50 years of Medicine (Pediatrics)
A Christian Academic Physician’s Retrospect
1974-2024
Élise W. van der Jagt, MD, MPH
Professor of Pediatrics and Critical Care
University of Rochester School of Medicine/Dentistry
Acknowledgments
my wife, Jan
my kids (7)
my patients
my mentors everywhere
my church
my God
50 Years of Pediatrics
My Background
University of Maryland School of Medicine MD 1974
Ped Intern – Strong Memorial Hosp/Pediatrics 1974-75
US Navy General Medical Officer 1975-1978
Ped Resident/Chief Resident 1978-1980
Strong Mem Hospital/Pediatrics
Rochester General Hospital/SMH 1982-87)
(Primary Care, Ped Hospitalist, Ped Intensive Care)
General Academic Pediatrics Fellowship/MPH 1980-82
Univ. of Rochester School of Med/Dentistry
Ped Critical Care Mini-Fellowship 1987
Children’s National Medical Center/Washington DC
Golisano Children’s Hospital at URMC
Ped Critical Care/Hosp.Medicine/
Ped Sedation Medicine
1987-2024
Areas of Interest
Work Areas
URMC 2023
New SON Bldg
(Includes Simulation Floors)
To be a physician is a CALLING
It is to be like Jesus
It is to function in the 3-fold office
of prophet/priest/king
PRIVILEGES/BLESSINGS RECEIVED
50 years of rapid, widespread and
highly impactful change
“Jesus is the same
yesterday and today and forever.”
(Hebrews 13:8)
“Jesus is the same
yesterday and today and forever.” (Hebrews 13:8)
Relationship of
Medicine and Christianity
has changed
JAMA 1891
The majority of medical men have long ago taken this position, and where they do not become active members of some regular church, are reverential believers and supporters of the fundamental principles of Christian religion. It is only the minority, which happily are growing less every year, who are skeptics, and who hide their weakness under the pitiful expression of Agnosticism. These men are always urging the idea of conflict between science and religion, which every true student of science denies, and every new truth of nature flatly contradicts. Learned theologians and scientists find no conflict or clash of the great truths of nature and theology; only the small, weak, half-learned men ae troubled by such possibilities.
Medicine 130 Years Ago
The clergyman is coming nearer the physician, and both are pointing out and applying the higher laws of physical and spiritual life, and urging men to live in accordance with them.
The highest form of theology points out the realm of the spiritual, from the physical, and shows the laws and forces which govern the life here and here after; and the highest form of medicine indicates the reign of physical laws, their scope and influence, over organic and tangible life.
JAMA 1891
The Flexner Report – 1910
Transitions in Medical Models
spiritual
biological
psycho
social
Spiritual
Biological
Psychological
Social
psycho
social
biological
spiritual
psycho
social
biological
spiritual
Flexner Report 1910
Before 1900
TJC 2001-Present
Engel - 1977
Christus und Hippokrates
Gemeinsame Zentralprobleme
in
Medizin Und Theologie
W.Kohlhammer Verlag 1958
Biopsychosocial Model 1977
Transitions in Medical Models
spiritual
biological
psycho
social
Spiritual
Biological
Psychological
Social
psycho
social
biological
spiritual
psycho
social
biological
spiritual
Flexner Report 1910
Before 1900
TJC 2001-Present
Engel - 1977
Transitions in Medical Models
spiritual
biological
psycho
social
Spiritual
Biological
Psychological
Social
psycho
social
biological
spiritual
PSYCHO
SOCIAL
biological
spiritual
Flexner Report 1910
Before 1900
TJC 2001-Present
Engel - 1977
Spirituality
A quality that goes beyond religious affiliation, that strives for inspirations, reverence, awe, meaning and purpose, even in those who do not believe in any god. The spiritual dimension tries to be in harmony with the universe, and strives for answers about the infinite, and comes into focus when the person faces emotional stress, physical illness or death. (Murray & Zentner 1985)
Spirituality is a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence, and experience relationship to self, family, others, community, society, nature, and the significant or sacred. Spirituality is expressed through beliefs values, traditions and practices.
International Consensus Conference 2012
1998 AAMC Medical School Objectives
The Joint Commission - 2001
Hospitals: requires practitioners to conduct an initial, brief spiritual assessment including as a minimum:
Provides sample questions to ask such as:
Biopsychosocial Model
Biopsychosociospiritual Model
Biological Model
? Psychosociospirituobiological Model
THE CHANGES
TECHNOLOGY - 1970s
No oximetry or capnography
Automated BP – just starting
No IV catheters; steel needles only
Glass bottles for IV fluids
Glass syringe infusion pumps
No ultrasound/echocardiograms
No CT/MRI/PET (fluoro only)
No ped phlebotomy tubes/lab procedures
No pediatric ventilators
No ped central venous catheters/PICCs
No ped ECG/Resp monitoring equipment
No ped hemodialysis equipment
Paper charts/chart racks
Landlines only
No computers
Shared Rooms/Limited parent visitors
Beginning PICUs
Oximetry + capnography
Automated BP standard
IV catheters
Plastic IV fluid bags
Ped phlebotomy equipment/lab assess
IV pumps (with med guard-rails)
Ped catheters – urinary/feeding/vascular
Ped monitors
Ultrasound/Echocardiogram
CT/MRI/PET
Ped ventilators (multiple)
Ped central line equipment
Ped ECMO and Dialysis Circuits
Electronic Charting
Computers/Cellphones
Private Rooms
Pediatric ICUs
TECHNOLOGY - 2020s
Advances in Ped Medical/Surgical Management
Pediatric Vaccines: Hemophilus influenzae Type B, Pneumococcal)
Neonatology (surfactant): – now able to manage down to 22-23 wk GA
Pediatric Congenital Heart Disease (e.g. single ventricle, ECMO, trans-catheter valvular repair/defect closures)
Pediatric Cancer (leukemias/lymphomas/brain tumors)
- better chemo, focused radiation therapy, BMT
Pediatric Bone Marrow Transplant for genetic diseases
Ped Epilepsy/Seizure management (EEG /new antiepileptics)
Pediatric Robotic Surgery
Pediatric Nephrology – hemodialysis, continuous renal replacement rx
Pediatric Transplant – renal/hepatic/intestinal/pancreatic/lung
DEATH
ALIVE
Single Ventricle Surgery
1970s
2020s
Pediatric Genetic Diseases:
- cystic fibrosis
- spinal muscular atrophy
- immunological disorders
Chronic, complex care patients (trache/vents, G/GJ tubes, dev delay)
Procedural Pain Management (new meds: midazolam/fentanyl/propofol/Precedex)
Ped Behavioral and Psychiatric Management (meds/therapies)
Spinal Muscular Atrophy Type 1
(bi-allelic mutation in SMN 1 gene resulting in defective SMN protein; anterior horn cell and lower brainstem motor nuclei atrophy; result in profound weakness but nl cognitive function)
Death by Age 2
1970s
IT nusinersen Q 4 mo.
Oral risdiplam
Onasemnogene
abeparvovec IV
Alive +/-Vent/GT
2020s
KNOWLEDGE EXPLOSION
DATA ACCESS BY COMPUTERS EVERYWHERE
DATA IN VIRTUAL AREAS/CLOUD
IMMEDIATE INFORMATION ABOUT PATIENTS/SYSTEMS/SCIENCE/FINANCE
DATA INCLUDES VISUAL/IMMEDIATE ACCESS TO RESOURCES
DATA MANIPULATION/ANALYSIS FOR REPORTS/TRENDS/SYSTEMS
INFORMATION/DATA EXPLOSION
REQUIRES CONSTANT
DECISION MAKING
Published 2000 and 2001
QUALITY MANAGEMENT
Quality Assurance
Individual
(Retrospective)
Quality Improvement
System
(Prospective)
Before 1990
Current
SUB-SPECIALIZATION
NON-PHYSICIAN PROVIDERS
TEAM CARE
Centers of Excellence/Regionalization
FINANCE
Physicians largely separate from billing issues (at least in med ctrs)
Didn’t matter what insurance pts had in pediatrics to encourage equal treatment for all
Physicians/Providers constantly taught/encouraged to provide adequate documentation for reimbursement; RVU concerns
Physician Executive development (business model)
1970s
2020s
“My brothers, as believers in our glorious Lord Jesus Christ, don’t show favoritism.”
(James 2:1)
http://www.penrithrsl.com.au/kids-entertainment/
RECOGNITION/INTERPRETATION/MANAGEMENT OF DIVERSITY AND DISPARITIES IN HEALTHCARE
The Rise of ETHICS
Principles
BASED ON A VARIETY OF VALUES:
UTILITARIAN, DEONTOLOGICAL, CASUISTRY, ETC.
Principles
USUALLY NOT BASED SPECIFICALLY ON CHRISTIAN VALUES
Francis Weld Peabody (1881-1927):
“The secret of the care of the patient is in caring for the patient.”
(graduated from Harvard Med School, taught at Johns Hopkins, died from Cancer) From: The Care of the Patient by F. Peabody. JAMA 1927; 88:877-882)
CARING vs. CURING
West CP, Dyrbye LN, Shanafelt TD. (Mayo Clinic, Rochester, MN; and Stanford University Medical Center, Stanford, CA, USA). Physician burnout: contributors, consequences and solutions (Review). J Intern Med 2018; 283: 516–529.
Physician burnout, a work-related syndrome involving emotional exhaustion, depersonalization and a sense of reduced personal accomplishment, is prevalent internationally. Rates of burnout symptoms that have been associated with adverse effects on patients, the healthcare workforce, costs and physician health exceed 50% in studies of both physicians-in-training and practicing physicians. This problem represents a public health crisis with negative impacts on individual physicians, patients and healthcare organizations and systems.
The Physician Well-Being Index is a validated screening tool to evaluate fatigue, depression, burnout, anxiety/stress, and mental/physical quality of life in medical professionals.
Religion and Spirituality May Be Protective against Burnout
Multiple studies have demonstrated that “religion and spirituality” can be protective against burnout. Studies have shown that higher levels of spiritual well-being (Kim and Yeom 2018), an active spiritual life and the practice of the virtue of humility (Doolittle, Windish, and Seelig 2013), regular attendance of religious services, and observing a day of rest for religious reasons (Salmoirago-Blotcher et al. 2016) are all associated with reduced overall burnout and burnout-related behaviors...........
…..While certainly it is true that spiritual exercises are not a replacement for prompt and appropriate treatment for mental health disorders, these studies suggest that a strong, active religious faith can protect against burnout.
CULTURAL CHALLENGES
1970s
2020s
https://www.rochester.edu/uhs/healthpromotion/focus-areas/sexualhealth/pregnancy-resources/#CommunityResources
Abortion
Euthanasia
Scientism
Atheism (no God)
Eastern Philosophies
Autonomy as Primary Good
Gender Fluidity
Utilitarianism
Uncertainty Unacceptable
Individualism Primary Value
Secular Humanism
Feminism
Religion is a Crutch
Relative Truth
Diversity (selective?)
Anti-Christian Thought
Materialism
Sexual Expression a Right
Non-Traditional Marriage
Pragmatism
Situational Ethics
Evolution
Christians are Anti-Intellectuals
Agnosticism
“Be very careful, then, how you live – not as unwise but as wise, making the most of every opportunity, because the days are evil.”
(Eph 5:15)
Key Texts to Live By
“In the same way, let your light shine before men, that they may see your good deeds and praise your Father in heaven.” (Matt 5:16)
“Do not think of yourself more highly than you ought, but rather think of yourself with sober judgment, in accordance with the measure of faith God has given you.” (Romans 12:3)
Christian Physician Characteristics
HUMILITY
MD
PT
STAFF
SYSTEM
CULTURE
LEVELS OF INTERACTION AND IMPACT
Adapted: Bronfenbrenner
Christian Academic Physician
Patient
Staff/Colleagues/Students
Local Healthcare/Academic System
Outside Organizations Culture
PRAY CONTINUALLY
Our example: JESUS
Philippians 4:6 “Do not be anxious about anything, but in everything by prayer and petition, with thanksgiving, present your requests God. And the peace of God, which transcends all understanding, will guard your hearts and your minds in Christ Jesus.
1 Thess 5:16 “ Be joyful always; pray continually;
James 5:13 “Is any one of you in trouble? He should pray…..The prayer of a righteous man is powerful and effective.”
1 Peter 3:12 “For the eyes of the Lord are on the righteous and his ears are attentive to their prayer.”
Embroidered by
Mrs. Susan Allen
mother of Andrea Allen
Andrea Allen
1981-2002
SEEK COMMON GROUND
Compassion
Kindness
Quality of Care
Listening
Respect
Efficiency
Burn-out Concern
Honesty
Truth-
telling
Good communication
Concern for Poor
Science
Patience
Education
Learning environment
Commitment
Cost Concern
Team based Care
Fair reimbursement
Spirituality
Peace
SHARED VALUES
Science
Christians
and
Non-Christians
Share Values
Accountability
Important
Changing Definitions/Content
Framework/Lens
EXERCISE EXCELLENCE
“Live such good lives among the pagans, that though they accuse you of doing wrong, they may see your good deeds and glorify God on the day he visits us.”
1 Peter 2:12
PARTICIPATE IN OPPORTUNITIES
Chaplaincy/Pastoral Services interface
Ethics Committee membership
Ethics Conferences participation
Training opportunities for Med Students/Residents
Address spiritual issues when rounding
Mentoring students – address spiritual issues sensitively
BE A GOOD COMMUNICATOR
“Gracious words are like a honeycomb, sweetness to the soul and health to the body.” Prov. 16:24
“……but only what is helpful for building others up according to their needs, that it may benefit those who listen.” Eph. 4:29
“Everyone should be quick to listen, slow to speak and slow to become angry, for man’s anger does not bring about the righteous life that God desires.” James 1:19
BE SELF-SACRIFICALLY COMMITTED
MODEL JESUS
OTHER-DIRECTED
PART OF BEING “CALLED”
SEEK WISDOM HOW TO PRIORITIZE
LIMITED TIME/FINITUDE
SPOUSE/FAMILY BUY-IN
“Time is the one thing that patients need most from their doctors – time to be heard, time to have things explained, time to be reassured, time to be introduced by the doctor personally to specialists or other attendants whose very existence seems to reflect something new and threatening. Yet the one thing that too many doctors find most difficult to command or manage is time. Indeed, some doctors tend to favor the new technology precisely because they don’t have time enough to allow the diagnosis to emerge from comprehensive direct personal examination, and from extended give and take with the patient.” )[. 137)
Norman Cousins (Anatomy of an Illness as Perceived by the Patient, Norton, New York, 1979). This was published by the NEJM in 1976 (COUSINS, N, NEW ENGLAND JOURNAL OF MEDICINE 295: 1458 (1976)). “Laughter is the best medicine” (p.40). He was hospitalized with ankylosing spondylitis; suggested treatment was aspirin and phenylbutazone; he started laughter and vitamin C. And got better.
LIVE BOTH YOUR PROFESSIONAL AND PERSONAL LIVES IN A WAY THAT IS WORTHY OF THE GOSPEL
“Whatever happens, conduct yourselves in a manner worthy of the gospel of Christ.” Phil 1:27
Godly Behavior
Godly Behavior
NURTURE YOUR FAITH
USING THE RESOURCES GOD GIVES
Guard your heart; � Continue to grow in the truth
The Lord’s Day (4th commandment)
MISSION:
VISION: Bringing the hope and healing of Christ to the world through healthcare professionals.
Christian Medical and Dental Association
BE STRONG AND COURAGEOUS
“Finally, be strong in the Lord and in his mighty power. Put on the full armor of God so that you can take your stand against the devil’s schemes.” Eph. 6:10-11
�
Speak the truth and do not be afraid
Speaking the Truth
�
Look for opportunities to engage and speak it
Speaking the Truth
Thanksgiving
“And whatever you do, whether in word or deed, do it all in the name of the Lord Jesus, giving thanks to God the Father through him.” Col 3:17
“Give thanks to the Lord for he is good…. Psalm 136:1
“Jesus is the same
yesterday and today and forever.”
(Hebrews 13:8)
“Jesus is the same
yesterday and today and forever.” (Hebrews 13:8)
Resources for the Christian Physician
American College of Pediatricians, Home | American College of Pediatricians (acpeds.org) (contains a lot of resources, papers that are scientifically based; not a formally Christian organization, but espouses Christian values)
Davis, John J. Evangelical Ethics: Issues facing the church today. 2nd edition. P&R Publishing, Phillipsburg, 1993
Lammers SE, Verhey A. On Moral Medicine: Theological Perspectives in Medical Ethics. Eerdmans Publishing, Grand Rapid, 3rd edition 2012
McAlpine S. Being the Bad Guys: How to Live for Jesus in a World That Says You Shouldn’t. The Good Book Company, United Kingdom, 2021
Stevens, David. Jesus MD: A Doctor Examines the Great Physician, Zondervan, Grand Rapids, 2001
VanDrunen David. Bioethics and the Christian Life: A guide to making difficult decisions. Crossway, Wheaton 2009
Behave in Accordance with the Truth
James 2:17 “In the same way, faith by itself, if it is not accompanied by action, is dead.”
Phil 4:5 “Let your gentleness be evident to all”
Eph 4:29 “Do not let any unwholesome talk come out of your mouths, but only what is helpful for building others up according to their needs.”
Gal 6:9 “Let us not become weary in doing good for at the proper time we will reap a harvest if we do not give up. Therefore, as we have opportunity, let us do good to all people, especially to those who belong to the family of believers.”
Gal 5:22 “The fruit of the Spirit is love, joy, peace, patience, kindness, goodness, faithfulness , gentleness and self-control”
Col 3:24 “Whatever you do, work at it with all your heart, as working for the Lord, not for men, since you know that you will receive an inheritance from the Lord as a reward. It is the Lord Christ you are serving.
Christian Beliefs and Threats
Christian World View
Threats
Physician Responsibilities and Threats
Responsibilities/Values
Threats
Academic Responsibilities and Threats
Responsibilities/Values
Threats