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Responding to the Challenge
Responding to the Challenge WILLIAM G. CROOK, M.D., F.A.A.P.
If a man does not keep pace with his companions, perhaps it is be-
cause he hears a different drummer; let him step to the music which he hears, however measured or far away. THOREAU
These familiar words have an application today in contemporary pediatrics. In fact, a number of different drummers are being heard around the country - some by those who struggle with the teeming masses of children in the ghettos of our cities; others by the dedicated and concerned pediatricians who enjoy practice, yet who have trouble in caring for all their patients as they would like to; and still others by those whose interests center on research. The drummer that I hear and all of these other drummers will have to join together if pediatric practice is to march ahead in unison. This is not to say that everyone in practice during the decades ahead will have to conform to any given set of standards. But the challenge to do the job better is there, and all of us will need to respond to it. The Ohio State Medical Journal for May 1969 carried an article by Michael J. Halberstam, M.D., a solo internist in Washington. Some of its points were so well made that I am passing them along. Said Dr. Halberstarn: "We all live with our private myths. And this is probably inevitable and desirable, but it is not necessary that we make others live by our illusions." He challenged the American Medical Association, social planners, and academic physicians to lay aside or at least to re-examine some of their myths and thereby help to achieve "some kind of relative trust, some kind of mutual respect, some kind of honest research." He said, further, than unless this step was taken, preordained, self-fulfilling "studies" would continue, and that whi1e they might indeed change medicine, they would not reform or improve it. Dr. Halberstam expressed little admiration for the stands that organized medicine had taken on social issues in the past and admitted that he admired many of medicine's critics. But at the same time he abhorred what he termed "the almost obscene enthusiasm" with which journalists and bureaucrats have latched on to the phrase "our nonsystem of medical care." "Of course we have a nonsystem of medical care," said Dr. Halberstam, just as we have a nonsystem of education, food production, home-building, and so on. "The American people and Pediatric Clinics of North America- Vol. 16, No.4, November, 1969
1001
1002
WILLIAM
G.
CROOK
American political theorists have been properly skeptical about systems." While medicine certainly does need to be modernized and improved, no "system" for better medical care can ever be devised by planners who have never practiced medicine. I agree that we cannot devise a single system of health care that can satisfy the needs of all American patients and all American doctors. This does not mean that I am completely "anti-system;" rather, I am in favor of many new systems (or approaches).
The Front Line of Practice Quality child health care must continue to include the personal care of a primary physician, who should be a superbly trained general pediatric specialist. Naturally, we cannot hope to produce enough such pediatricians next year or even 10 years from now, but I believe that we must continue to work toward the goal of providing them. Obviously, too, such pediatricians need adequate numbers of allied health personnel. The physician needs to remain in charge, and yet he need not perform every single function needed to deliver quality health care. The personal pediatrician needs to have available the means that enable him to effectively and productively utilize his talents to the maximum benefit of the greatest number of children. He must be able to maintain and improve his expertise, not only by keeping abreast of the latest developments in medical research, but also by upgrading such basic skills as interpersonal communication. Until a short time ago, it was my opinion that solo practice was obsolescent and that virtually all pediatricians would need to join forces and form groups so that they could share the facilities and resources of a health center. But I have changed my mind; I still believe that most pediatricians would gain by participating in group practices, but there will always be solo practitioners because some men like it that way. So do some patients, of course. But these men, too, can be more productive, gain greater satisfaction, and give their patients better service by adopting modern methods.
Financing More funds must be devoted to child health care, from both the private insurance industry and the federal government. Surely at a time when the American public has decisively shown that it wants health care financed by third-party plans, those responsible for providing such plans must include office care and ambulatory care of both sick and well children. At the same time, in my opinion, parents should participate in paying for the cost of care. Preventive services should be completely covered. On the other hand, in a society where people willingly spend $1.50 or more to see a motion picture, or 40 cents for a package of cigarettes, it seems to me that a similar out of pocket payment is not unreasonable for a visit to a doctor. Poor patients might not be able to afford $2 a visit, but they could pay $1, or 50 cents, or even less. The small amount of money will make
RESPONDING TO THE CHALLENGE
1003
no difference to the doctor or health center in comparison to the cost of offering medical service, but there are three distinct advantages to requiring some payment from everyone. (1) When a patient pays out of pocket for something, it is usually for something he wants. People value things more highly when they cost money and when they can share directly in paying for them. (2) When any patient, no matter how humble or poor, pays the doctor, then the doctor is working for him. (3) Although there are many people in the world who perform their tasks in life with no thought of monetary return, most people, including doctors, health workers, and patients, combine such altruism with a realistic sense of economics. Some direct payment by the patient serves as an incentive. Doctors and patients relate to one another better and possess a higher degree of morale-of mutual trust and confidence-when the patient shares in paying for his medical care.
Facilities and Methods Many pediatricians practice in crowded offices, believing (often rightly) that they cannot afford additional space. Some have two examining rooms, others three, and a few four. Yet there are instances of great increases in productivity made possible by having six or eight examining rooms; one example is in my own group. Of course, physicians urgently need supporting health workers in order to make use of this added space. One pediatrician I know sees 60 patients a day, stays on schedule, gives each patient a better examination, and spends more time talking to parents than he did 3 years ago seeing 20 or 25 patients a day. Time-andmotion studies have shown that a pediatrician who sees 20 to 30 patients a day customarily spends only about 8 minutes with each of them; the rest of the day is taken up by paperwork, telephone calls, and various kinds of interruptions. It simply does not make sense for a skilled professional to function at 40 per cent or even 30 per cent efficiency. Already available are machines and methods that would have seemed unbelievable 10 or 20 years ago. They include such elementary things as magnetic tape dictating machines and such more sophisticated ones as computer-operated typewriters. Closed·circuit television can connect outlying health stations to a doctor's office, or different parts of the same office. Audiovisual instruction for patients is on the market. Programed learning materials for allied health workers are not far off, nor are computerized history-taking systems and billing systems. The president of a new computer company has told me that within 3 years it will be possible to set up a system whereby every patient can be furnished with a permanent plastic identity card. Then, if a youngster suffers an infection far from home, all the parent will have to do is go to the nearest health center, where the receptionist will insert the card into a computer terminal. In less than a minute, the local doctor will get a print-out of the child's immunization record, or even his entire health record.
Supporting Personnel My opinions on this important topic are discussed extensively in this issue (p. 929). I shall simply repeat here my belief that if more money
1004
WILLIAM
G.
CROOK
could be channelled into child health care, then pediatricians could begin to afford more assistants, aides, nurses, nurse practitioners, secretaries, and other helpers needed by any modern business if it is to function effectively. Some will object to my calling health care a "business," but the term is being used increasingly by planners, sociologists, economists, and even physicians. The statement has been made that within another 10 years, the "health industry" will employ more people than farming, recreation, or manufacturing, and will be America's largest industry.
Medical Center Affiliation Several contributors to this issue have discussed the problem of keeping up to date. The practicing pediatrician who does not continually "recharge his batteries" by reading journals and attending medical meetings soon finds that his knowledge is obsolescent. More and more of the pediatricians I talk to report that they want to spend time on the wards and in the nurseries of medical centers. But there is no guarantee that merely working in a university hospital will so change a practitioner that he is better able to care for his patients. In the practice of pediatrics over the past 20 years, my associates and I have made many interesting observations relating to patient care, just as have many other practicing pediatricians. We have reported some of them in the medical literature; we might have written up more of them if we had not been seeing patients 60 hours a week. It might have helped too if we had known how to obtain government or foundation grants for research work. But except for an occasional brief visit from an interested professor, resident, or intern, we have never been able to show our academic colleagues some of the interesting things that we have done. During the 1950's, along with most other practicing pediatricians, we were deluged with allergic children. Evidence that pediatricians in general put a high priority on learning about allergy can be found in the records of the annual seminars given by the American Academy of Pediatrics. These are filled each year on a "first come, first served" basis, and in every year from 1951 through 1960 the seminar on allergy was the first one to be filled. Yet during this same period, a leading journal published less than 10 papers on pediatric allergy, while publishing more than a hundred articles on cystic fibrosis. Even today, allergy remains the "stepchild" in the medical center, segregated from the mainstream of pediatrics and taught in a subspecialty clinic. It seems to me that in order to teach "everyday" allergy, the teacher must get away from these clinics and into the offices of private practitioners. Otherwise, the resident's experience will be confined to asthmatic children, who are often refractory to therapy and are thus not challenging or stimulating to the resident. When I entered practice in 1949, I believed that food allergy was not particularly common, and that when it did occur, it caused skin rashes. I never considered food when I was confronted with a stopped-up nose, or asthma, or recurrent bronchitis. My associates and I were the only
RESPONDING TO THE CHALLENGE
1005
full-time pediatricians in our community, and so we had the unique opportunity (and the frustrating responsibility) of treating and following children we never helped. We treated many asthmatics with vaccines, and we considered many pale, tired, nervous children as having emotional problems and treated them with counseling, tranquilizers, and the like. At some point, we began to think about food allergy and used elimination diets. We were surprised and pleased to find that such allergies were causing many noses to stuff up and fluid to accumulate in ears. Even more fascinating, we observed that food allergy caused scores of children to become pale, tired, and nervous. Many of them suffered from stomach ache, headache, or bedwetting, and some developed personality, behavior, and learning problems. Speer described a number of similar children in a 1954 issue of these Clinics, under the title "The Allergic Tension-Fatigue Syndrome." I read his paper for the first time in 1956, soon after an alert, insistent mother convinced me that milk gave her child a headache and made him "so hateful" that she could not stay in the house with him. Thereupon I began to search for these patients, reporting 23 before the Allergy Section of the Academy in Chicago in 1958 and 50 in Pediatrics in 1961. More recently, I have enlarged this interest to cover toxic or allergic reactions to other substances in the environment, such as food additives, air pollutants, odors, plastics, and chemicals. Such substances can cause a variety of physical and mental symptoms in susceptible persons and have been reported by many observant physicians. Yet, like food allergy years ago, such illness goes unrecognized by academic clinics oriented to subspecialties. It goes without saying that historically there have been many conditions recognized and studied by practitioners of medicine long before those sheltered in the universities realized that they existed. Practitioners who continually observe patients over a generation possess a unique advantage over subspecialty consultants in medical centers. This has been a long digression in an effort to document my belief that academic pediatricians must· look to the practicing pediatricians and give us a chance to show what we are doing. Whenever we talk about continuing education, we must try to jar loose some of the people who are teaching and serving as models for medical students so that they can see some of the problems that we face in daily practice. Two or three days "in the field" would help; a month would be better, and the full-time teacher would enjoy the experience more than he might anticipate. I do not suggest that every pediatric office in the country could offer interesting problems to a visiting teacher, resident, or medical student. Neither would I recommend every hospital in the country for a pediatric residency or preceptorship. But I am convinced that throughout the nation there are pediatric offices and clinics in which top-flight general pediatricians continue to deliver superb medical care to their patients and would be well worth emulating by today's students. I urge the academic community to re-examine its goals and its purposes. I do not want research to be short-changed, nor do I want
1006
WILLIAM
G.
CROOK
subspecialty expertise to be neglected. But I believe strongly that the academic community must remember that the basic reason for its existence is to improve the health of American children. For that reason, I challenge it to more realistically educate and re-educate pediatricians so that they may better respond to the health needs of those children. One of the ways in which they can accomplish this, in my opinion, is to meet the practitioner half way, so that we can contribute to their education just as they do to ours.
Management Having pointed out that the health industry is on the way to becoming a big business, it is appropriate to mention that no business runs itself. Factories, department stores, hotels, and even hospitals need managers, and we will need to attract management people into pediatrics too. Neither the government, the insurance companies, nor the consumer will pay $30 to $40 for a brief health visit or a check-up if that cost could be cut by half or more using modern management techniques.
Concluding Comments Thousands of words have been written in this issue by contributors who represent different segments of our national community, both in and out of the field of pediatrics. Yet all were directed toward a single goal- better health care for America's children. No one questions the need for channelling more of the American health care dollar- both private and governmental-into caring for the ambulatory child. Nor is there any disagreement about the need for more professionals, better facilities, and better organization. But there has been considerable difference of opinion in certain areas, including the future role of the federal government and specific methods of financing. Views especially tended to polarize in responding to the question of whether highly trained pediatric specialists should continue to be oriented toward general pediatrics, or whether 80 per cent or more of such care could be turned over to professionals with much less training. While I have included in this issue representative views of many pediatric disciplines, I have intentionally emphasized the contributions and points of view of pediatric practitioners, whose voices are not always clearly heard by those who would draw up plans for the future health care of American children. I hope that this dialogue, and even the dissent, will help many of us who are working toward the same goal to communicate more effectively in the future. Only by communication and cooperation, augmented by vision and hard work, can we effectively serve the health care needs of the oncoming millions of American children. 648 W. Forest Avenue Jackson, Tennessee 38301
If a man does not keep pace with his companions, perhaps it is be-
cause he hears a different drummer; let him step to the music which he hears, however measured or far away. THOREAU
These familiar words have an application today in contemporary pediatrics. In fact, a number of different drummers are being heard around the country - some by those who struggle with the teeming masses of children in the ghettos of our cities; others by the dedicated and concerned pediatricians who enjoy practice, yet who have trouble in caring for all their patients as they would like to; and still others by those whose interests center on research. The drummer that I hear and all of these other drummers will have to join together if pediatric practice is to march ahead in unison. This is not to say that everyone in practice during the decades ahead will have to conform to any given set of standards. But the challenge to do the job better is there, and all of us will need to respond to it. The Ohio State Medical Journal for May 1969 carried an article by Michael J. Halberstam, M.D., a solo internist in Washington. Some of its points were so well made that I am passing them along. Said Dr. Halberstarn: "We all live with our private myths. And this is probably inevitable and desirable, but it is not necessary that we make others live by our illusions." He challenged the American Medical Association, social planners, and academic physicians to lay aside or at least to re-examine some of their myths and thereby help to achieve "some kind of relative trust, some kind of mutual respect, some kind of honest research." He said, further, than unless this step was taken, preordained, self-fulfilling "studies" would continue, and that whi1e they might indeed change medicine, they would not reform or improve it. Dr. Halberstam expressed little admiration for the stands that organized medicine had taken on social issues in the past and admitted that he admired many of medicine's critics. But at the same time he abhorred what he termed "the almost obscene enthusiasm" with which journalists and bureaucrats have latched on to the phrase "our nonsystem of medical care." "Of course we have a nonsystem of medical care," said Dr. Halberstam, just as we have a nonsystem of education, food production, home-building, and so on. "The American people and Pediatric Clinics of North America- Vol. 16, No.4, November, 1969
1001
1002
WILLIAM
G.
CROOK
American political theorists have been properly skeptical about systems." While medicine certainly does need to be modernized and improved, no "system" for better medical care can ever be devised by planners who have never practiced medicine. I agree that we cannot devise a single system of health care that can satisfy the needs of all American patients and all American doctors. This does not mean that I am completely "anti-system;" rather, I am in favor of many new systems (or approaches).
The Front Line of Practice Quality child health care must continue to include the personal care of a primary physician, who should be a superbly trained general pediatric specialist. Naturally, we cannot hope to produce enough such pediatricians next year or even 10 years from now, but I believe that we must continue to work toward the goal of providing them. Obviously, too, such pediatricians need adequate numbers of allied health personnel. The physician needs to remain in charge, and yet he need not perform every single function needed to deliver quality health care. The personal pediatrician needs to have available the means that enable him to effectively and productively utilize his talents to the maximum benefit of the greatest number of children. He must be able to maintain and improve his expertise, not only by keeping abreast of the latest developments in medical research, but also by upgrading such basic skills as interpersonal communication. Until a short time ago, it was my opinion that solo practice was obsolescent and that virtually all pediatricians would need to join forces and form groups so that they could share the facilities and resources of a health center. But I have changed my mind; I still believe that most pediatricians would gain by participating in group practices, but there will always be solo practitioners because some men like it that way. So do some patients, of course. But these men, too, can be more productive, gain greater satisfaction, and give their patients better service by adopting modern methods.
Financing More funds must be devoted to child health care, from both the private insurance industry and the federal government. Surely at a time when the American public has decisively shown that it wants health care financed by third-party plans, those responsible for providing such plans must include office care and ambulatory care of both sick and well children. At the same time, in my opinion, parents should participate in paying for the cost of care. Preventive services should be completely covered. On the other hand, in a society where people willingly spend $1.50 or more to see a motion picture, or 40 cents for a package of cigarettes, it seems to me that a similar out of pocket payment is not unreasonable for a visit to a doctor. Poor patients might not be able to afford $2 a visit, but they could pay $1, or 50 cents, or even less. The small amount of money will make
RESPONDING TO THE CHALLENGE
1003
no difference to the doctor or health center in comparison to the cost of offering medical service, but there are three distinct advantages to requiring some payment from everyone. (1) When a patient pays out of pocket for something, it is usually for something he wants. People value things more highly when they cost money and when they can share directly in paying for them. (2) When any patient, no matter how humble or poor, pays the doctor, then the doctor is working for him. (3) Although there are many people in the world who perform their tasks in life with no thought of monetary return, most people, including doctors, health workers, and patients, combine such altruism with a realistic sense of economics. Some direct payment by the patient serves as an incentive. Doctors and patients relate to one another better and possess a higher degree of morale-of mutual trust and confidence-when the patient shares in paying for his medical care.
Facilities and Methods Many pediatricians practice in crowded offices, believing (often rightly) that they cannot afford additional space. Some have two examining rooms, others three, and a few four. Yet there are instances of great increases in productivity made possible by having six or eight examining rooms; one example is in my own group. Of course, physicians urgently need supporting health workers in order to make use of this added space. One pediatrician I know sees 60 patients a day, stays on schedule, gives each patient a better examination, and spends more time talking to parents than he did 3 years ago seeing 20 or 25 patients a day. Time-andmotion studies have shown that a pediatrician who sees 20 to 30 patients a day customarily spends only about 8 minutes with each of them; the rest of the day is taken up by paperwork, telephone calls, and various kinds of interruptions. It simply does not make sense for a skilled professional to function at 40 per cent or even 30 per cent efficiency. Already available are machines and methods that would have seemed unbelievable 10 or 20 years ago. They include such elementary things as magnetic tape dictating machines and such more sophisticated ones as computer-operated typewriters. Closed·circuit television can connect outlying health stations to a doctor's office, or different parts of the same office. Audiovisual instruction for patients is on the market. Programed learning materials for allied health workers are not far off, nor are computerized history-taking systems and billing systems. The president of a new computer company has told me that within 3 years it will be possible to set up a system whereby every patient can be furnished with a permanent plastic identity card. Then, if a youngster suffers an infection far from home, all the parent will have to do is go to the nearest health center, where the receptionist will insert the card into a computer terminal. In less than a minute, the local doctor will get a print-out of the child's immunization record, or even his entire health record.
Supporting Personnel My opinions on this important topic are discussed extensively in this issue (p. 929). I shall simply repeat here my belief that if more money
1004
WILLIAM
G.
CROOK
could be channelled into child health care, then pediatricians could begin to afford more assistants, aides, nurses, nurse practitioners, secretaries, and other helpers needed by any modern business if it is to function effectively. Some will object to my calling health care a "business," but the term is being used increasingly by planners, sociologists, economists, and even physicians. The statement has been made that within another 10 years, the "health industry" will employ more people than farming, recreation, or manufacturing, and will be America's largest industry.
Medical Center Affiliation Several contributors to this issue have discussed the problem of keeping up to date. The practicing pediatrician who does not continually "recharge his batteries" by reading journals and attending medical meetings soon finds that his knowledge is obsolescent. More and more of the pediatricians I talk to report that they want to spend time on the wards and in the nurseries of medical centers. But there is no guarantee that merely working in a university hospital will so change a practitioner that he is better able to care for his patients. In the practice of pediatrics over the past 20 years, my associates and I have made many interesting observations relating to patient care, just as have many other practicing pediatricians. We have reported some of them in the medical literature; we might have written up more of them if we had not been seeing patients 60 hours a week. It might have helped too if we had known how to obtain government or foundation grants for research work. But except for an occasional brief visit from an interested professor, resident, or intern, we have never been able to show our academic colleagues some of the interesting things that we have done. During the 1950's, along with most other practicing pediatricians, we were deluged with allergic children. Evidence that pediatricians in general put a high priority on learning about allergy can be found in the records of the annual seminars given by the American Academy of Pediatrics. These are filled each year on a "first come, first served" basis, and in every year from 1951 through 1960 the seminar on allergy was the first one to be filled. Yet during this same period, a leading journal published less than 10 papers on pediatric allergy, while publishing more than a hundred articles on cystic fibrosis. Even today, allergy remains the "stepchild" in the medical center, segregated from the mainstream of pediatrics and taught in a subspecialty clinic. It seems to me that in order to teach "everyday" allergy, the teacher must get away from these clinics and into the offices of private practitioners. Otherwise, the resident's experience will be confined to asthmatic children, who are often refractory to therapy and are thus not challenging or stimulating to the resident. When I entered practice in 1949, I believed that food allergy was not particularly common, and that when it did occur, it caused skin rashes. I never considered food when I was confronted with a stopped-up nose, or asthma, or recurrent bronchitis. My associates and I were the only
RESPONDING TO THE CHALLENGE
1005
full-time pediatricians in our community, and so we had the unique opportunity (and the frustrating responsibility) of treating and following children we never helped. We treated many asthmatics with vaccines, and we considered many pale, tired, nervous children as having emotional problems and treated them with counseling, tranquilizers, and the like. At some point, we began to think about food allergy and used elimination diets. We were surprised and pleased to find that such allergies were causing many noses to stuff up and fluid to accumulate in ears. Even more fascinating, we observed that food allergy caused scores of children to become pale, tired, and nervous. Many of them suffered from stomach ache, headache, or bedwetting, and some developed personality, behavior, and learning problems. Speer described a number of similar children in a 1954 issue of these Clinics, under the title "The Allergic Tension-Fatigue Syndrome." I read his paper for the first time in 1956, soon after an alert, insistent mother convinced me that milk gave her child a headache and made him "so hateful" that she could not stay in the house with him. Thereupon I began to search for these patients, reporting 23 before the Allergy Section of the Academy in Chicago in 1958 and 50 in Pediatrics in 1961. More recently, I have enlarged this interest to cover toxic or allergic reactions to other substances in the environment, such as food additives, air pollutants, odors, plastics, and chemicals. Such substances can cause a variety of physical and mental symptoms in susceptible persons and have been reported by many observant physicians. Yet, like food allergy years ago, such illness goes unrecognized by academic clinics oriented to subspecialties. It goes without saying that historically there have been many conditions recognized and studied by practitioners of medicine long before those sheltered in the universities realized that they existed. Practitioners who continually observe patients over a generation possess a unique advantage over subspecialty consultants in medical centers. This has been a long digression in an effort to document my belief that academic pediatricians must· look to the practicing pediatricians and give us a chance to show what we are doing. Whenever we talk about continuing education, we must try to jar loose some of the people who are teaching and serving as models for medical students so that they can see some of the problems that we face in daily practice. Two or three days "in the field" would help; a month would be better, and the full-time teacher would enjoy the experience more than he might anticipate. I do not suggest that every pediatric office in the country could offer interesting problems to a visiting teacher, resident, or medical student. Neither would I recommend every hospital in the country for a pediatric residency or preceptorship. But I am convinced that throughout the nation there are pediatric offices and clinics in which top-flight general pediatricians continue to deliver superb medical care to their patients and would be well worth emulating by today's students. I urge the academic community to re-examine its goals and its purposes. I do not want research to be short-changed, nor do I want
1006
WILLIAM
G.
CROOK
subspecialty expertise to be neglected. But I believe strongly that the academic community must remember that the basic reason for its existence is to improve the health of American children. For that reason, I challenge it to more realistically educate and re-educate pediatricians so that they may better respond to the health needs of those children. One of the ways in which they can accomplish this, in my opinion, is to meet the practitioner half way, so that we can contribute to their education just as they do to ours.
Management Having pointed out that the health industry is on the way to becoming a big business, it is appropriate to mention that no business runs itself. Factories, department stores, hotels, and even hospitals need managers, and we will need to attract management people into pediatrics too. Neither the government, the insurance companies, nor the consumer will pay $30 to $40 for a brief health visit or a check-up if that cost could be cut by half or more using modern management techniques.
Concluding Comments Thousands of words have been written in this issue by contributors who represent different segments of our national community, both in and out of the field of pediatrics. Yet all were directed toward a single goal- better health care for America's children. No one questions the need for channelling more of the American health care dollar- both private and governmental-into caring for the ambulatory child. Nor is there any disagreement about the need for more professionals, better facilities, and better organization. But there has been considerable difference of opinion in certain areas, including the future role of the federal government and specific methods of financing. Views especially tended to polarize in responding to the question of whether highly trained pediatric specialists should continue to be oriented toward general pediatrics, or whether 80 per cent or more of such care could be turned over to professionals with much less training. While I have included in this issue representative views of many pediatric disciplines, I have intentionally emphasized the contributions and points of view of pediatric practitioners, whose voices are not always clearly heard by those who would draw up plans for the future health care of American children. I hope that this dialogue, and even the dissent, will help many of us who are working toward the same goal to communicate more effectively in the future. Only by communication and cooperation, augmented by vision and hard work, can we effectively serve the health care needs of the oncoming millions of American children. 648 W. Forest Avenue Jackson, Tennessee 38301