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The American Pediatric Society History of Pediatric Subspecialties

The American Pediatric Society History of Pediatric Subspecialties This book is the result of a commission from the American Pediatric Society in 1997 to develop a history of the pediatric specialties. Finberg and Stiehm convened a “committee to select the topics, choose the authors, solicit and edit the manuscripts.” Most attention is devoted to those subspecialties in which one now becomes certified by pursuing a fellowship (usually 3 years following one's 3-year pediatric residency) before submitting to a certifying examination produced by the various subboards of the American Board of Pediatrics (ABP). That list (and the dates of their first examinations) includes cardiology (1961), hematology-oncology (1974), nephrology (1974), neonatology (1975), endocrinology (1978), pulmonology (1986), critical care (1987), gastroenterology (1990), rheumatology (1992), and adolescent medicine (1994). Some major pediatric subspecialties are not yet (nor likely to be) graced by an ABP subboard certifying examination—neurology, allergy/immunology, and genetics. Genetics is a very new clinical focus and in some medical schools is represented by a full department, as is neurology, within which internists and pediatricians serve, rather than within departments of medicine and pediatrics. The book is more than its title suggests, for it includes several excellent (historical and concurrent) chapters on infectious disease, vaccine development, nutrition (oral and intravenous), and fluid balance. Each chapter is well, if differently, written, has an excellent bibliography covering the past and present developments of the field, and is replete with wonderful name-dropping (a veritable “who's who”); all the founding, as well as continually contributing, members of (at least American) pediatrics are here as are the reasons for their inclusion. Since, by chronologic accident, my own career has brought me into contact with or influence by many of those cited, I find these chapters of considerable personal interest. We learn, for instance (in “A History of Pediatric Immunology”), that: By 1917, aided by the widespread use of x-rays to document thymic enlargement, thymic irradiation was so widespread that it was deemed mandatory, particularly in the preoperative period, as a way of avoiding lawsuits. While I don't believe my mild mathematician father was threatening a lawsuit in 1929, the fact remains that his infant son (me) had received the dreaded diagnosis of “status thymolymphaticus,” which was thought to be contributory to sudden infant death. Accordingly, and in the practice of the day, my newborn throat was overlain with radon seeds. I am pleased, nonetheless, to report that neither thyroid nodule nor dearth of T cells has yet developed. The practitioner who had diagnosed and treated my condition was (from “A Short History of Pediatric Endocrinology in North America”): . . . a private pediatric practitioner in Baltimore, Maryland, who was invited by Dr Edwards Park to establish an endocrine clinic at the Harriet Lane House at Johns Hopkins in 1935. [He] managed his practice and the clinic until 1946, when, at the age of 52, he accepted a full-time position at the University. The Lawson Wilkins Pediatric Endocrine Society was founded in 1971 in that practitioner's honor. Such is the march of medicine. As all these fields began to develop and the demands for expertise in subspecialty areas began to increase in teaching hospitals, competent generalists began to disappear from teaching rounds, spending more and more time in their private offices, to the extent that the distribution of pediatric generalists and specialists began to look like that of Great Britain in the ‘50s. In America, practicing generalists may still be welcome on the wards, but rarely seen. Worse, the hospital-bound subspecialists tend to be rather feckless instructors on a general pediatric ward. Hence, we have seen the rising of the not-yet-certified “hospitalist” (a natural progression from the comfortably certified “intensivist”) and, especially, the Ambulatory Pediatric Association, which has become a proud refuge for generalists thus displaced, their energies now, as always, devoted to the massive outpatient departments (largely for poor children) attached to most urban teaching hospitals. From the “History of Academic General and Ambulatory Pediatrics”: To include other aspects of nonhospitalized pediatric services, eg emergency rooms, community health centers, and private office practices, the word ambulatory caused much debate. [It was] considered preferable at the time to the alternate suggestion of the Society of Out-Patient Directors, even though the major organizers of this group held such positions. And, as a further to final natural progression, we have seen the establishment of “academic general pediatrics” programs, whose “procedures” tend to be devoted to: “ . . . epidemiology, statistics, genetics, anthropology, sociology, psychology, law, and political science.” In the beginning, most individual specialty clinics were begun by founding practitioners who were determined to bring better care to children with special needs. Then, after attracting younger practitioners to work with them, they developed training programs, initially funded privately before National Institutes of Health support arrived in the 1950s. Soon these fields all developed intellectual and artisanal bases that are well beyond the scope of any single individual, whether generalist or specialist. The foundations for these fields were mostly laid in the first half of the 20th century. But one will notice that these dates of subspecialty origin are not only post-World War II, they are post–Korean War and coincide with the increasing role of governmental financing in medical care. As government agencies began to demand documentation of expertise as the basis for reimbursement for professional services, internal medicine (from the second rib of which pediatrics originally arose) began to set up examination-documented subspecialties. Pediatric subspecialists then began to feel competitive pressures from certified internists on their livelihoods. This pressure was first felt in cardiology from Crippled Children’s Services (1939 Title V of the Social Security Act), but also from other third-party payers (from the “History of Pediatric Hematology Oncology”): Some pediatric hematologists became concerned that third party payers, including some Crippled Children's Services, might decide to reimburse only certified sub-specialists and that certified internist hematologists and oncologists might be designated to care for children with these diseases. Democracy is hard! In addition to their intellectual foundations, most of these subspecialties have also developed procedures requiring considerable expert dexterity and entailing significant patient (and, thus, physician) risk—catheterization and echocardiography (cardiology), life support (critical care and neonatology), endoscopy (gastroenterology), bronchoscopy and lung biopsy (pulmonology), dialysis and renal biopsy (nephrology)—furthering the case for their certification. Scant attention is paid to a phenomenon noted by virtually all of the original subboard certifying committees. In virtually every subspecialty, the certifying examinations regularly failed to certify certain individuals without whom the field would not have been founded while simultaneously anointing as certified other individuals with whom one might not wish to be associated. This phenomenon gave rise to “Tooley’s Law” (from William Tooley, a beloved founder of neonatology, now deceased,): Have the ABP show me the ranked exam scores, along with the names of the examinees, and I'll advise The Board where to make the cut. This book is a wonderful little pocket text of pediatrics, enfolded within the intellectual history (most often well told) of our specialty and its parts. Correspondence: Dr Nelson, Pennsylvania State University, College of Medicine, 34 Hubbard Ln, Topsham, ME 04086 (nmn1@psu.edu). Financial Disclosure: None reported. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Pediatrics & Adolescent Medicine American Medical Association

The American Pediatric Society History of Pediatric Subspecialties

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Publisher
American Medical Association
Copyright
Copyright © 2007 American Medical Association. All Rights Reserved.
ISSN
1072-4710
DOI
10.1001/archpedi.161.5.525
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Abstract

This book is the result of a commission from the American Pediatric Society in 1997 to develop a history of the pediatric specialties. Finberg and Stiehm convened a “committee to select the topics, choose the authors, solicit and edit the manuscripts.” Most attention is devoted to those subspecialties in which one now becomes certified by pursuing a fellowship (usually 3 years following one's 3-year pediatric residency) before submitting to a certifying examination produced by the various subboards of the American Board of Pediatrics (ABP). That list (and the dates of their first examinations) includes cardiology (1961), hematology-oncology (1974), nephrology (1974), neonatology (1975), endocrinology (1978), pulmonology (1986), critical care (1987), gastroenterology (1990), rheumatology (1992), and adolescent medicine (1994). Some major pediatric subspecialties are not yet (nor likely to be) graced by an ABP subboard certifying examination—neurology, allergy/immunology, and genetics. Genetics is a very new clinical focus and in some medical schools is represented by a full department, as is neurology, within which internists and pediatricians serve, rather than within departments of medicine and pediatrics. The book is more than its title suggests, for it includes several excellent (historical and concurrent) chapters on infectious disease, vaccine development, nutrition (oral and intravenous), and fluid balance. Each chapter is well, if differently, written, has an excellent bibliography covering the past and present developments of the field, and is replete with wonderful name-dropping (a veritable “who's who”); all the founding, as well as continually contributing, members of (at least American) pediatrics are here as are the reasons for their inclusion. Since, by chronologic accident, my own career has brought me into contact with or influence by many of those cited, I find these chapters of considerable personal interest. We learn, for instance (in “A History of Pediatric Immunology”), that: By 1917, aided by the widespread use of x-rays to document thymic enlargement, thymic irradiation was so widespread that it was deemed mandatory, particularly in the preoperative period, as a way of avoiding lawsuits. While I don't believe my mild mathematician father was threatening a lawsuit in 1929, the fact remains that his infant son (me) had received the dreaded diagnosis of “status thymolymphaticus,” which was thought to be contributory to sudden infant death. Accordingly, and in the practice of the day, my newborn throat was overlain with radon seeds. I am pleased, nonetheless, to report that neither thyroid nodule nor dearth of T cells has yet developed. The practitioner who had diagnosed and treated my condition was (from “A Short History of Pediatric Endocrinology in North America”): . . . a private pediatric practitioner in Baltimore, Maryland, who was invited by Dr Edwards Park to establish an endocrine clinic at the Harriet Lane House at Johns Hopkins in 1935. [He] managed his practice and the clinic until 1946, when, at the age of 52, he accepted a full-time position at the University. The Lawson Wilkins Pediatric Endocrine Society was founded in 1971 in that practitioner's honor. Such is the march of medicine. As all these fields began to develop and the demands for expertise in subspecialty areas began to increase in teaching hospitals, competent generalists began to disappear from teaching rounds, spending more and more time in their private offices, to the extent that the distribution of pediatric generalists and specialists began to look like that of Great Britain in the ‘50s. In America, practicing generalists may still be welcome on the wards, but rarely seen. Worse, the hospital-bound subspecialists tend to be rather feckless instructors on a general pediatric ward. Hence, we have seen the rising of the not-yet-certified “hospitalist” (a natural progression from the comfortably certified “intensivist”) and, especially, the Ambulatory Pediatric Association, which has become a proud refuge for generalists thus displaced, their energies now, as always, devoted to the massive outpatient departments (largely for poor children) attached to most urban teaching hospitals. From the “History of Academic General and Ambulatory Pediatrics”: To include other aspects of nonhospitalized pediatric services, eg emergency rooms, community health centers, and private office practices, the word ambulatory caused much debate. [It was] considered preferable at the time to the alternate suggestion of the Society of Out-Patient Directors, even though the major organizers of this group held such positions. And, as a further to final natural progression, we have seen the establishment of “academic general pediatrics” programs, whose “procedures” tend to be devoted to: “ . . . epidemiology, statistics, genetics, anthropology, sociology, psychology, law, and political science.” In the beginning, most individual specialty clinics were begun by founding practitioners who were determined to bring better care to children with special needs. Then, after attracting younger practitioners to work with them, they developed training programs, initially funded privately before National Institutes of Health support arrived in the 1950s. Soon these fields all developed intellectual and artisanal bases that are well beyond the scope of any single individual, whether generalist or specialist. The foundations for these fields were mostly laid in the first half of the 20th century. But one will notice that these dates of subspecialty origin are not only post-World War II, they are post–Korean War and coincide with the increasing role of governmental financing in medical care. As government agencies began to demand documentation of expertise as the basis for reimbursement for professional services, internal medicine (from the second rib of which pediatrics originally arose) began to set up examination-documented subspecialties. Pediatric subspecialists then began to feel competitive pressures from certified internists on their livelihoods. This pressure was first felt in cardiology from Crippled Children’s Services (1939 Title V of the Social Security Act), but also from other third-party payers (from the “History of Pediatric Hematology Oncology”): Some pediatric hematologists became concerned that third party payers, including some Crippled Children's Services, might decide to reimburse only certified sub-specialists and that certified internist hematologists and oncologists might be designated to care for children with these diseases. Democracy is hard! In addition to their intellectual foundations, most of these subspecialties have also developed procedures requiring considerable expert dexterity and entailing significant patient (and, thus, physician) risk—catheterization and echocardiography (cardiology), life support (critical care and neonatology), endoscopy (gastroenterology), bronchoscopy and lung biopsy (pulmonology), dialysis and renal biopsy (nephrology)—furthering the case for their certification. Scant attention is paid to a phenomenon noted by virtually all of the original subboard certifying committees. In virtually every subspecialty, the certifying examinations regularly failed to certify certain individuals without whom the field would not have been founded while simultaneously anointing as certified other individuals with whom one might not wish to be associated. This phenomenon gave rise to “Tooley’s Law” (from William Tooley, a beloved founder of neonatology, now deceased,): Have the ABP show me the ranked exam scores, along with the names of the examinees, and I'll advise The Board where to make the cut. This book is a wonderful little pocket text of pediatrics, enfolded within the intellectual history (most often well told) of our specialty and its parts. Correspondence: Dr Nelson, Pennsylvania State University, College of Medicine, 34 Hubbard Ln, Topsham, ME 04086 (nmn1@psu.edu). Financial Disclosure: None reported.

Journal

Archives of Pediatrics & Adolescent Medicine – American Medical Association

Published: May 1, 2007

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