US children continue to live in communities where failing schools are common, food desserts exacerbate obesity, and violence is endemic, giving rise to the expression that when it comes to health, your zip code dominates your genetic code. The health outcomes of US children and youth are troubling: our infant mortality rate ranks 56th among world countries,1 homicide is the leading cause of death for African American youth,2 and, despite a recent decline, our teen birth rate remains the highest in the developed world.3 Today nearly half of US children live in low-income families and 22% live under the poverty line.4 Although 4 of 5 physicians acknowledge a need to write prescriptions for their patient’s unmet social needs, they simultaneously lament their ability to do so.5 Addressing these “Millennial Morbidities” in training and in practice remains the context of community pediatrics.6
The field of pediatrics is leading in addressing the mismatch between what physicians need to do and currently do. Required training in community health and advocacy7 to address the root cause of health disparities began in 1999. Reshaping pediatrics to extend beyond the bedside and clinic to incorporate community engagement was prescient, and it was Dr Anne E. Dyson’s vision and philanthropy that enabled the evolution. The Anne E. Dyson Community-Based Pediatric Training Initiative invested in 10 pediatric training programs nationwide to develop innovative training models of community engagement.8,9 Astutely a simultaneous evaluation arm was established to rigorously measure the investment’s impact.
Today we learn the answer to the question that the field of community pediatrics has waited 15 years to learn: Does training in community pediatrics change the way a pediatrician practices? The answer is yes. In this issue of Pediatrics, Minkovitz et al reveal elevated rates of self-reported participation in community pediatrics by Dyson site graduates compared with age-matched controls (43.6% vs 31.1%, P < .01) in “Five Years Later: Community Pediatrics Training Initiative Graduates and Community Involvement.” This is particularly important when considered in the context of an ongoing decline in pediatricians’ involvement in community engagement between 2004 and 2010.10
The Dyson initiative’s sustained and significant investment in community pediatric training has “immunized” graduates against the backdrop of waning community involvement nationally, despite the Residency Review Committee requirement for such training in 1999. This brings to mind the adage of “you get what you pay for” on 2 levels.
First, the Dyson Initiative was a significant investment, the likes of which will likely not be replicated. Each Dyson site received $400 000 to $500 000 per year for 5 years, allowing for intensive faculty development, significant technical assistance, and creation of sustained partnerships between academic pediatric programs and community-based organizations. But the initiative’s impact was greater than the programs it funded: it produced a wide range of training models,11–14 developed leaders in the field, and now has provided definitive evidence of the training’s effect. Models working to bring community pediatrics training to scale exist. For example, The California Collaborative has worked with 13 pediatric institutions and residency programs across California over 3 years15 and the American Academy of Pediatric’s Community Pediatrics Training Initiative, successor to the Dyson Initiative, has provided smaller amounts of funding and technical assistance to more than 60 additional pediatric residency programs nationwide in the past 7 years.16 Despite these efforts, the evidence of an overall decline in community engagement indicates more needs to be done. We now know that investing in community pediatrics training can change how pediatricians practice, but the question remains: who is willing to make the sustained investment required to ensure the pediatrician of the 21st century is working to address growing child health inequality and our most concerning child health outcomes?
The answer lies in health reform and brings us to the second exemplar of “you get what you pay for”: when the child health care system begins to reimburse practicing pediatricians for community engaged work, the declining trends of community engagement will likely reverse. The current backdrop of decreasing community engagement between 2004 and 2010 occurred despite continuing high levels of pediatricians reporting child health as their responsibility, instead being ascribed to younger pediatricians having competing priorities (young families and high levels of educational debt) making it difficult to “volunteer.” Here exists great promise. The Affordable Care Act incorporates new payment models, including Accountable Care Organizations, where the responsibility shifts from the individual patient level to the health of a defined community. This new paradigm aligns well with community pediatrics. This shift requires bridges be built between academic medical centers, community organizations, and departments of public health: the very nexus where community pediatric expertise exists.17 In a new system in which effective prevention creates savings, the funds captured could and should support the work of pediatricians engaged in evidence-based community partnerships. It will be important to track pediatricians’ community engagement in areas where these models are already in place.18 This shift will require the leadership of pediatrics, particularly at the level of the states, to go this last mile.
Our time is now. The emerging model of health care delivery, with its focus at the population level, can support community pediatrics and offer the remarkable opportunity to bring to scale the role of pediatricians in practicing to address the social determinants of health and our most concerning child health outcomes. With the significant contribution of Minkovitz et al, we have evidence that training in community pediatrics changes the practice of pediatricians. Thus, now is the time to reimburse pediatricians who do this work. Realization of this transition, moving community pediatrics from a professional aspiration to a defined obligation,19 will honor the legacy of Anne Dyson in perpetuity.
- Accepted April 21, 2014.
- Address correspondence to Lisa J. Chamberlain, MP, MPH, Department of Pediatrics, Stanford University School of Medicine, 770 Welch Road, #100, Palo Alto, CA 94304. E-mail:
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found on page 83, and online at www.pediatrics.org/cgi/doi/10.1542/peds.2013-3357.
Central Intelligence Agency. The World Factbook. Country comparison: infant mortality rate. Available at: https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html. Accessed April 10, 2014
The Centers for Disease Control and Prevention. Issues, evidence and public health implications of protective factors for youth violence perpetration. Available at: www.cdc.gov/violenceprevention/pub/YV_ProtectiveFactors.html. Accessed April 10, 2014
The Centers for Disease Control and Prevention. Prepregnancy contraceptive use among teens with unintended pregnancies resulting in live births — Pregnancy Risk Assessment Monitoring System (PRAMS), 2004–2008. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/mm6102a1.htm?s_cid=mm6102a1_w. Accessed April 10, 2014
National Center for Children in Poverty. Child poverty. Available at: www.nccp.org/topics/childpoverty.html. Accessed April 10, 2014
Robert Wood Johnson Foundation. Health care's blind side: unmet social needs leading to worse health. Available at: www.rwjf.org/files/research/RWJFPhysiciansSurveyExecutiveSummary.pdf. 2011. Accessed May 13, 2014
- 6. ↵
Residency Review Committee for Pediatrics. ACGME Program Requirements for Graduate Medical Education in Pediatrics. Available at: www.acgme.org/acgmeweb/tabid/143/ProgramandInstitutionalAccreditation/MedicalSpecialties/Pediatrics.aspx. Accessed May 13, 2014
- Nader PR ,
- Kaczorowski J ,
- Benioff S ,
- Tonniges T ,
- Schwarz D ,
- Palfrey J
- 9. ↵
- Minkovitz CS ,
- Grason H ,
- Solomon BS ,
- Kuo AA ,
- O’Connor KG
- 11. ↵
- Willis E ,
- Frazier T ,
- Samuels RC ,
- Bragg D ,
- Marcdante K
- 14. ↵
- Chamberlain LJ ,
- Wu S ,
- Lewis G ,
- et al
Community Pediatrics Training Initiative. Current grantees. Available at: http://www2.aap.org/commpeds/cpti/grantees.htm. Accessed April 10, 2014
- 17. ↵
The Centers for Medicare and Medicaid Innovation (CMMI) Health Care Innovation Award. Available at: www.partnersforkids.org/hcia/. Accessed May 13, 2014
- 19. ↵
- Copyright © 2014 by the American Academy of Pediatrics