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Choose article section... In memoriam Congenital hypotonia: Not a Dx Bioterrorism and changing priorities Whither the general pediatrician?

In memoriam

Editor's note: The following letter is a tribute to Walter Tunnessen, Jr., MD, a member of the Contemporary Pediatrics editorial board and editor of Pediatric Puzzler until his death in November.

I suspect that anyone who had the good fortune to meet Walter Tunnessen or, even better, to learn from him came away with a remarkably similar impression: Here was a gentle man, a caring physician, a superb teacher, possessing equal and abundant measures of knowledge, skill, compassion, and grace. No need to select from a differential diagnosis here; he was all this, and more.

That gentle nature did not take the edge off a firm expectation that every student of the healing arts should do his absolute best, a rigorous standard that I think he applied more to himself than anyone else. For he was a student all his life, fascinated by how very much there was to learn; a devoted collector of pearls who was willing to dive deep to retrieve them.

How fortunate that thousands of pediatricians across the country who never had the chance to hear him speak had the opportunity to sit in his "classroom" through the pages of this publication. That opportunity began in September 1984, with the very first installment of Pediatric Puzzler in the very first issue of Contemporary Pediatrics. Incredibly, Walter continued without pause for more than 17 years, a legacy of more than 200 teachable moments.

Walter taught us how to learn and to have fun doing so. It took me a while to appreciate the wickedly clever clues buried in the headlines of his articles; in an installment titled "Splenomegaly: Something's bad in the air," the eventual diagnosis was mal-aria.

Like any good teacher, Walter Tunnessen was, above all, an illuminator. He shed light that enabled the curious clinician to find the reasons behind things . . . to be capable of surprise (like finding a case of leprosy in the US) . . . to appreciate the humanity as well as the science of medical practice . . . to understand how precious children are . . . and always to find the good in people. The man is gone, much too soon, but his light endures.

Jeff Forster
Vice President, Editorial, Thomson Medical Economics, and Editor, Contemporary Pediatrics, 1985­1993

Congenital hypotonia: Not a Dx

"A guide to early detection of scoliosis" (September 2001) is an important article. However, "congenital hypotonia" should not appear as a diagnosis in the list of neuromuscular conditions with which scoliosis can occur. Congenital hypotonia is nothing more than a descriptive term that, regrettably, still appears on patients' charts and in articles and textbooks. Of the many neuromuscular conditions that can cause congenital hypotonia, the most important ones are: congenital muscular dystrophy, Prader-Willi syndrome, spinal muscular atrophy, mitochondrial myopathies, congenital myasthenia gravis, myotonic dystrophy, and congenital myopathies (such as central core or minicore, myotubular, congenital fiber-type disproportion, and nemaline rod).

It is important that a specific diagnosis be made when there is hypotonia because of the risk of malignant hyperthermia in some patients with muscle disorders. In addition, without a specific diagnosis, appropriate genetic counseling cannot be offered and parents may not know the risk involved in having more children. The two most important diagnostic tests, other than a detailed patient and family history and physical and neurological examinations, are creatine phosphokinase and muscle biopsy under local anesthesia.

Charlotte E. Thompson, MD
San Francisco, Calif.

The author replies: My thanks to Dr. Thompson for her excellent letter. It is an important clarification of the diagnostic evaluation of congenital hypotonia.

Kingsley R. Chin, MD

Bioterrorism and changing priorities

I agree with Dr. McMillan that the problems of September 10, 2001, have not disappeared ("Choosing from a menu of enemies," Editorial, November 2001), but her comments trivialize the enormity of what occurred on September 11 and what has happened since (bioterror attacks in the United States, the war in Afghanistan). Our nation was attacked by enemies who wish to destroy us using weapons of mass destruction. The vote by students at the school of Dr. McMillan's son reflects, on a small scale, the change in priorities our nation has had to face since that day. Rest assured, inadequate education, HIV, substance abuse, poverty, and influenza will be with us long after terrorism is eliminated from the face of the earth. But if we do not survive this threat to our existence, the rest won't matter much, will it?

John J. Fraser, Jr., MD
Galveston, Texas

Whither the general pediatrician?

The practice milieu of pediatrics is changing, with implications for the very future of our profession and so the care of children. Even with newer antibiotics, vaccines, diagnostic tools, and special hospital units (NICUs and PICUs), a malaise plagues our specialty.

One reason for this malaise is a real shift in training philosophy. Years ago, pediatric house officers were taught: "You will be a specialist in the care of children." Today's pediatric residents receive a different, double message: "You will be a specialist in the care of children, but you will not be good enough to care for complex problems in infectious disease, neurology, cardiology, gastroenterology, pulmonology, developmental medicine, and so on. Complicated (interesting) patients must be referred for diagnosis and care to the pertinent 'subspecialist.'"

This mantra does little for the self-image of the general pediatric resident. Ask today's house officer for a treatment plan for a child with any complicated problem and the response is "We need a [fill in the subspecialty] consult." This philosophy carries over into the practice years, leading the pediatrician to assume the function of a triage physician for children.

The reason for this change in philosophy? Years ago, the few existing pediatric subspecialists, because of their patient load, trained pediatric residents to handle the everyday problems in their specialty. This did wonders for the future pediatrician's self-confidence. Now, the plethora of pediatric subspecialists cannot survive financially without referrals, so there is little incentive for subspecialist teachers to train house officers in the skills necessary to handle the most common problems in their specialty.

There has also been a major change in what pediatricians actually do, which has further eroded our self-image as true specialists for children. Ten years ago, pediatricians attended cesarean sections and complicated deliveries. They hospitalized and treated their own patients, saw after-hours emergencies, and took care of all their patients' medical needs from birth through adolescence. The pediatrician was involved and felt important. Many of today's pediatricians prefer not to attend cesarean section births and do not want to, or feel competent to, handle hospitalized patients. Often, office practice, time off, and take-home pay are the goals. Consequently, the pediatrician gives up the care of the really interesting cases that make pediatrics so fascinating and satisfying. Many important skills (and hospital privileges) are then lost—forever.

If this practice milieu continues, cost-conscious managed care plans will realize that care for their clients is available without the general pediatrician. With cesarean section teams, emergency departments, hospitalists, and the growing number of pediatric subspecialists, everything else can be done by the good, but less expensive, pediatric nurse practitioner. And, the family practice physician lurks on the sidelines, offering convenient "one-stop" service for the entire family.

Thus the role of the pediatric nurse practitioner and family practitioner will expand. Care for children may not be as good, or as personalized, as that given by the general pediatrician, but it will be adequate. This is what much of the population, desiring most of all to pay less for health care, seems willing to settle for. The insurance companies, getting pediatric care at a cheaper rate, will have no complaints.

And what will become, then, of the general pediatrician?

Horst D. Weinberg, MD
Holmdel, N.J.


Readers' Forum. Contemporary Pediatrics 2002;2:24.

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