The Pediatrician’s Role in Community Pediatrics

INTRODUCTION

Today’s children and families live in a period of rapid social change. The economic organization of the health care and other human service systems in the United States is undergoing profound changes. Pediatric training programs are searching for the optimal blend of knowledge, skill, attitudes, and experience to prepare tomorrow’s pediatricians for the new challenges and morbidities that they will face.^1–3 As clinicians and educators encounter new demands on their expertise and resources, it is important to reaffirm the vital and long-standing role of pediatricians in promoting the physical, mental, and social health and well-being of all children in the communities they serve.

DEFINITION OF COMMUNITY PEDIATRICS

The American Academy of Pediatrics (AAP) offers a definition of community pediatrics to remind all pediatricians, generalists and specialists alike, of the profound importance of the community dimension in pediatric practice. Community pediatrics is all of the following:

• A perspective that enlarges the pediatrician’s focus from one child to all children in the community;

• A recognition that family, educational, social, cultural, spiritual, economic, environmental, and political forces act favorably or unfavorably, but always significantly, on the health and functioning of children;

• A synthesis of clinical practice and public health principles directed toward providing health care to a given child and promoting the health of all children within the context of the family, school, and community⁴;

• A commitment to use a community’s resources in collaboration with other professionals, agencies, and parents to achieve optimal accessibility, appropriateness, and quality of services⁵ for all children and to advocate especially for those who lack access to care because of social, cultural, geographic, or economic conditions or special health care needs^6,7; and

• An integral part of the professional role and duty of the pediatrician.

For many pediatricians, efforts to promote the health of children have been directed at attending to the needs of particular children in a practice setting, on an individual basis, and providing them with a medical home.⁸ This approach, in combination with pediatricians’ own personal community interests and commitments, has proven to be very successful. Increasingly, however, the major threats to the health of America’s children, the new morbidities,⁹ arise from problems that cannot be addressed adequately by the practice model alone.¹⁰ These problems include high infant mortality rates, children with chronic health care needs, obesity, disproportionately high levels of intentional and unintentional injuries, exposure to lead and other environmental hazards, substance abuse, behavioral and developmental consequences of inappropriate care and experience, mental health conditions, poor school readiness,¹¹family dysfunction, sexually transmitted diseases, unwanted pregnancies, and lack of access to medical homes.¹² An integral component of a community-pediatrics approach incorporates interdisciplinary practice. As former AAP president Robert Haggerty, MD, FAAP, reminded us in 1995, “we must become partners with others, or we will become increasingly irrelevant to the health of children.”¹³

Communities should impart a sense of health, safety, and well-being and promote a supportive environment for families of all types. Just as children depend on the interaction of families in which they live, the communities that support them affect families. The health and welfare of children depend on the ability of families and the community support system to foster positive emotional and physical development.¹⁴ Recently the AAP’s Task Force on the Family examined the concept of family pediatrics and the discipline that must be practiced within the context¹⁵ of the community.^16,17

Pediatricians remain instrumental in efforts to create, organize, and implement changes in communities’ efforts that can substantially improve the health of children. As far back as Abraham Jacobi, MD (1830–1919), a leading child advocate of his time and a founder of the discipline of pediatrics, pediatricians recognized that children are best understood, and their needs attended to, within interlinking contexts of biology, family, and community.¹⁸ More recently, Haggerty identified the unique contribution and focus of community pediatrics: Community pediatrics [has sought] to provide a far more realistic and complete clinical picture by taking responsibility for all children in a community, providing preventive and curative services, and understanding the determinants and consequences of child health and illness, as well as the effectiveness of services provided. Thus, the unique feature of community pediatrics is its concern for all of the population—those who remain well but need preventive services, those who have symptoms but do not receive effective care, and those who do seek medical care either in a physician’s office or in a hospital.¹⁹

With the sweeping changes occurring in medicine and other human services, it is especially important now for pediatricians to reexamine and reaffirm their role as professionals in the community, as community pediatricians, and prepare themselves for it just as diligently as they prepare for traditional clinical roles.

RECOMMENDATIONS

1. Pediatricians should use community data (epidemiologic, demographic, and economic) to increase their understanding of the health and social risks on child outcomes and of the opportunities for successful collaboration with other child advocates.

2. Pediatricians should work collaboratively with public health departments and colleagues in related professions to identify and decrease barriers to the health and well-being of children in the communities they serve.^20,21

3. Pediatricians should become comfortable with an interdisciplinary collaborative approach and advocacy effort to child health. Pediatricians can play an important role in coordinating and focusing new and existing services to realize maximum benefit for all children.^22,23

4. Pediatricians and other members of the community should interact and advocate to improve all settings and organizations in which children spend time (eg, child care facilities, schools, youth programs). School and community resources should be considered as assets in developing strategies for the problems that children will face now and throughout their lives.

5. Pediatricians should nurture and advocate for neighborhood structures that support healthy families capable of promoting optimal health, safety, and development in their children.

6. Pediatricians should advocate improving the effectiveness and efficiency of health care for all children, striving to ensure that every child in the community has a medical home.

7. Pediatricians should educate themselves concerning the availability of community resources that affect the health and well-being of the children they serve.

8. Pediatricians are encouraged to become involved in the education of residents and medical students in community settings. Pediatricians have the unique opportunity to model roles outside the traditional clinical roles that students and residents encounter. Pediatric academicians should use resources from the AAP and the Ambulatory Pediatric Association to engage the community pediatrician as an educator, both in the care of individual patients in community-based practice and in roles related to promotion of the well-being of all children in the community. Community-based resources outside the bounds of the traditional hospital and outpatient office setting should be used to instruct residents in the effect of the community on child health status and the positive effect of interdependent collaboration of community agencies with health professionals on child health.²⁴

9. Medical student, resident, and continuing medical education programs should consider and periodically review basic community pediatric competencies to be included in training and maintenance of certification efforts for pediatricians.²⁵

10. AAP chapters and their members should provide leadership for furthering the understanding of community pediatrics and encourage participation in creative, community-based, integrated models such as those supported through the Community Access to Child Health program and the Healthy Tomorrows Partnership for Children.

11. AAP chapters should provide leadership, support, and recognition for pediatricians involved in advocacy efforts at the local, state, and national levels to ensure that children have access to care and to foster integration of these activities as an integral part of the professional role and duty of the pediatrician.

Caring, compassionate, and knowledgeable pediatricians should address the needs of their patients and all children in the context of the community.

Committee on Community Health Services, 2003–2004

Helen M. DuPlessis, MD, MPH, Chairperson

Suzanne C. Boulter, MD

Denice Cora-Bramble, MD

Charles R. Feild, MD, MPH

Gilbert A. Handal, MD

Murray L. Katcher, MD, PhD

Ronald V. Marino, DO, MPH

*Francis E. Rushton, Jr, MD

Wyndolyn C. Bell, MD

David L. Wood, MD, MPH

Stanley I. Fisch, MD

Past Committee Member

Liaisons

Jose Belardo, MSW, MS

Maternal and Child Health Bureau

Lance E. Rodewald, MD

Ambulatory Pediatric Association

Consultant

Denia A. Varrasso, MD

Staff

Aiysha Johnson, MA