Chapter 1. Role of the Pediatrician

As pediatrics and the delivery of children’s health care enter the 21st century, the role of the pediatrician continues to evolve and change. Guided by the knowledge, skills, and tools that the profession has accumulated over many decades, pediatricians must strategically respond to changing conditions, health determinants, and epidemiology of childhood as well as to shifting social and cultural norms of what constitutes healthy child development. Our knowledge of the pathophysiology of many diseases has evolved from simple causal models based on germ theory to more complex notions of gene-environment interactions. As pediatric care has triumphed over many infectious diseases and made significant strides in the management of chronic disease, newer morbidities have emerged, including a growing prevalence of developmental, behavioral, and mental health conditions. To impact child health, 21st-century pediatricians must provide care with an expanded concept of healthy child development and must acquire skills to effectively practice in collaboration with other individuals and entities involved in promoting and supporting that development.

Societal expectations for healthy child development are a reflection of our collective hopes for what our children should achieve and what challenges they must successfully face in their transition to adulthood. These expectations are being transformed by an expanded understanding of what constitutes a healthy child as well as by a globalized economy that places a higher value on cognitive and emotional performance in the workplace, especially within developed nations.

The 2004 Institute of Medicine’s landmark report, Children’s Health, The Nation’s Wealth,1 presents a new definition of child health and three associated, measurable domains:

“Children’s health should be defined as the extent to which individual children or groups of children are able or enabled to (a) develop and realize their potential, (b) satisfy their needs, and (c) develop the capacities to allow them to interact successfully with their biological, physical, and social environments.”

The domains include health conditions, capturing the traditional notions of health measured by disorders or illnesses of body systems; functioning, assessing how health affects an individual’s daily life; and health potential, identifying the assets and positive aspects of health, such as competence, capacity, and developmental potential.

The new definition and domains help establish the goals of child health care, which go beyond diagnosing and treating disease and preventing and managing chronic health conditions. They include promoting the health capacities of each child and optimizing the health potential of all children. Underlying this definition and these goals is a new and more dynamic conceptual model of how health develops; the model can be represented by a health trajectory that is influenced by a range of biopsychosocial and environmental risks, as well as by protective and promoting factors (Fig. 1-1).2

Pediatricians play an important, collaborative role in influencing factors that can optimize the child health trajectory. For one, the role and professional responsibility of the pediatrician is greatly expanded by ever-increasing medical knowledge and new, more powerful and expensive technologies. In addition, evolving performance guidelines of health care systems redefine expectations and attributes of the well-trained pediatrician. These expectations include the areas of professionalism, systems-based practice, patient care, interpersonal and communication skills, medical knowledge, and practice-based learning and improvement. As such, pediatricians of the 21st century, in striving to improve child health, whether at the individual or population level, must master a new, important array of knowledge, skills, and attitudes (Table 1-1).3

This evolution includes a shift in focus from dealing with the symptoms and empiric treatment of diseases, as well as with syndromic identification, to a greater understanding of underlying mechanisms of disease and treatments based on those mechanisms and of the important role of genes and environment. In many situations, this evolution has moved medical care from observation and palliative care to sophisticated diagnostics and therapeutics, including gene manipulation.

The ability to deal with the inherent complexity of 21st-century medical care is facilitated by information systems, including the Internet and electronic health records. These systems also create immediacy with regard to new knowledge that is available not only to pediatricians but also to patients and families, with an expectation of more timely application of that knowledge.

As patients and families have gained increased access to medical information, a corresponding emphasis on more patient-centered and family-centered medical care has developed. Decision-making is shifting from a traditional physician-focused process to one determined by informed patient and family preferences. Widespread access to evidence-based guidelines and benchmarked systems transparent about patient outcomes have created an expectation that pediatric health care will be highly reliable with systems in place to assure safety, consistency, and high quality. It also has underscored the need for medical homes that not only provide continuous care but can translate the barrage of information. Further, family-centered models of care require that pediatricians are skilled at collaborative service delivery efforts that include the variety of settings and professionals that serve children within the context of their families. All these dimensions of care are particularly driven by the Institute of Medicine’s 2001 report, Crossing the Quality Chasm, which stipulates that health care should be safe, effective, patient centered, timely, efficient, and equitable.

With regard to settings of care, many influences are making it difficult for an individual practitioner to care for children in multiple settings: inpatient, outpatient, or community health settings. This is particularly true for generalists and not as true for pediatricians in more rural settings or for subspecialists. As a result, there is an increasing focus on providing care in one setting, whether inpatient or outpatient, with a few practitioners focusing on community health. This trend underscores the importance of collaboration across sectors (eg, education, family support, child welfare) to effectively influence and promote optimal child health.

Even with all these changes in pediatric health care, child health from a whole population perspective has only slightly improved. For specific disease entities, such as cancer, congenital heart disease, cystic fibrosis, and type 1 diabetes, important new treatment modalities have achieved cures and extended life. However, persistently disparate and high infant mortality rates, increasing incidence of some diseases, such as autism and attention deficit hyperactivity disorder, and an epidemic obesity that is leading to chronic medical disease such as type 2 diabetes in younger populations, underscore the continued challenge of improving child health. Our advances in understanding the determinants and meaning of child health, as reflected in the Institute of Medicine’s new developmentally focused definition, is evidence of the complementary nature of technical knowledge and collaborative strategies.

In this new era of child health, pediatricians and pediatric care needs to continue to focus on care at the level of the individual child but also needs to incorporate a population and community health perspective. Solutions to ongoing child health issues will be found within the context of the pediatrician’s medical practice and also within the larger environmental context that now also includes the physician. In this context, the pediatrician can serve as the interpreter and synthesizer of clinical, public health, and social factors, moving beyond the confines of individual focused-care models to one that also captures and incorporates a population and community health perspective. The 21st-century pediatricians skilled in these arenas can and should play a significant role in impacting the health of children in their century.