The 2020 Joseph W. St Geme, Jr. Leadership Award Address: On Leadership and the Joy of Pediatrics

The following is an address given by the author in receipt of the Joseph W. St Geme, Jr Leadership Award, presented by the Federation of Pediatric Organizations at the Pediatric Academic Societies meeting on April 30, 2021.

It is difficult to describe the feeling of receiving the Joseph W. St Geme, Jr Leadership Award, established in honor of my dad. The award has enormous meaning to me, as is likely obvious. My dad died on October 11, 1986, nearly 35 years ago, at the age of 55. If he were still alive today, he would be 90 years old, born in April 1931. Accordingly, some members of the pediatric community knew my dad as a colleague, some knew him as a teacher or mentor, and some may have known him as an examiner for the American Board of Pediatrics, but most never had the good fortune to know him. So I want to tell people about him and what I learned from him.

My dad was born in Los Angeles, the first of 2 sons to my grandfather Joseph William Sr and my grandmother Malvina Pozzo. By the time I knew him, he was a big man, 6 ft 2 in tall, with broad shoulders and an athletic physique. He filled a room in every sense possible. Although he made no effort to dominate conversation or assume center stage, he naturally captured the attention of others, and when he spoke, people listened. He was gregarious, filled with interesting stories and pithy messages and a knack for word choice that made people smile. He took an interest in others, and he had a special gift for making people feel important. Consistent with his physique, he was an athlete, and he often used examples from sports to express his points. I learned many lessons from him.

I learned the importance of optimism, of inspiring confidence, and of never giving up. My dad was the most positive person I have ever met. He knew how to find a silver lining in everything that seemed challenging or overwhelming. I remember watching the Stanford–University of Southern California (USC) football game at the Los Angeles Coliseum in 1969, when Jim Plunkett was the quarterback for Stanford, on his way to winning the Heisman Trophy. In the third quarter, Stanford was behind, and Plunkett was sacked for a big loss on second down. As a result, the offense faced third down with 27 yards to go for a first down, deep in their own territory. I had gained my dad’s passion for Stanford football by that point, and I was pretty dejected and expressed my disappointment out loud. My dad turned to me and said, “Third and 27, here comes a big play.” Indeed, Plunkett hit Randy Vataha for a long gain and a first down, leading to a touchdown and setting the stage for Stanford to win the conference, earn a berth in the Rose Bowl, and then beat Ohio State in the Rose Bowl on New Year’s Day. From then on, anytime we faced a tough situation as a family, my dad would say “Third and 27, here we go, time for a big play!” And more often than not, there would be a big play.

I learned to embrace diversity. My dad used to say that it takes all kinds to make the world go ‘round. He welcomed countering points of view and healthy disagreement during discussions, appreciating that broad perspectives resulted in better decisions. He commented that diverse faculty and diverse faculty personalities should be encouraged, not merely tolerated. He talked about his teammates on the Stanford football team: Harry Hugasion and Gary Kerkorian, Chuck Essegian, Norm Manoogian, and Les Kaprilian, all from families that were recent immigrants to the United States. As the Chair of Pediatrics at Harbor-UCLA Medical Center, he celebrated the Harbor-UCLA residency program match results when the incoming intern class had higher numbers of women and when they attracted underrepresented minorities. And he felt privileged to practice medicine at a county hospital and to provide care for children and families with limited resources.

I learned the importance of taking a breather now and then, whether a pause in the day, a day off, or a vacation. My dad used to talk about Bob Mathias, a teammate on the football team at Stanford and an Olympian who won the gold medal in the decathlon in both the 1948 Olympics and the 1952 Olympics. Whereas most decathletes would finish an event and then pace back and forth before the next event in the 10-event competition, Mathias would take a nap between events, regaining his physical and mental energy and competing with a freshness that other competitors lacked. Finding a source of resilience as a strategy to avoid burnout was not a common concept or point of discussion during my dad’s era, but that is what he was talking about.

I learned about the importance of discipline, having a routine. During my time in middle school, high school, and college, we lived in a home in southern California with a lap pool in the backyard. My dad would come home at the end of the day and would religiously go for a swim in the backyard, typically a quarter mile, regardless of what time it was and how long the rest of us might have been awaiting his arrival for dinner. This was his approach to winding down, to getting regular exercise, to maintaining his edge as a physician and as a father.

I learned the importance of competition. I remember how my dad would pour over the program for the Society for Pediatric Research meeting in Atlantic City each year, counting abstracts from faculty, fellows, and residents at Harbor-UCLA and comparing numbers of abstracts and awards with Boston Children’s Hospital, Children Hospital of Philadelphia, Cincinnati Children’s Hospital, and other large programs. He frequently told us the story of David versus Goliath. He loved being the underdog, and he loved beating the favorite. He thrived on competition and the drive for excellence, and he instilled this passion in everyone around him.

I learned the importance of recruitment and fostering personal development. When my dad first assumed responsibilities as Chair of Pediatrics at Harbor-UCLA, there were 3 faculty. In a short period of time, he increased the faculty number to >40, virtually all superstars, recruiting at least 8 people who subsequently became pediatric department Chairs, including Larry Shapiro, Mike Kaback, David Rimoine, Del Fisher, Spike Miller, Bill Oh, Mark Sperling, and Rosemary Leake, and others like Bud Anthony, Jim Seidel, Carol Berkowitz, Alan Jobe, Dennis Murray, Terry Yamauchi, and Margie Keller, among others, who were major leaders in their field. During the 21 months that he was Dean of the School of Medicine at the University of Colorado, he recruited 8 new department chairs, transforming the University of Colorado.

I learned about being a communicator. I recall a story from Carol Berkowitz that highlights this quality. Carol was recruited to Harbor-UCLA by my dad and worked with him for 7 years, before he left for Colorado. Harbor-UCLA is a county hospital in Los Angeles County and is a part of the UCLA system. Carol reports that one year back in the early 1980s, the leadership of Los Angeles County had given all county employees (including physicians) a cost-of-living increase. Shortly after this decision, my dad brought together the faculty in the Department of Pediatrics and explained that they could all go ahead with the cost-of-living increase along with the supplemental stipend that they typically received from UCLA, or instead they could take the cost-of-living increase from the county but forgo the UCLA stipend, which would then revert to the Department and could be used to recruit additional faculty or other extras for the Department. He said the choice was up to the faculty, but he had a clear preference. There was a brief discussion, and the faculty then voted unanimously to turn the UCLA stipend over to the Department and wind up with essentially no change in their salary, all feeling good about their decision. According to Carol, the faculty walked out of the hospital conference room and someone said, “Did we just vote to not increase our salary?” In Carol’s words, my dad was a master at making a persuasive case and then assuring that everyone felt heard and that everyone felt involved in the decision-making.

I learned to loathe excuses. In considering this issue, I want to share an exerpt from a eulogy published in Pediatrics by Marty Smilkstein shortly after my dad died.¹  Dr Smilkstein trained in Pediatrics at Harbor-UCLA and then subsequently went into Emergency Medicine. He was the supervising physician in the Emergency Department at University Hospital in Denver when my dad was wheeled in after suffering a cardiac arrest at home, and he was the physician who ultimately declared my dad dead. In his words, “[Dr St Geme] hated excuses. He lived in a world with a thousand excuses for failure. He accepted none of them. If a goal was important to him, the roadblocks of political climates, budgetary constraints, and other immovable (to others) objects were not offered or accepted as valid reasons for nonattainment. If he believed it was right and important, nothing seemed to be able to stop him. This made him hard to whine to. Sleep deprivation, busy clinics, not enough time to read - these reasons and more were tried by residents to explain various less than perfect performances. If it was important and worthwhile, it should be done, despite the cost or effort involved. Because he practiced life and medicine up to that standard, there was little we could say.” Dr Smilkstein went on to say, “To this day (and it’s often quite annoying), if I compromise on something important in my medical practice or teaching, and begin to justify the compromise by making excuses, I can see [Dr St Geme] set his jaw and look disgusted. I reconsider.” This intolerance of excuses applied to our life at home as well and was a message that we all came to embrace.

I learned the value of family meals. As a family of 8, we had a busy schedule, with all of us going different directions. But we always had dinner together, and we always had Sunday brunch together. Many days it worked out to sit down for dinner at a normal time like 6:30 pm or 7:00 pm, but oftentimes my dad had a late meeting or 1 of us or sometimes 2 or 3 of us had a baseball game or a football game or a track meet or some other school-related activity. We would all wait until everyone was home, sometimes late in the evening, allowing us to sit down together for dinner and to review how the day went. On Sunday mornings we would attend Mass together and then come home to prepare Sunday brunch, with each of us assigned a different task, rotating tasks from 1 week to the next. This practice ensured an opportunity to communicate as a family, discuss life lessons, reinforce family values, plan for the future, at the same time strengthening good table manners and good grammar.

I was drawn to pediatrics for a variety of reasons. Growing up in a big family, with 5 siblings, all close in age, I was always surrounded by children. Outside the family, I had a variety of experiences with children during my teenage years, as a little league baseball umpire, a junior football referee, a middle school lunch supervisor, and a summer recreation program instructor. But most compelling was my relationship with my dad and my sense of the joy that he experienced as an academic pediatrician.

Beginning at an early age, I would periodically join my dad on his weekend trips into the laboratory to check on animals and cell cultures. When I was in college, I had the opportunity to join him occasionally on rounds on the pediatric ward and in the NICU, watching him interact with patients and families and communicate with residents and medical students. I met his colleagues in social gatherings at our home and at department functions involving softball games and touch football games, in our backyard and at local parks. I was introduced to the faculty, the residents, and the senior administrative staff in his department. My dad used to talk about the challenge and the reward of considering a chief complaint in a young infant, with the patient unable to express himself or herself and hence unable to describe anything beyond what his or her parents could report on the basis of their observations.

When I began my clerkships in medical school, I enjoyed everything, but there was something special about pediatrics: the patients, the families, the people in pediatrics (pediatricians, pediatric surgeons, pediatric radiologists, pediatric nurses, pediatric therapists, and other pediatric staff). And today I realize that there is even more that is special about pediatrics, really special. Although I recognize that I am biased, I feel strongly that pediatrics is unrivaled as a medical specialty and is more exciting now than ever before.

Life in pediatrics represents an opportunity to engage children and to influence the future of our society in a way that is virtually unique in medicine, all the while benefiting from the refreshing innocence and candor of children and gaining inspiration from the remarkable resilience of children and the amazing strength of pediatric patients to battle illness and to overcome adversity, often recovering on their own. As highlighted by my dad, the diagnosis and management of disease in infants and young children requires refined clinical skills, including history taking, physical examination, and thoughtful diagnostic testing to overcome the inability of these patients to communicate directly and articulate their symptoms. On the other end of the pediatric spectrum, gathering information from preteenagers and teenagers often requires special skills to gain the patient’s confidence and to assemble a story that allows optimal intervention.

Pediatrics is synonymous with holistic care and family centered care, with input routinely from social workers, psychologists, dieticians, pharmacists, and therapists, among others. High-quality care requires attention to growth and development, to the home, the community, and the school environments, and to the family history. The pediatric environment is uplifting and inspiring, with colleagues who are invested in caring for youth and families, with art and images that capture the creativity and the optimism of children, with bright colors and open spaces, creating an atmosphere that conveys a sense of hope, hope for patients, hope for families, and hope for the medical team.

As pediatricians, we all play a role as advocates for children, who in aggregate represent roughly 20% of our population in the United States but are unable to vote and cannot advocate for themselves. We serve as advocates for individual children when we interact on their behalf with parents, with other physicians, with insurance companies, and with community service agencies. We advocate for all children when we interact with government officials regarding Medicaid support, Children’s Hospital Graduate Medical Education funds for training pediatricians, and National Institutes of Health funding for child health research. Similarly, as pediatricians we are all teachers, at a minimum in conversations with parents and other care givers about individual patients and in many cases in providing instruction to students, residents, fellows, and other medical colleagues.

The career opportunities in pediatrics are enormous, for clinicians, for scientists, for educators, for community leaders, for academic leaders, for preventing disease and maintaining health, for managing acute illness, for caring for patients with chronic disease. The field of Pediatrics continues to evolve markedly, and current times are especially exciting. In just the past few years there have been major scientific and clinical advances. The first cell therapy product to be licensed by the Food and Drug Administration stemmed from work in pediatrics, Kymriah, for children and young adults with refractory acute lymphoblastic leukemia.²  Similarly, the first gene therapy product to be licensed by the US Food and Drug Administration resulted from work in pediatrics, Luxturna, for patients with Leber’s congenital amaurosis.³  Other gene therapy products that have now been licensed for use in children include products for spinal muscular atrophy, β thalassemia, and severe combined immunodeficiency disease.^4–6  Beyond cell and gene therapy, breakthrough medications have recently been licensed for cystic fibrosis, sickle cell disease, and spinal muscular atrophy.^7–9  With the routine availability of genome sequencing and other omics technologies, we are increasingly able to establish a genetic and molecular diagnosis, often amenable to cure with bone marrow transplant and more and more often allowing identification of new drug targets.¹⁰ 

A whole list of additional cell and gene therapy products for pediatric patients are in active clinical trials (Table 1), with a number that are likely to be licensed soon, transforming the prognosis for a growing number of diagnoses that have been grim historically. Other examples of interventions that are likely to change pediatric care include the artificial womb,¹¹  partial liquid ventilation,¹²  and manipulations of the microbiome,¹³  to name just a few. Importantly, we continue to learn about how exposures and experiences during fetal life and during early childhood represent the origins of adult disease, underscoring the critical role of pediatric research for advances in child and adolescent health and also for advances in adult health.¹⁴ 

Although we have witnessed many staggering advances in pediatric care in recent years, we also have a number of fundamental challenges to address as a medical discipline. In particular, food insecurity, poverty, asthma, and obesity remain common among children and adolescents. In addition, behavioral health disorders are a major problem in the pediatric population, exacerbated by the coronavirus disease 2019 pandemic.¹⁵ 

In closing, I want to share 2 quotes that convey important messages. This first of these quotes reminds us of the privilege that we have as pediatricians in caring for children, and the second highlights the lesson that we can learn from observing our patients. In 1963, John Kennedy said “Children are the world's most valuable resource and its best hope for the future.” And George Bernard Shaw said “We don’t stop playing because we grow old; we grow old because we stop playing.”

As a final comment, I want to express my deep gratitude to both my mom Monica St Geme and my dad for carving a path for me and for many others in Pediatrics.

USC

University of Southern California