The following is declared in the World Health Organization Workforce 2030 report:
Mere availability of health workers is not sufficient: only when they are equitably distributed and accessible by the population, when they possess the required competency, and are motivated and empowered to deliver quality care that is appropriate and acceptable to the sociocultural expectations of the population, and when they are adequately supported by the health system, can theoretical coverage translate into effective service coverage.1
In their article titled “Characteristics and Workload of Pediatricians in China,” Zhang et al2 begin to measure many of those necessary facets for a functioning pediatric workforce and raise some interesting questions.
What Are the Qualifications of a Pediatrician?
In China, some individuals with only 3 years of postsecondary education are referred to as pediatricians, which is significantly less training than the norm in most other countries. This does not mean those individuals do not have an important contribution to make; indeed, task shifting, particularly of health care provision for predictable and simple disorders, is an important means of allowing providers to work at the “top of their license” and expanding access to care. An example is the Freedom of Breath, Foundation of Life: China Neonatal Resuscitation Program,3 in which China, along with numerous multisectoral public and private partners, scaled up neonatal resuscitation training, including for midwives and nurses. The question is whether health worker training is well aligned with the roles in which they are asked to serve in the health system, and whether patients and families can therefore trust the quality of care provided.
What Is a Reasonable Workload for Pediatricians?
Many pediatricians across the globe feel pushed to work harder with less time per patient. As we learn more about the provision of high-quality care, the importance of patient experience and trust, and the myriad causes of physician burnout, we are balancing those imperatives against the rising cost of health care and too few providers in certain geographic areas. However, the Chinese tertiary pediatrician average of 80 to 100 patient visits per day would challenge any clinician. The World Health Organization 2030 report declared that health workforce needs should be quantified by workload rather than by population or facility norms.1 Countries in which pediatricians care for adolescents or provide a significant amount of primary care likely require a higher pediatrician density for effective coverage. Zhang et al2 found a median of 0.4 pediatricians per 1000 children up to age 14 in China but up to 1 per 1000 on the east coast. Authors of a recent global pediatric workforce study found a median of 0.72 pediatricians per 1000 children up to age 18 in high-income countries and 0.30 in upper-middle–income countries, with the highest regional pediatrician density in Europe at a median of 0.87 per 1000 children.4
Because medicine is increasingly a team effort, pediatricians’ workload depends in part on the supporting structure as well as who is on their team and how well that team functions. The growing number of advanced-practice clinicians in the United States and elsewhere is a signal that the team is evolving, and pediatricians’ roles may thus need to evolve as well.5 China averages ∼1 nurse per doctor, which is significantly lower than the ratio of 3 to 4 nurses per doctor in most other countries.6 Developing roles of nursing and other staff may help reduce workload and stem the tide in China of pediatricians leaving the workforce.
How Do We Motivate and Empower Pediatricians To Deliver Quality Care?
Zhang et al2 refer to some efforts to increase numbers of pediatricians. Initiatives that treat pediatrics differently from other subspecialties, particularly those that may result in the profession being held in less esteem, are likely to further decrease the morale within the profession and deter aspiring pediatricians. Although harder to achieve, a more durable solution is to improve structures of pediatric care: ensuring appropriate compensation to make the field of pediatrics desirable for aspiring physicians, clarifying the role of pediatricians and other supporting providers, and aligning training initiatives with those roles. China is already embarking on a tremendous initiative to standardize residency training and increase the quality of graduate medical education.6 Building a functional primary care system that families can trust to provide quality pediatric care would alleviate some burden, particularly on tertiary care centers, but doing so will require substantial investment to improve the quality of care provided.7 Drawing patients toward primary care by designing it with satisfactory patient experience in mind would provide a pull in addition to the push of introducing gatekeeping and costs for seeing specialists.
Ultimately, China’s pediatric dilemma is a sign of success because its rising middle class expects more of the health care system for its children. A well-trained and supported team-based pediatric workforce will alleviate professional dissatisfaction and satisfy the public’s expectations.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2018-3532.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: Dr Russ received grant funding from an independent foundation, the China Medical Board, for development and implementation of faculty development workshops in China in April 2018; and Dr Alden has indicated he has no financial relationships relevant to this article to disclose.