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Johns Hopkins Pediatric

Reflections on a Half-Century Practice

November 13, 2013

When Columbia, Md., pediatrician Will Standiford first hung out his shingle he worked long hours, diagnosed patients with his hands, performed his own spinal taps, and, because health insurers didn’t cover office visits, sometimes got paid in vegetables and whiskey.

Will Standiford, MD

With a young patient, community pediatrician Will Standiford.

What was pediatrics like when you opened your practice?

When I started in 1966 we charged $4 for office visits and $7 for house calls. We’d see patients in the morning, schedule a block of time in the afternoon for house calls, then come back and see patients into the early evening. We saw patients on Saturday mornings, too, and on Sunday mornings for urgent cases.

Why so many hours?

At that time there were no answering services, no pediatric EDs, no hospitalists. If you got a call in the middle of the night you’d see the patient. If they had a condition like croup or epiglottitis, which could completely close off the windpipe, you had to see them because there was no alternative. In those days these kids would have to undergo tracheotomy so they could breathe. We didn’t have the vaccines we have today.

Did you see patients at the local hospital as well?

Yes, we admitted our patients and took care of them at St. Agnes, our primary hospital. We’d communicate with the residents, see patients on rounds in the morning and sometimes later in the day, depending on how sick the patient was. One of us in our four-physician practice would be on-call overnight for our patients in the hospital, and then be expected to work the next day and possibly the next night. It was a demanding schedule but we were used to a demanding schedule. Now we have office hours until 6 p.m., send patients to the pediatric ED or an urgent-care center, and admit our patients to hospitalists, which has taken a lot off our load.

Were you doing procedures you don’t do today?

We were seeing our newborns in the hospital, but there was no neonatal intensive care unit. One issue we had to deal with was RH incompatibility, which required exchange transfusions to remove and replace the patient’s blood. Exchange transfusions were frequent and took a lot of time, and we were the ones who did them. We also performed our spinal taps in the ED, but I haven’t done one in the past 20 years.

Any other significant changes?

Radiology has changed our practice a lot, too. If one suspected the child had a tumor, a neurosurgeon had to put the kid to sleep, make a burr hole in the head, put a needle through the brain into the ventricle, aspirate the spinal fluid and inject air. Then, by manipulating the air and fluid levels around the ventricular system, one would attempt to identify where the tumor was. We could order arteriograms back then, too, to detect problems in blood vessels around the brain, heart, kidneys and lungs. When I first saw a CT scan I couldn’t believe what I saw. It was all there—everything you always wanted to see.

Do you see any downside to such technological advances?

With more information gained in electronics and imaging, there’s less physical diagnosis today. When I was a resident, a senior doctor, who was an excellent diagnostician, said you don’t need an EKG, just look at the AVC (atrial ventricular contraction) wave in the neck. We said, ‘What?’ but we learned you can see the venous wave in the neck, which indicates how the heart is functioning. So there were things he saw on physical exam that we didn’t see because we would order an EKG. Today, many physicians are no longer putting their hands on the patient.

Has that influenced your practice?

We don’t have an X-ray machine in this practice, so in our clinical clerkship students make a diagnosis of pneumonia by listening and looking. Here, everything is hands-on.

Do you enjoy teaching?

Teaching has become more important for me. Also, I appreciate the insights of the younger students and residents while sharing my experiences with them. I don’t want to be the pediatrician who’s forgotten everything.

Do you see any changes in the way parents interact with you?

Parents are more savvy today because they can go online and have a whole differential diagnosis ahead of time. That’s fine. I kind of enjoy that because you have a basis for discussion rather than a dictation of what you think. That may threaten some parents but it shouldn’t because it’s helpful, though sometimes it creates anxiety for them before they get a chance to talk about it.

Any observations about health insurers over the years?

When I first started practice insurers only covered hospital stays and not office visits, so many times I got paid in vegetables and whiskey. In recent years, insurance companies have presented a complicating factor in the practice of medicine for patients as well as physicians. Many times they try to dictate patient care. Today, I leave a lot of this hassle to the younger people on our staff.

Anything you would change?

No. I enjoy the practice of pediatrics today as much as ever, maybe more. I get to teach the residents, and hear case presentations and didactic talks with community experts. I always thought pediatrics was a good fit for me—I didn’t particularly enjoy taking care of geriatric patients and I didn’t have the personality to be a good surgeon. I enjoyed working with kids—I still do.  

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