Advances in Pediatrics 56 (2009) 1–9

ADVANCES IN PEDIATRICS

Foundations of Pediatrics:Henry K. Silver, MD (1918–1991)

Henry K. Silver, MD

Andy Silver, MD, Ronald Gotlin, MD, Ruth Kempe, MDy,Donald C. Bross, JD, PhD, Richard D. Krugman, MD,Anita Duhl Glicken, MSW*

yRuth Svibergson Kempe, M.D., Emerita Professor of Psychiatry and Pediatrics at the

University of Colorado School of Medicine passed away Friday, July 24, 2009 at theage of 87. Her professional life was devoted to practice in child psychiatry and, in partnershipwith her husband, C. Henry Kempe, MD, to the prevention and treatment of child abuse.Ruth was one of only two women in her class at the Yale School of Medicine in the 1940’s.Her publications included Child Abuse, part of Brunner’s Developing Child Series anda best-seller in the United Kingdom, and the last two editions of The Battered Child, forwhich she was a lead Editor as well as a chapter contributor. She was a wonderful motherand grandmother and is survived by her five daughters, Karin, Annie, Miriam, Allison andJenny, and sixteen grandchildren.

Vision, passion, loyalty, and wisdom are all words often used todescribe Henry K. Silver. The following stories and anecdotes,collected from some of Henry’s colleagues, friends, and family, paint

a picture of a man steadfastly committed to improving the lives of childrenand families; a man whose vision and tenacity gave birth to an enduringlegacy. His many contributions to pediatric endocrinology, the diagnosisand treatment of child abuse and neglect, as well as his efforts to change

*Corresponding author. E-mail address: anita.glicken@ucdenver.edu (A. Duhl Glicken).

0065-3101/09/$ – see front matterª 2009 Elsevier Inc. All rights reserved.doi:10.1016/j.yapd.2009.08.004

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the culture of medical education would have been sufficient to rank himamong the world’s most influential pediatricians. However, these pale incomparison to his significant contributions to the health care workforcethrough the creation of innovative education programs for nonphysicianproviders at the University of Colorado School of Medicine. Theseprograms, specifically designed to address provider shortages, would changethe face of the medical workforce both in the United States and abroad.Henry, a true futurist, would likely not have been surprised to learn that40 years later, over 200,000 nurse practitioners and physician assistants haveentered the workforce, primary contributors to a health care system thatcontinues to struggle in the face of unmet needs.

HENRY SILVER—THE MANBY ANDY SILVER, MDMy father, Henry K. Silver, MD, was born in Philadelphia on April 22, 1918.Several years later his family moved to Los Angeles, where his parents rana small, open-air grocery store, and where he later graduated from FairfaxHigh School. He went to the University of California, Los Angeles for under-graduate work and received his MD in 1942 from the University of California,San Francisco (UCSF). Dr. Silver did his internship at the University Hospitalin San Francisco and then went to the Children’s Hospital of Philadelphia forresidency. He returned to UCSF from 1944 to 1952 as a research assistant,Instructor, and Assistant Professor in Pediatrics. It was during this time hemet C. Henry Kempe, MD, and for the next 40 years, formed a mutualbond of friendship, respect, admiration, and understanding. They would laterbe known at the University of Colorado as the ‘‘two Henrys.’’ Many of HenrySilver’s first papers were co-authored by Dr. Kempe. From 1952 to 1957, DrSilver was an Associate Professor of Pediatrics at Yale University School ofMedicine. In 1953, he published his first significant paper in pediatrics [1],describing congenital asymmetry, short stature, and variations in sexual devel-opment, known as the ‘‘Silver-Russell Syndrome.’’

In 1957 Henry Kempe, now Chairman of the Department of Pediatrics atthe University of Colorado School of Medicine, asked Henry Silver to joinhim in Denver. My father did and remained there until his death in 1991.During this time he was Professor of Pediatrics, Vice-Chairman of the Depart-ment of Pediatrics, Director of the Child Health Associate Program (CHAP)(1969–1991), and Associate Dean of Admissions for the School of Medicine(1977–1991). Henry Silver was devoted to the University of Colorado, lovedthe climate of Denver, and greatly enjoyed the yearly pediatric summer sympo-siums held in the Rocky Mountains, initially in Estes Park and later in Aspen.He had a deep respect for the people of Colorado, whose progressive thinkingwould enable him to forge ahead with many of his innovative projects.

The early years in Colorado focused on child abuse and pediatric endocri-nology. The first paper on abuse was ‘‘Problem of parental criminal neglectand severe physical abuse of children,’’ published in 1959 [2]. This was

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followed by the landmark article ‘‘The battered child syndrome’’ in the Journalof the American Medical Association in 1962 [3], recently reviewed as a JAMAClassic in 2008. Also during this time, Henry Silver established the firstacademic department of pediatric endocrinology, with emphasis on growthand pubertal problems in children.

The second phase of Henry Silver’s career would mark his legacy. In theearly 1960s he realized that many children were not receiving adequate medicalcare. He developed 3 programs to help address this need: in 1967, the PediatricNurse Practitioner Program [4], in 1968, the CHAP [5], and in 1970, the SchoolNurse Practitioner Program [6]. Dr. Silver and the University of Coloradosoon became recognized nationally and internationally as leaders in the alliedhealth care field. In 1966, my father was invited to attend the signing of theAllied Health Professions Personnel Training Act by President Johnson atthe White House. In 1990, he received the Gustav Lienhard Medal for theAdvancement of Health Care from the Institute of Medicine of the NationalAcademy of Sciences.

My father’s final major focus was as Associate Dean of Admissions for themedical school in Denver. Under his leadership, there was a shift towardmore women and minority applicant admissions; more applicants majoringin nonbiology fields were being considered; and the previously ‘‘rarely dis-cussed’’ problem of medical student abuse was brought to light [7].

Henry K. Silver was a remarkable and brilliant innovator, advocate, teacher,mentor, and friend. In addition to his professional ‘‘creations’’ previouslydescribed, in his private life he created his own brand of art, combining fabricsand wood pieces in framed pictures. There was the perpetual scribbling ofnotes during the middle of the night. Was it that he was always thinking ofways to improve things and never slept, or was he trying to turn his dreamsinto reality? Personally, I think it was the latter.

My father was the ultimate advocate for those most in need. He alwaysstrove to help improve the lives of children, be they undergrown, maltreated,or undertreated. He was a champion for the ‘‘underqualified,’’ be they ‘‘lessthan perfect’’ nurse practitioner/child health associate/medical school appli-cants, or ‘‘just not quite there’’ junior faculty. Many of the programs or individ-uals my father advocated for were often controversial, but I must admit, as hewould, that he loved a good intellectual fight. An example of this was duringthe period that the child health associates were being considered for accep-tance/licensure in the state of Colorado. The major challenges did not comefrom the legislatures, but from fellow pediatricians and some in the nursingprofession. Physicians did not want ‘‘assistants,’’ and nurses did not want‘‘extenders.’’ With tenacity, and some luck, Henry Silver won over these earlyskeptics.

One of Dr. Silver’s favorite passions was teaching. His sessions with thehouse staff at the old Fitzsimons Medical Center were known as ‘‘SilverPearls.’’ Early CHAP classes were small and held in his office, where no oneescaped from participating. He was always challenging the students, as he

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did all of us, to expand our way of thinking. Finally, along with Dr. Kempe, Dr.Silver was the editor of Handbook of Pediatrics and Current Pediatric Diagnosis andTreatment for many years.

My father was a mentor to many fellow peers and junior faculty, particularlywhen it came time to writing papers for publication in various medical andnursing journals. The rewrite after rewrite drove many individuals crazy,but in the end their paper would inevitably be accepted. In his latter years,he spent many hours with applicants who had failed to get into medical school,the ‘‘life coach’’ of today.

Finally, Henry K. Silver, MD was a friend to countless physician andnursing colleagues, and to nurse practitioners, CHAP, and medical students.He spearheaded the nomination of Henry Kempe for the Nobel Peace Prizein 1984, and described his deeply cherished friend as ‘‘the best of what a humanbeing ought to be.’’ Always supportive and nonjudgmental, I am proud thatHenry Silver was not only my father, but my best friend as well.

HENRY SILVER—THE ENDOCRINOLOGISTBY RONALD GOTLIN, MDMy first memory of Dr. Henry Silver is from 1962. I was a third-year medicalstudent early in my first clinical year. He was the featured lecturer in a requiredafternoon lecture series. I still remember that the subject was coagulation ina problem-solving format. Dr. Silver was a pediatrician and pediatric endocri-nologist, but was also well versed in hematology and infectious diseases. Hiscontributions to academic pediatrics and health care were many, and he pub-lished over 120 articles in various pediatric fields. His clinical work in endocri-nology produced many publications, but perhaps 3 were most memorable. Hisinitial description in 1953 of a syndrome characterized by hemihypertrophy,short stature, and gonadal insufficiency (elevated urinary gonadotropins) [1]is now well recognized as Silver or Silver-Russell syndrome. Later, in 1958,he was one of the first to associate long-standing primary hypothyroidismwith precocious puberty [8], and during his activism in child abuse recognitionin the 1960s, he identified a specific syndrome of growth retardation andbehavioral abnormalities in emotionally deprived children, ‘‘deprivationaldwarfism’’ or psychosocial short stature [9].

More memorable was Dr. Silver himself. He was tall, slim, well groomed,and he wore the traditional long white coat. Beneath the coat he wore a whiteshirt, dark thin tie, black trousers, and black military oxford shoes (more aboutthe oxfords later). His stethoscope was neatly contained in a waist pocket.There was no need for the symbolic round-the-neck ornament. He was easilyidentified as a doctor and a professor.

Dr. Silver’s delivery was calm and his manner very engaging. He alwaysseemed to have a reassuring, ever so slight smile. This composure remaineda constant whether he was lecturing, seeing patients, or stressing a viewpointin a large faculty discourse. His countenance gave the impression that he wasready to accept contrasting viewpoints, but this was not necessarily the case.

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His conclusions were reached after considerable thought and once he hadreached a conclusion or viewpoint, he was prepared to defend it.

One of the most memorable training highlights was Dr. Silver’s ‘‘SilverNuggets.’’ These were small group problem-solving sessions in which he wouldpresent general pediatric cases and the trainees would attempt to solve theproblem. To this day, former pediatric trainees remember these cases, particu-larly the infant who had not passed a stool for 1, 2, 3 or more days.

With the exception of 2 years when I was on active duty in the navy,Dr. Silver and I saw patients with endocrine disorders together from 1965through the 1970s. Beginning in the early 1970s, he became more involvedin the development of training programs for pediatric caregivers in nonresi-dency traditional programs. The Nurse Practitioner Program was first, butwas soon followed by the CHAP. Both programs continue to this day (see laterdiscussion).

I also learned early in my experience with Dr. Silver that he was troubled bymoderate (at times severe) problems with his back, which required a specificchair in clinics and was aided by the military oxfords mentioned earlier. Heindicated that these were the only shoes that afforded him some comfortwith his back, and indicated that he lived in some degree of continuous pain.He did so always without complaint or significant change in his composureor interaction with others. Moreover, pain did not dampen his sense of humoror change his love of wit. For example, Dr. Silver always attended medicalschool graduation in cap and gown. His cap and gown were rented, andwhen asked at a faculty lunch why he had not already purchased the regalia,he replied that he already had too much invested in rentals. These lightmoments came through daily, and I found him to be a delight to know andwith whom to work.

While there are other memories, I believe those mentioned here providea clear picture of one of our pediatric masters. Those of us who had the oppor-tunity to know him were indeed fortunate. I have purposely avoided excessiveuse of superlatives or mawkish embellishments. However, it should be clearthat in Dr. Silver we saw an exceptional human being. He hoped for andworked for a better mankind, society, and planet his entire life. Were it notfor his untimely death, his work in seeking better models of teaching, patientcare for children, and the human race in general would have continued indef-initely and continues through the efforts of others today.

HENRY SILVER—THE ADVOCATE AGAINST CHILD ABUSEBY RUTH KEMPE, MD, AND DONALD C. BROSS, JD, PhDHenry Silver and C. Henry Kempe probably met when Henry Kempe wasa medical student on the pediatric service and Henry Silver was a pediatric resi-dent at UCSF.

Their personal friendship and collaboration was important to both menbecause it was totally supportive and noncompetitive. Despite their differentpersonalities and somewhat different professional interests, they shared many

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cultural and ethical values. Both also kept a deep interest in medical education.They shared not only ideas but helped one another in practical ways, such asthe work required to communicate to legislators and to lobby for much-neededlegislation, whether it be for child protection or provision of medicalmanpower.

Concerned about the large number of injured children they were seeing onthe 4 pediatric wards in Denver, they were distressed by unwillingness on thepart of doctors to believe abuse could happen. The Two Henrys wrote a paperthat was printed in 1959 in abstract only, entitled ‘‘The problem of parentalcriminal neglect and severe physical abuse of children’’ [2]. The article pre-sented a ‘‘review of several incidents of criminal neglect and severe physicalassault on more than one sibling in a family,’’ and discussed the need for pedi-atricians to become aware of the problem so they could make a firm diagnosisand provide protection for children.

From the Department of Psychiatry, Dr. Brandt Steele was persuaded to seeone of the parents of an abused infant, and became very much interested in herhistory. That marked the beginning of his major contributions to the under-standing of the difficulties in caregiving which led to abuse and neglect—andadded another member to the ‘‘team’’ that proved so necessary. In 1962, the‘‘Battered child syndrome’’ [3], authored by Kempe, Silverman, Steele, Droeg-mueller, and Silver, was published in JAMA. This was a true multidisciplinarydiscussion of the problem of child abuse, with descriptions of the clinical find-ings, the convincing radiographic evidence to document the injuries, and thehistory of psychiatric evaluations of the parents. It also described the develop-ment of the diagnosis, and of a treatment and management plan for thiscondition.

As time went on, Dr. Silver went on to focus on other problems in pediatrics,and mainly to develop his interest in alternative medical care providers. This didnot mean that his concern about child abuse and neglect had ended, and as anexample, he published an early paper on deprivation dwarfism in 1967 [9].

Dr. Silver’s long involvement with the recruitment and training of youngphysicians led him to question whether some aspects of medical educationmight be abusive and detrimental to the development of future physicians,and in 1984 he and Dr. Donna Rosenberg published their classic paper entitled‘‘Medical student abuse: an unnecessary and preventable cause of stress’’ [7].

Whereas the development of pediatric physician assistants and nurse practi-tioners in pediatric care is addressed elsewhere, Henry Silver’s 1967 article [4]on these developments coincided with C. Henry Kempe’s early efforts to usehealth visitors to prevent child abuse.

In a 1984 letter to his old friend, Henry Silver, thanking him for his part innominating him for the Nobel Peace Prize, Dr. Kempe said:

You did accomplish, and are still doing so much, that only now the fullimplications of what you have begun in health care is being felt—and ithas revolutionized child care at all levels, by many professionals.

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HENRY SILVER—INNOVATOR IN ALLIED HEALTH ANDMEDICAL SCHOOL EDUCATIONBY RICHARD D. KRUGMAN, MD,AND ANITA DUHL GLICKEN, MSWFollowing his outstanding career in pediatric endocrinology, Henry’s primaryinterest in pediatrics turned to health care delivery and the delivery of primarycare services to children. He was interested in medical education, which hethought was unfocused, not competency based, wasted a lot of time, andwas not geared to preparing physicians for what they were eventually goingto do in practice. During the period 1964 to 1981 he pursued approaches tochanging both how health professional education and the provision of primarycare services to children and adults would be organized and delivered.

During this time, Henry and his colleagues searched for additional solutionsto address health care disparities and a predicted shortfall in the pediatric work-force. In 1965, a revolution, generally unrecognized at the time, occurred in theUnites States health care system when Henry and Loretta Ford launched anexperiment to see whether it was possible to give pediatric nurses enough addi-tional training and skills to be able to assist in the provision of primary care forchildren. Henry assumed that if he took someone who had basic nursingtraining and 5 years of experience as a pediatric nurse in an ambulatory setting,and then provided 4 months of additional training in history taking and phys-ical diagnosis, that the nurse could provide much of the ambulatory primarycare services that children needed. These ‘‘pediatric nurse practitioners(PNPs)’’ were educated to answer 3 questions:

1. Is this child sick or well?2. If the child is sick, is it a mild or self-limited illness?3. Does a physician need to see this child now or later?

The program was a success [10]. PNPs were able to care for 90% of childrenwho came to pediatric offices for health maintenance and minor acute illnesses,demonstrating that nonphysicians could provide many of the health careservices previously assigned only to phsyicians. The nurses worked collabora-tively with physicians, who reported that they had at least one-third more timethan they formerly had for patient care and other activities. Although theprogram began in the Department of Pediatrics in the School of Medicine,the School of Nursing later took over the program, lengthened the training,and provided a Master’s degree.

There are now about 120,000 practicing NPs in the United States, with 6000new NPs prepared each year in over 325 educational programs. NPs continueto have education beyond their registered nurse preparation; but most nowhave Master’s degrees and many have doctorates. In addition to the limitedrole that Silver envisioned, NPs now provide an expanded range of servicesincluding diagnosis and treatment of acute and chronic conditions, and coveralmost 600 million patient visits each year. A subgroup of the profession stillspecialize in pediatric/child health, whereas others now specialize in acute

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care, adult health, family health, gerontology, neonatology, oncology, psychi-atry, women’s health, and many other variations on this original theme.

At the time, Henry also wondered what curriculum would be necessary toprovide someone with no previous health care experience the competenciesnecessary to do much of the primary care in ambulatory settings as well aslow-risk nursery. Thus in 1968, Henry created a second program designedto meet the workforce shortage, Henry’s own version of a physician assistant.Unlike their NP colleagues, the child health associate (CHA) entered theprogram without prior training in medicine. The 3-year program representeda significant shift from traditional medical education in preparing nonphysi-cians to provide extensive primary care, including diagnosis and treatment ofpatients. Henry’s intent was to train graduates in problem-solving and deci-sion-making that would approach that of physicians and allow them to provideextensive health care to most patients. Within clearly defined limits they wouldmake independent decisions, and assume responsibility and accountability fordecisions and performance. The first class enrolled in 1969, the same year theColorado general assembly, in partnership with the Colorado Board ofMedical Examiners (BME), passed the Child Health Associate Act, whichwas the first in the United States to establish a framework for certification ofan allied health profession, a nonphysician, to practice pediatrics [11]. Henrywas instrumental in moving this act through the legislature; this ground-breaking legislative process became the precursor to many subsequent statepractice acts. Overall, the training program prepared the graduate to care for80% to 90% of patients seen in pediatric practice. Extensive evaluations of earlygraduates demonstrated that they provided high-quality, comprehensiveprimary care to infants, children, and adolescents including diagnostic, preven-tive, and therapeutic services. The graduates also provided extensive parentand patient education, counseling, and support. In 1973, under Henry’s leader-ship, the program achieved another milestone; it was the first in the country tooffer a Master of Science degree.

In 1981, Henry became Associate Dean for Admissions at the University ofColorado School of Medicine, and he held this post for 12 years until his death.He completely changed the face of the School’s graduates by admitting largenumbers of women, minorities, and middle-aged students who came to medicalschool after having had previous careers. He had no doubt about the motiva-tion of individuals to be physicians if they left a well-paid job to come tomedical school, whereas it was often not clear how to gauge the motivationof a 22-year-old student who was on the ‘‘pre-med track’’ from preschool on.

Henry also made an important observation while Associate Dean. Henoticed that when the class sat at graduation 4 years later, they had changed.I (Glicken) remember him telling me one day: ‘‘I wonder what causes so manyof our medical students to go from such happy, excited, altruistic young peoplein their first week to such cynical, flat, almost depressed men and women attheir graduation? It reminds me of the children Henry Kempe and I saw inthe early sixties. Do you think they are abused?’’ This led to his study

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published with Donna Rosenberg in 1984 [7] and then to his further studiespublished in 1990 [12]. Medical student abuse is now recognized as so preva-lent that the Liaison Committee on Medical Education has issued standardsto assure that Schools of Medicine recognize and address the issue.

Three months before Henry died in 1991, I (A.G.) sat in his office andreflected on the work ahead. There was still so much to be done. We plannedto share an office and, in our ‘‘free time,’’ envision new models of health caredelivery and better ways to educate students. As in the case of countless others,I had already learned invaluable lessons from Henry about passion, tenacity,commitment, and hope, but I was particularly excited about the concept ofusing multidisciplinary/interprofessional teams to reintegrate an increasinglyfragmented health care system, and to expand safety and access to patient care.

As we face another projected workforce shortage, Henry’s spirit and wisdomcontinue to inspire and lead us to better solutions. I can think of few individualsin health care that have had the breadth and depth of influence of Henry K.Silver. The full implications of Henry’s work have yet to be realized. Asa mentor, colleague, friend, and father he is clearly missed, but his legacycontinues through the programs he inspired and the work of countless gener-ations of new health care providers.

References

[1] Silver HK, Kiyusu W, George J, et al. Syndrome of congenital hemihypertrophy, shortness of

stature and elevated urinary gonadotropins (Silver syndrome). Pediatrics 1953;12:368–76.

[2] Silver HK, Kempe CH. Problem of parental criminal neglect and severe physical abuse ofchildren. Am J Dis Child 1959;95:528.

[3] Kempe CH, Silverman FN, Steele BF, et al. The battered child. J Am Med Assoc 1962;181:19–24.

[4] Silver HK, Ford LC, Stearly SG. A program to increase health care for children: the pediatricnurse practitioner. Pediatrics 1967;39:756–60.

[5] Silver HK, Hecker JA. The pediatric nurse practitioner and the child health associate: newtypes of health professionals. J Med Educ 1970;45(3):171–6.

[6] Silver HK, Nelson N. The school nurse practitioner program: a new concept in providinghealth care. Medical Tribune 1970.

[7] Rosenberg DA, Silver HK. Medical student abuse: an unnecessary and preventable cause ofstress. JAMA 1984;251:739–42.

[8] Silver HK. Juvenile hypothyroidism with precocious sexual development. J Clin EndocrinolMetab 1958;18:886–91.

[9] Silver HK, Finkelstein M. Deprivational dwarfism. J Pediatr 1967;70:317–24.[10] Silver HK. Use of new types of allied health professionals in providing care for children. Am

J Dis Child 1968;116:486–90.[11] Jones AA, Krugman RD. The Child Health Associate Act: licensure of an allied health profes-

sion. Ethics Sci Med 1976;3:65–9.[12] Silver HK, Glicken AD. Medical student abuse: incidence, severity and significance. J Amer

Med Assoc 1990;263:527–32.