I am green with envy......

I have had a career in academic paediatrics that would have seemed unattainable as I entered Medical School at the University of the Witwatersrand, Johannesburg in 1967 directly out of high school. Serendipity and opportunity have combined to lead me on a journey starting with my internship in Johannesburg, paediatric residency in Toronto, endocrinology fellowship in Toronto and Pittsburgh, and in 1981 beginning a faculty position at the University of Toronto and The Hospital for Sick Children. It is winding down in 2017 as I have reached the end of my 10-year tenure as Chair of the University’s Department of Paediatrics and SickKids’ Paediatrician-in-Chief and edge into retirement. Two complimentary words keep cropping up that best describe these past almost 50 years: joy and privilege. When combined, these words define a remarkably fulfilling career, one that indeed remains a joy and a privilege. Denis Daneman Yet, as the title of ‘My Letter’ to you says, I am green with envy at my younger colleagues either just entering their training or reaching the pinnacles of their careers. This is not just a matter of wanting to be 32 years of age again (though I wouldn’t argue against that), but rather because medicine/health care is right on the precipice of passing from what I have termed current ‘Sweat of our brow’ therapy toward a future of much more precise approaches based on increasingly exquisite knowledge of molecular and cellular mechanisms (called by some ‘Precision’ medicine, by others ‘Personalized or Individualized’). What is abundantly clear to me is that some diseases (perhaps mostly single-gene dependent) will eventually buckle under the new technologies that allow manipulation of the altered biological process by relatively simple/targeted small molecules or genetic alteration (e.g., cystic fibrosis), while more complex diseases dependent on gene–environment interactions or multiple gene dysfunctions may be more recalcitrant (e.g., type 1 diabetes). Simply put, you, my younger colleagues, must prepare yourselves to take on the new therapeutics with a vengeance. And it is not going to be that simple, because in addition to this new knowledge (genetics or genome science, as well as the rapidly emerging field of brain science) needed to precisely define the disorder, you will be faced with some important challenges. The patient population is increasingly well informed about their or their child’s ailment, not infrequently the more the information that is gleaned, the greater the opportunity for confusion, hence the need for very clear communications and decision-making pathways, and what to do when things do not work out as predicted. Let me suggest to you that there will always be two important challenges in paediatric medicine, both are potentially highly tragic: first, when the disease ‘wins’, as the disease is too far advanced or is resistant to our treatment, we do not understand the disease sufficiently well, the wrong diagnosis is entertained, the treatment has known/unknown side-effects, the child is compromised by the disease or its therapy, etc. The second tragedy we see in paediatrics is that of exclusion, disadvantage and prejudice/bias. It is of considerable discomfort to me that in a country as bountiful as Canada, we rank, according to the latest UNICEF reports, in the lower half among the richest countries of the world (OECD rankings) with respect to indicators of child health outcomes (1). Among the groups most affected are Aboriginal Canadians, refugee and immigrant families and those of lower socioeconomic status. This is not unexpected because the health of our children has four major contributors: ~15% of illness and death is due to genetic factors, ~10% of risk is associated with threats from the physical environment, ~25% a result of the health care system and delivery of service, and the single biggest impact on health, the remaining 50%, is associated with the so-called social determinants of health, most particularly economics (poverty), food and shelter (in)security, a sense of belonging and freedom from abuse and/or neglect (2). These latter issues constitute what we paediatricians have come to refer to as ‘Social Paediatrics’, throwing the responsibility at us (paediatricians) to address. I prefer the expression ‘child well-being’, making it a greater societal imperative, involving not only the health care system, but also the education and social services systems and more (3). What then, are the major themes I would encourage you to think about as your career evolves? First, a career in paediatrics is not a boom-bam-crash acquisition of all the skills needed to do a great job, but rather a steady evolution/maturation of knowledge, data gathering and perspective. A successful career in medicine has and will always depend on the acquisition of sufficient knowledge and experience to enable patterns of disease and their variants to be identified, diagnosed and appropriately managed—Osler’s diagnostic skills. It is unlikely that humans are going to be replaced by information technology systems any time soon. Sir William Osler was quoted as saying that ‘the value of experience is not in seeing much, but in seeing wisely’ (4). There are two broad aspects to the data gathering part of the equation: ‘taking’ a history and ‘listening’ to the patient (in paediatrics, this often means the parents or alternate caregivers). The history leads down the pathway to diagnosis, the listening part to an understanding of each patient’s individual interpretation of their disease, their anxieties, their wishes, in other words, themselves revealed. To do this, the paediatrician often has to reveal something of her/himself before the patient or family will ‘open up’. This requires experience, time and skill. Second, the characteristics of an excellent clinician were recently studied by my colleague, Sanjay Mahant: high intrinsic motivation, passion/commitment and humility were the fundamental features that emerged. Think about these carefully, especially perhaps humility (5). This means knowing when you need to seek further assistance from the literature, one’s colleagues or by observation of the natural history of the disorder. Third, for me one of the great things about working in an interdisciplinary health care team, with doctors, nurses, dietitians and other health professionals, is the different perspectives each brings to the situation, and how much richer the provision is of service under such circumstances. Integral to the team approach to medical care is the development of a common treatment philosophy among the different professionals. Fourth, there is the perspective one gains from caring for individual children/teens and their families over many years. This allows one to assess what is in the best interests of the entire group just not the single patient. This demands that the clinician evolve from attention to the single to the design of systems of health care for the many. This entails principles of public health, including developing appropriate services close to home when possible, or preferably within the home. Fifth, my career has been ‘lived’ entirely within the academic realm, so my next remarks are for those in the same/similar situations (6). It has been my increasing impression/experience that academic medicine is splitting along three fault lines, each with its own challenges: those few who train to become clinician scientists: their training puts them in the forefront of new knowledge development; the education pedagogues who construct and evaluate changes in the curriculum; and the remaining large number of predominantly academic clinicians who are tasked with the majority of the patient care and medical student teaching. I would encourage those in academic situations to develop their teaching skills wherever possible so as to be able to share knowledge in as effective a manner as possible. Second, I would strongly encourage all of these individuals to involve themselves in study projects that address questions along the spectrum of mechanisms of disease through to safety, quality, outcomes, health policy and more. The better you understand a disease process, the better positioned you are to treat it most effectively. Finally, the care of children and attention to their well-being do not start and stop at the door to your office or clinic. Rather it extends, particularly in those with chronic diseases or disabilities, to all aspects of their lives, such as ensuring that they have access to the best school facilities, with special education when needed, and integration when not, and ensuring the most appropriate form of adult care when time to transition out of the paediatrician’s office arrives. This is often the time when we play the hardest roles as patient advocates. Advocacy starts with single patients and extends to groups of patients if one works in such an environment, e.g., chronic diseases such as diabetes, inflammatory bowel diseases, rheumatologic disorders, cystic fibrosis, childhood cancers and more. Here, there is a rich opportunity to become involved in organizations such as the Canadian Diabetes Association (now Diabetes Canada), The Arthritis Foundation, the CF Foundation and many more. To conclude, a career in academic paediatrics has provided me with excesses of job enjoyment and satisfaction (we should take what we do very seriously, ourselves less so) far greater than I would’ve predicted. I highly recommend it. Denis Daneman obtained his MBBCh in 1973, FRCP(C) in 1981 and DSc(Med), the University of the Witwatersrand’s highest degree, in 2013 for his thesis entitled ‘Contributions to Type 1 Diabetes in Children and Adolescents’. He has been on the staff at SickKids and UofT since 1981, from 1993 to 2006 as Head, Division of Endocrinology, 2000 to 2005 as Associate Chief, Clinical of the SickKids’ Research Institute and from 2006 to 2016 as Chair of UofT’s Department of Paediatrics and Paediatrician-in-Chief at SickKids. He has published well over 200 papers mainly in the field of diabetes in children and youth and co-authored 3 books, one of which, When a Child Has Diabetes, has served as the major manual for Canadian families with children with recently diagnosed diabetes. He co-chaired the first diabetes clinical practice guidelines in Canada and continues to be involved in guideline development. Denis has been involved in a number of multicenter international trials, including the DCCT, TRIGR and AdDIT. He has played leadership roles in both national (Canadian Paediatric Endocrine Group, Canadian Diabetes Association) and international organizations (International Society for Pediatric and Adolescent Diabetes [ISPAD]). He has received innumerable awards, most recently the 2010 ISPAD Prize, the 2013 Canadian Diabetes Association’s Lifetime Achievement Award and the 2015 Canadian Association for Academic Healthcare Centres (CAPHC) Award for Contributions to Child Health. In October 2016, he received an Honorary Fellowship from Faculty of Paediatrics of the Royal College of Physicians of Ireland. In June 2017, he was appointed an Officer of the Order of Canada.

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