But interestingly, plenty of things haven’t.
- My pediatric pocket handbook from 1979 was 296 pages long. My newest one (which of course includes a smart phone app) is 1131 pages long, with much smaller font!
- Back then there was only one generation of cephalosporins. Now I have to try to remember the difference between all of the cephalo du jours.
- The IV loading dose of aminophylline is 7 mg/kg. Please check a level 1 hour after the loading dose. Gosh, when was the last time I did that? I used to know the doses of Slophyllin, Theodur, Quibron and metaprel by heart. I haven’t made an asthmatic vomit from SQ epi injections in a long time.
- The immunization schedule was easy to memorize because it pretty much just included DPT, OPV and MMR. Parents were excited for their babies to get immunizations and never questioned the wisdom of vaccines.
- Kawasaki’s was treated with high dose aspirin, but no IVIG.
- I treated meningitis (and there was more of it before the HIB vaccine) with ampicillin and chloramphenicol.
- We knew Reye’s often happened after the flu, but we didn’t yet understand the aspirin link.
- I knew how rectal paraldehyde for seizures could smell up the whole treatment room.
- All of my patients with acute myeloblastic leukemia were going to die soon. Now the 5-year survival rate is 60% or more.
- CT scanners came to my medical school in 1976. They were slow, grainy, and slices were thick. But they were revolutionary. Now, CTs can be done in a matter of minutes. MRIs exist now and can make lovely 3D reconstructions.
What hasn't changed?
- The ability to take a thorough history and do a complete physical exam is the most important tool we have (More important than the CRP or the MRI machine). Also important is the understanding that we don’t really “take” a history; we begin a history. We continue to add to it as we ask more questions while we continue to care for the patient.
- Examine the throat last. That way, if you elicit a gag and the baby vomits, you’re done with the exam.
- Be prepared for the results of any lab test you order. Think about what you’ll do if it is normal. Think about what you’ll do if it is abnormal. If you’ll do the same thing either way, you probably don’t need to order the test.
- Making sure parents know that you care is high on the list of important things.
- The nurses usually know more than we do. Always ask the nurses their opinions. A good nurse is your right arm.
- Expect to learn something new every day.
- Children are way more fun to take care of than adults.
As I look back on all of this, what strikes me is that the science of medicine has changed dramatically. We are always told that over 50% of what we learn in residency is obsolete within 10 years, and I believe that is so. Very little of the tests and medications I order now could have been ordered in the 1970’s. Not to mention that I now order everything on a computer……….
The speed of change seems to be accelerating.
Ahhhh. But it is the ART of medicine that is not changing. The all-important laying on of hands, listening, understanding, caring….That has not changed and isn’t going to change.
Advice from Leonard Janchar, MD, FAAP
I was certified in Pediatrics in 1977 after passing a written exam and an oral exam for which I had to travel to Nashville, Tennessee. I then took another written exam as part of a voluntary recertification program. The next written exam I took was part of a required recertification program. I then continued in the recertification program, enrolling in MOC starting in 2003. I subscribed to Pediatrics in Review (PIR) when the program began in 1979. It was an excellent way to keep up and to practice taking tests. I continued to subscribe to PIR for 36 years while active in practice.
Technology has changed how I delivered care. Research brought more immunizations, saved more lives, and required me to talk to parents more, with the VIS sheets being my talking points. Digital imaging brought a rapidness of diagnosis-an ultrasound to diagnose pyloric stenosis. Pediatrics functioned well in small group practices with a family atmosphere for that “second home.” Today, corporations are buying pediatric practices and changing that to a “corporate home.”
I would tell today’s graduating pediatric trainees to really look at health equity to see how patients differ in their susceptibility to disease. It makes a difference where you live, what you eat, where you go to school, and what income the family has. The lows in these categories result in the highs for disease incidence—deaths due to prematurity and accidents, incidence of asthma and infections, developmental delay and insufficient immunizations. Pediatrics is a community practice-do what is needed to make your community a better place to live.
Our Learning Never Ends
As a senior member who had my board certification grandfathered in, I was not required to take the MOC exam. I've had mostly administrative roles towards the end of my career, so did not think much of the need.... until I stepped away from those admin jobs and re-entered the work force as a locum. In addition to the joy and honor of helping families again, I felt it important to benchmark my knowledge.... and took the MOC test. As I was driving away from the exam, it struck me that nearly every question either did not exist/had no answer when I completed my residency, or the answer changed from 1976! I did pass, but it was not from cramming before the test. It was from incremental learning facilitated mostly by my subscription to Pediatrics and Pediatrics in Review.
Message to our youth: learning is continual, lifelong and if history is to repeat itself, PIR is the vehicle to keep up to date.
The children’s faces on new PIR journal covers is why we do what we do... I cannot remember the last clinic I had where I did not say "I love this job!" [double negative meaning I am so privileged to care for our kids!)
Harry F. Laws, MD, FAAP
“Thoughts of a Seasoned Pediatrician” republished from the Best of the Bulletin, AAP Section on Senior Members, March 2017
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