When I learned I was the recipient of this year’s Joseph W. St Geme Jr Award, I was honored, to say the least, and for a while at a loss for written or spoken words, which for those who know me is highly unusual. It is humbling to be considered in the same category as previous awardees and as someone who exemplifies what Dr St Geme strove for in his own life as a leader, consensus builder, unifier, and collaborator. In thinking about receiving this award and how I might reflect on the values and attributes of Dr St Geme, I wondered what he might say about the world in which we live today.
Instead of consensus building, in 2014 we live in a world of silos, meaning more and more aspects of pediatrics are becoming stand-alone towers that seem unable to connect with one another. There are certainly the silos we are familiar with in medical education—undergraduate, graduate, and continuing medical education, and new ones like maintenance of certification—all hoping to join together, but each with their own curriculum, standards, and assessments.
Clinical care has also become increasingly more fragmented. Think of the many pediatric subspecialties that exist today, each with their own set of boards and requirements, and the new ones being developed, such as general academic pediatrics and hospitalist medicine, which are now striving to be recognized as separate board-certifiable fields when they had not until recently been considered as such.
In addition to clinical pediatrics, research has also become more siloed. Just how specialized has our field of pediatric research become? Just look at the program for this past year’s Pediatric Academic Societies (PAS) meeting, and it’s no longer a simple listing of papers and posters on neonatology. Instead you can select your area of interest from 13 different subcategories of neonatology alone, and that’s just 1 pediatric specialty. The same is true even in general pediatrics at the PAS meetings, with at least 9 different subcategories to choose from.
Nowhere is there a better example of pediatrics being an increasingly fragmented field than at the PAS meeting itself. Most attendees stay securely in their own provincial corner of their PAS program for fear of venturing into areas where one’s perceived knowledge base or clinical skills might be deemed weaker than others. Perhaps the initials PAS should not stand for Pediatric Academic Societies but rather Partitioning of All Specialties.
While I accept the fact that specialization is certainly required nowadays, given the fast pace of discovery in virtually every aspect of pediatrics, specialization and fragmentation without unification is a formula for disaster when it comes to making sure we are aligned with respect to the health and wellbeing of infants, children, and adolescents—the goal for which Dr St Geme and most if not all of us strive.
What is the cost of fragmentation? Is it really better health outcomes, or is it worsening access to care for those who are socioeconomically disadvantaged or challenged by the complexities of chronic illness and special health needs? Is it more advanced care for those who can afford it, or is it less for those who cannot? How do we connect the pediatric primary, secondary, tertiary, and quaternary care work we are doing in this country and exploring at this meeting—and the health issues of children in other parts of the world, developed and developing?
As I learned more and more about the work of Dr St Geme, it struck me that there is a way to connect the silos. It involves carving or perhaps recarving out an area of pediatrics that is not specified in the scientific meetings we attend, the journal articles or textbooks we refer to, or a field that we can refer our patients to—but once recognized by all who focus on improving the health of children and families, it becomes evident that this unsung but critical special area of pediatrics is embedded in everything we need to be doing if we as pediatricians are going to make the differences we are striving for day in and day out.
So what is the area of pediatrics that has not even had one article published on it until now in Pediatrics or any other peer-reviewed journal? I Googled this term and could not find it, and I noted that even Wikipedia does not have an entry about this unique area—an area that, if we truly recognize it, unites all of us who care for children. What is this unsung specialty that cannot be found?
It can be summarized in one word, leadiatrics, the art and science of becoming a leadiatrician dedicated to doing what Dr Joseph St Geme Jr wanted us all to do: unite around the children and families who need us perhaps more than ever before and lead them to the best health outcomes possible.
Yet how do you develop a lifelong learning career as a leadiatrician? It turns out that it can be done in 5 steps, steps that I have not mastered but try to improve upon each and every day. Let me take you through them, one by one, and in doing so share how these 5 steps or domains of leadiatric competency allow us to succeed in our chosen profession.
Step 1: Change Something for the better Daily
Step 1 is simply to change something for the better each and every day in what we do for children. This does not mean radical or revolutionary change on a daily basis. Given that we are focused on the smallest patients, baby steps are all that are required.
For example, the first day I became department chair 20 years ago, I noticed that students sat in one part of the room for our morning report, residents sat in another, and faculty too sat in their own groups, even with generalists sitting separately from specialists. Although this had been a tradition in our department, it was not the way to engage in collaborative cross-disciplinary thinking. So on that first day I took over as chairman, I made one baby-step change: I simply moved chairs into one central area of the room and told everyone to sit wherever they wanted but not with someone at their own level of training or specialty.
The eventual result was a community of shared knowledge and collegiality, leading to improved partnerships between faculty, trainees, nurses, staff, and families, coming together to improve how we deliver pediatric health care in Vermont. Our department and children’s hospital are now a model for patient-focused, family-centered collaborative care.
The power of a small change can amplify far beyond one’s expectations. When you read about or hear about an idea that might change the way you practice or investigate, even if it’s a small change, think about how you might implement it in your office, hospital, or laboratory setting to improve the way you practice.
For me, Step 1 to becoming a leadiatrician means I do not go home at night until I have reflected on what I did to help change something for the betterment of children. In doing so, I am on the road to meeting the first attribute of becoming a competent leadiatrician.
Step 2: Help Advocate for Patients and Community
Step 2 in becoming a leadiatrician is to help advocate for the good of your community and patients who live in that community. Caring for children is not about the power of one but of establishing a medical home in which care is coordinated, cohesive, comprehensive, and collaborative (all words that start with c, like the Step 1 word change) that can only be achieved through advocacy.
There is not one faculty member in our department in Vermont who fails to tell me every year what they are doing to make their community better in one way or another. Unless we take pediatrics out of the inpatient ward, the outpatient office, the operating rooms, and the laboratories and into the community, we are missing where we can make the most difference in improving the health of the children we serve.
Advocacy also often means taking risk—going out of your comfort zone to walk in the shoes of those who may not even be able to afford shoes. For a number of faculty and staff in our department this past year, it meant going on food stamps for a week to understand food insecurity and then using that experience to design more effective strategies in the office and in the community to ensure there is food on the table. Such strategies involved our faculty, house staff, and students heading up food drives or teaching families how to shop and prepare healthier low-cost foods with high nutritional value, including some foods that families may never have tried before.
Those of you who are already advocacy champions must remember to press the federal government to fund the basic, clinical, and translational science that will advance child health. We may be ready to help our communities, but unless we come up with new medications, vaccines, diagnostic tests, or other medical and surgical advances in knowledge, we will be limited in our long-term ability to improve health care outcomes.
Step 3: Improve Ourselves
Step 3 to becoming a leadiatrician is to improve ourselves, not just in areas we feel most competent but, again, outside of our comfort zone. This may be as simple as upgrading one’s knowledge in new areas of pediatric science, but it may also mean using scientific meetings, journals, online tools, or simulation centers to get better in the competencies that are less familiar to many of us, such as systems-based care or practice-based learning. To accomplish this requires our gaining a better understanding of health service research, safety and quality improvement science, or even communication skills and cultural sensitivity, diversity, and inclusion training.
For example, even if you pride yourself on your one-on-one communication skills during patient rounds, does it take into account what the patient wants to talk about and not just what you think the patient wants to talk about? How do you convince patients and their families that they are meant to actively participate during rounds, instead of just listening to laboratory test results repeated by trainees (often solely for the benefit of an attending on rounds)? If your communication is not truly family-centered, family members are likely to lose interest, and the only question they might ask is when they might be able to go home.
For many of us, there is a seventh competency outside of the traditional 6 proposed by the Accreditation Council on Graduate Medical Education and the American Board of Medical Specialties, and one where I could also improve upon: personal wellness. Finding time to do the things that refresh our minds and bodies so that we in turn can help our patients do so is critical. I am fortunate to have my wife, children, my parents, and some wonderful friends who make sure my own health is not forgotten while I worry about the health of others. For that I am eternally grateful.
Step 4: Learn to Use the Media in a Positive Manner
The fourth step in becoming a leadiatrician is to learn to appreciate and more actively use media in a positive manner. With so much being written about the influence of technology on our children, let alone ourselves, we need to “carpe media” and use it to educate the public more effectively. I knew nothing about using the media until I came to Vermont and participated in a public affairs radio show that aired early Sunday mornings in the milking barns of our state on our country music FM station, WOKO. I decided to use a bit of humor on that program and talked about how “moo-ving” it is to care for children and that I wanted to “milk” the importance of nutrition in children for everything it’s worth. When I finished taping, two disc jockeys from the morning drive show who had listened in on the broadcast stopped me on my way out of the station, and offered to teach me about country music if I taught their listeners about child health.
That was the start of more than 18 years of weekly broadcasts called “First With Kids” on radio, television, and a weekly column in several community newspapers. As a result of my working with the media in this way, the community has learned to appreciate the value of a pediatrician and children’s hospital. A great example is the annual Big Change Roundup, in which the WOKO deejays ask their listeners if they appreciate what it means to have a children’s hospital in our state and, if so, to collect their spare change for 8 weeks. Then, for 5 days in March, deejays and I travel around the state of Vermont and into upstate New York as well in a large recreational vehicle (RV) called the Big Change Roundup Coach for Kids.
The Roundup is broadcast live for most of each of those 5 days. Families line up with their pennies, nickels, dimes, and quarters to greet us in the RV, with story after story about what our children’s hospital means to them. These stories are emotionally powerful and result in lots of compassionate tears—not just from listeners but also from the deejays themselves, along with yours truly, as we broadcast the Roundup across the region served by our department and children’s hospital. Believe it or not, the change that is donated adds up to where this past year we raised $268 136.69. Even more important than the fundraising, however, was the “friendraising” that occurred, which solidified members of our department as true leadiatricians for child health in our community.
As pediatricians in a small children’s hospital within a larger adult hospital, helping our community see us as being essential to their wellbeing would not have been possible without the use of media. The same possibilities are available not just for radio, TV, and newspapers but for pediatricians educating through social media networks as well. Step 4 as a leadiatrician means also becoming a “mediatrician” and perhaps even a “tweetiatrician.”
Step 5: Develop a Sustainability Plan
The fifth and final step is not just to be a leader for child health in the present but sustain the gains for children in the future by mentoring and being a role model for others. When I was a medical student, I struggled in my first clinical rotation, internal medicine. An internal medicine renal fellow at the time (Dr Leslie Fang) recognized I was having difficulty and met with me daily to refine my differential diagnosis skills and presentation skills and teach me how to critically assess the literature. I could not believe he would spend an hour a day with me every afternoon while on this rotation. Without his help I am not sure I would have succeeded in my career as a physician.
I remember, when my rotation was over I asked Dr Fang what I could do to pay him back for his time and effort—take him to dinner, give him a gift certificate, submit his name for a teaching award—and he simply said, “Pay it forward,” a phrase I carry with me every day in making sure I never turn down a request from a trainee, nurse, staff, or faculty member for help, advice, or problem solving.
I thank the late Dr Ralph Feigin, former chair of pediatrics at Texas Children’s Hospital and one of my mentors, for suggesting I pay it forward by carrying on with the elective he created for his residents that I call “So you want to be the chair or editor,” which allows my senior residents to walk in my shoes and see the world I see each day so they can one day become an even better leadiatrician than I can ever hope to be. I also thank my many other mentors, too many for me to mention in the space allotted, who have instilled in me their values and attributes so I can pay it forward in their honor for the rest of my life. I only hope all of you reading this have had mentors that instill in you the same desire to pay it forward.
Reviewing the 5 Steps
These are the 5 steps to leadiatrics that you probably cannot find in a textbook, at least not yet. I believe these are the essential features that Dr St Geme would embrace were he with us in the year 2014 and would encourage all of us to incorporate into who we are and what we do. Let me review them 1 last time to emphasize their importance:
Change something for the betterment of children each and every day.
Help advocate for the individual patient, the communities in which you and those patients live, and for ongoing advances in the science of child health.
Improve yourself in all 7 domains of competency, including the hard ones that you may never have learned about or emphasized in medical school, and your own personal wellness.
Learn to use the media effectively to educate the public more effectively.
Develop a sustainability plan for how you can improve child health by paying it forward through role modeling and mentoring of others to further secure your leadership role when it comes to improving the health of children and families.
By taking the first letter of the first word of each of those steps, you get what leadiatrics and being a leadiatrician is all about: the CHILD. Never forget that what we do as leadiatricians is always for the child, and by using these 5 principles of leadiatrics you will feel even better about our chosen field. You will find the fragmentation that so easily plagues medicine today is reduced when it comes to being leaders in children’s health. This is what I believe Dr St Geme would want of us, and it is what all of us can do if we want children not simply to survive but to thrive.
Dr St Geme, in defining our role as leadiatricians as a means of securing the future for children and for our profession, probably said it best in an article he wrote for Pediatrics in November 1981 titled “Let’s Speak Up for Pediatricians”: “Let’s stand up, pediatricians. Let’s consider the legacy for not only our patients but also the young people who will follow us in our professional careers. We may not need an increase in the number of pediatricians in this country, but we certainly need an increase in the percentage of pediatricians of the moment and the future who believe in themselves, their mission, their training, their capabilities, and their worth.”1
That is what being a leadiatrician is all about.
- Accepted September 24, 2014.
- Address correspondence to Lewis R. First, MD, UVM, Department of Pediatrics, Given Courtyard, S250, Burlington, VT 05405. E-mail:
This work was presented as the Joseph W. St Geme Jr Leadership Award Address at the Pediatric Academic Societies Annual Meeting, Vancouver, Canada, May 3, 2014.
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
- Copyright © 2014 by the American Academy of Pediatrics