Who Takes Care of the Children? Questions About the Pediatric Workforce

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.

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.

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.