Pediatricians hopeful of gaining in prestige Clinton health plan backs primary care

November 05, 1993|By John Fairhall | John Fairhall,Washington Bureau

WASHINGTON -- Back at medical school, Dr. Barbara Siskind felt the condescending sting of classmates when she embraced children's medicine, a career that has led her to a pediatric practice in Ellicott City. "Oh, you're only going to go into primary care," they sniffed.

That attitude remains a dubious hallmark of the U.S. health care system, unique in the world for having twice as many specialists as primary care doctors -- the internists, family physicians and pediatricians who work on medicine's front lines but are at the back of the pack in pay and glamor.

But now President Clinton has presented a health reform plan that would put primary care and children's health at the forefront of an overhauled medical system. It's about time, say many pediatricians, more than 3,000 of whom gathered in Washington this week for an American Academy of Pediatrics meeting. The academy has 46,000 members and is generally supportive of the plan.

If the plan delivers what it promises, there would be better care for children, less paperwork, fewer insurance hassles and -- just maybe -- some improvement in what pediatricians earn compared with the salaries of specialists.

While the median income of all doctors is $139,000, pediatricians earn an average of $105,000, according to the American Medical Association. Had Dr. Siskind become a radiologist, she could be earning about $223,000, the median for what the AMA says is the highest-paying specialty.

She doesn't seem to have any regrets, however. "You've got to accept that up front before you go into" pediatrics, she says.

"My greatest joy is examining a brand new baby and congratulating the parents and being there at the beginning of the child's life," she says. "Or getting a hug from a kid" who just underwent an unpleasant treatment.

For such pleasures, she pays a price that many of her old `D classmates at the University of Maryland School of Medicine wouldn't endure. "Being on call Thursday night, all night. At least two weekends out of every four, having some calls." And, two weeks out of four, she does pediatric rounds at St. Agnes Hospital or Howard County General Hospital, before and after her regular work day begins.

In a speech to the group Monday, Hillary Rodham Clinton gave voice to many of the pediatricians' hopes for change, not only for themselves, but for their patients. She cited the grim statistics: Nine million children are uninsured. One in five had no contact with a doctor in 1992. Thirty percent of children under the age of 2 have not been immunized against disease.

'A disgrace'

"It is a disgrace," she said of the number of uninsured, all of whom would be covered under a plan that guarantees every American coverage and provides special attention to children: preventive care beginning before birth, with "no deductibles and no co-pays for well-baby and prenatal care."

She struck a deep chord among physicians like Dr. Gilbert L. Fuld, a pediatrician in Keene, N.H.

"We feel embattled," he says. "We take care of kids, and kids don't vote. We have to be lobbyists for kids."

Even in his middle-class college town of Keene, he sees sick children whose parents can't afford medical care for them.

Last spring, a 3-month-old boy showed up in the emergency room with seizures caused by a sodium deficiency. Dr. Fuld discovered that the baby's mother was watering down his formula, mixing 1 1/2 ounces with water, instead of two ounces, to make it last longer. She saved money but unwittingly made her son ill.

Insurance problems

The present insurance system causes other problems, he says. It generally reimburses on the basis of procedures that are done by the doctor, not the time a doctor often would like to spend with a patient.

Dr. Siskind faults an insurance system that burdens her with paperwork and forces her to consider coverage rules in deciding how to treat a child.

"When I want to do a throat culture, I take out a list" of 30 insurance plans, she says, to determine which laboratory to send a culture to. "If it's a kid who has a certain kind of insurance," she can do a quick test in the office, which could help her prescribe immediate treatment. For others, she has to wait for lab results.

"It impacts on how the kid gets treated," she says. "That's something I would like to see changed."

It's something the Clinton plan seeks to change, by establishing standard forms for billing and uniform benefits for all Americans. Such changes would thrill Dr. George L. Blum, a pediatrician in Southfield, Mich., who has had to hire three employees in his office just to obtain insurance approval for tests and for referrals of his patients to specialists.

Once he had to wait 12 days to obtain a magnetic resonance imaging test for an 11-year-old boy with an injured knee. It turned out the boy had a fracture. "Now the family is mad at me because he didn't get immediate treatment," Dr. Blum complains.

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