From 2019 to 2022, the For Our Children project gathered a team of Chinese and American pediatricians to explore the readiness of the pediatric workforce in each country to address pressing child health concerns. The teams compared existing data on child health outcomes, the pediatric workforce, and education and combined qualitative and quantitative comparisons centered on themes of effective health care delivery outlined in the World Health Organization Workforce 2030 Report. This article describes key findings about pediatric workload, career satisfaction, and systems to assure competency. We discuss pediatrician accessibility, including geographic distribution, practice locations, trends in pediatric hospitalizations, and payment mechanisms. Pediatric roles differed in the context of each country’s child health systems and varied teams. We identified strengths we could learn from one another, such as the US Medical Home Model with continuity of care and robust numbers of skilled clinicians working alongside pediatricians, as well as China’s Maternal Child Health system with broad community accessibility and health workers who provide preventive care.
In both countries, notable inequities in child health outcomes, evolving epidemiology, and increasing complexity of care require new approaches to the pediatric workforce and education. Although child health systems in the United States and China have significant differences, in both countries, a way forward is to develop a more inclusive and broad view of the child health team to provide truly integrated care that reaches every child. Training competencies must evolve with changing epidemiology as well as changing health system structures and pediatrician roles.
The World Health Organization Workforce 2030 Report declared that “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 2019, recognizing unmet child health needs and rapidly changing environments in which children live, the China Medical Board launched For Our Children (FOC) as a dialog between American and Chinese pediatricians to explore the readiness of the pediatric workforce in each country to address pressing child health concerns. The FOC dialog coincides with other discussions in the United States and China about the pediatric workforce and education.2–5
From 2000 to 2022, the under-5 mortality rate reduced by 25% in the United States from 8/1000 to 6/1000, and reduced by 80% in China from 39/1000 to 7/1000.6 However, in both countries, there remain significant health disparities based on geography, social and economic factors, and racial and ethnic characteristics.7–14 In both countries, perinatal conditions and congenital anomalies contribute largely to under-5 mortality, with higher mortality from infectious diseases in China.12,15–17 For older children, injuries are prominent: automobile crashes in both countries, gun violence in the United States, and drowning in China.18–23 Mental health is a major concern in both countries, with suicide among the top 3 causes of death for adolescents and young adults.18 Mortality rates for youth aged 15 to 19 and 20 to 24 are higher in the United States (3.5/1000 and 7/1000) than in China (2/1000 and 3/1000) primarily because of interpersonal violence and drug use disorder.18 Both countries are witnessing an increase in chronic morbid conditions, such as obesity and asthma.24–29 Many children with disabling conditions now live longer and more productive lives but may need intense and complex care.14,30,31
Based on the review of child health outcomes, the FOC dialog focused on the education and roles of pediatricians in each country’s health care system. We organized our analysis using the World Health Organization’s description of an effective health workforce.
Pediatrician characteristics: numbers, workload, satisfaction, and competency
Pediatrician accessibility: distribution, practice locations, and payment mechanisms
Pediatrician roles in child health systems
We explored country-specific and overlapping factors that promote or hamper the efficacy of the child health workforce in providing equitable and effective child health care.
Methods
Our inquiry was undertaken from a constructivist theoretical perspective, seeking to gain insights through dialog and exploring the issues from different viewpoints. Working groups composed of team members from both countries probed national and international data sources to obtain information on different aspects of child health outcomes, workforce, and education. We held 1 in-person meeting and multiple virtual meetings to discuss the findings. For some topics, direct numerical comparisons were straightforward, but other topics necessitated moving past direct comparison and exploring the context and meaning of the data. We ultimately combined qualitative and quantitative comparisons with thematic analysis of the different aspects of health workforce efficacy.
Workforce
We used the American Board of Pediatrics (ABP) data on currently certified pediatricians aged ≤70 years.32 Additional literature review provided workforce characteristics and workload information.33–38 We used the Chinese Health Commission data supplemented with detailed workforce information from a recent national survey.33,39 Because data in China combine information about pediatricians and assistant pediatricians, we combined these 2 groups in our analyses, despite differences in the roles and training.33 In both countries, we included generalist and subspecialty pediatricians.
Child Cohorts
The age of transition to adult care differs in the United States and China. American pediatricians often care for patients >18 years of age; in China, pediatricians’ licenses restrict care to children <18 years of age. Chinese internists may care for children >12 years of age. Given differences in “child” definitions in national data sets, we used national census data for both countries: 0 to 17 years for the United States and 0 to 14 years for China.40,41
Roles
To assess organizational structures, financing, and utilization, we did extensive literature reviews and gathered in-depth information from pediatric leaders in the 2 countries. We identified the roles and training of child health clinicians by searching professional organization databases, existing literature, and policy documents.
Results
Pediatrician Characteristics
The United States has almost twice the number of pediatricians per child as China, accounting for different ages of transition to adult care (Table 1). As of March 2020, there were 77 792 currently certified pediatricians in the United States (aged 70 or younger). This represents 1.06 pediatricians per 1000 children aged 17 and younger.32 Of these, 75% were certified solely in general pediatrics. From 2008 to 2018, 38% of pediatric residency graduates were certified as subspecialists.
Pediatrician Workforce Comparison: United States and China
. | United States . | China . |
---|---|---|
Characteristics | ||
Quantity | 77 792 pediatricians32 | 158 543 pediatricians39 |
1.06 pediatricians/1000 children aged 17 and younger | 0.63 pediatricians/1000 children aged 14 and younger | |
Sex | 62.5% women32 | Estimate ∼70% women34 |
Workload | Generally low: | Generally high: |
AAP national survey:36 | National survey in tertiary hospitals:33 | |
Average 42.7 h/wk | Average >50 h/wk | |
Mean of 69.5 patients/wk | 80–100 patients/d | |
More team members: | Fewer team members: | |
US nurse:physician ratio 3:146 | China nurse:physician ratio 1:146 | |
APCs: 18 000 pediatric nurse practitioners and 4700 certified physician’s assistants working in pediatrics in 201949,50 | No APCs | |
Satisfaction | Generally high | Generally low |
Cohort study of early-career pediatricians:45 97% to 98% continue practice | National survey study (2015–2016) of hospitals about pediatricians:46 12.6% left practice in the previous 3 y | |
Systems for Competency | State licensure: not specialty specific | Province licensure: pediatrics specific |
ACGME standardized pediatric training: shifting to competency based | National Health Commission standardized pediatric training in 2014: not yet competency based | |
ABP certification | Emphasis on academic degrees, eg, PhDs | |
CME: for relicensure and ABP recertification | National pediatric residency graduation certification examination being established | |
CME for relicensure | ||
Accessibility | ||
Distribution | Pediatrician density more varied by state32 | Pediatrician density varied by province but less than in the United States33 |
Lower in rural settings | Lower in rural settings | |
Practice Locations | Private or group practice:37,38 | 99% work in public hospitals:39 |
55% of general pediatricians | 16% in MCH system of hospitals | |
23% of subspecialty pediatricians | 12.6% in public children’s hospitals | |
Community Hospitals: | Rest in general primary, secondary, or tertiary hospitals | |
16% of general pediatricians | ||
17% of subspecialty pediatricians | ||
University hospitals/medical schools: | ||
11% of general pediatricians | ||
44% of subspecialty pediatricians | ||
Payment | 95% of children with health insurance69 | Universal free preventive care:77 near universal government health insurance coverage but limited with emphasis on inpatient care |
36% government insurance (CHIP, Medicaid)69 | Disparities in coverage by province | |
Disparities in coverage by state74 | High out-of-pocket medical expenditures (29%)77 | |
Low out-of-pocket medical expenditures (9%)78 |
. | United States . | China . |
---|---|---|
Characteristics | ||
Quantity | 77 792 pediatricians32 | 158 543 pediatricians39 |
1.06 pediatricians/1000 children aged 17 and younger | 0.63 pediatricians/1000 children aged 14 and younger | |
Sex | 62.5% women32 | Estimate ∼70% women34 |
Workload | Generally low: | Generally high: |
AAP national survey:36 | National survey in tertiary hospitals:33 | |
Average 42.7 h/wk | Average >50 h/wk | |
Mean of 69.5 patients/wk | 80–100 patients/d | |
More team members: | Fewer team members: | |
US nurse:physician ratio 3:146 | China nurse:physician ratio 1:146 | |
APCs: 18 000 pediatric nurse practitioners and 4700 certified physician’s assistants working in pediatrics in 201949,50 | No APCs | |
Satisfaction | Generally high | Generally low |
Cohort study of early-career pediatricians:45 97% to 98% continue practice | National survey study (2015–2016) of hospitals about pediatricians:46 12.6% left practice in the previous 3 y | |
Systems for Competency | State licensure: not specialty specific | Province licensure: pediatrics specific |
ACGME standardized pediatric training: shifting to competency based | National Health Commission standardized pediatric training in 2014: not yet competency based | |
ABP certification | Emphasis on academic degrees, eg, PhDs | |
CME: for relicensure and ABP recertification | National pediatric residency graduation certification examination being established | |
CME for relicensure | ||
Accessibility | ||
Distribution | Pediatrician density more varied by state32 | Pediatrician density varied by province but less than in the United States33 |
Lower in rural settings | Lower in rural settings | |
Practice Locations | Private or group practice:37,38 | 99% work in public hospitals:39 |
55% of general pediatricians | 16% in MCH system of hospitals | |
23% of subspecialty pediatricians | 12.6% in public children’s hospitals | |
Community Hospitals: | Rest in general primary, secondary, or tertiary hospitals | |
16% of general pediatricians | ||
17% of subspecialty pediatricians | ||
University hospitals/medical schools: | ||
11% of general pediatricians | ||
44% of subspecialty pediatricians | ||
Payment | 95% of children with health insurance69 | Universal free preventive care:77 near universal government health insurance coverage but limited with emphasis on inpatient care |
36% government insurance (CHIP, Medicaid)69 | Disparities in coverage by province | |
Disparities in coverage by state74 | High out-of-pocket medical expenditures (29%)77 | |
Low out-of-pocket medical expenditures (9%)78 |
ACGME, Accreditation Council for Graduate Medical Education; CME, Continuing Medical Education; CHIP, Children’s Health Insurance Program.
In China, in 2019, there were 158 543 pediatricians, representing 0.63 pediatricians per 1000 children aged 14 and younger.39 Of these, 10.6% were assistant pediatricians, who have limited training and primarily provide care in rural primary care settings.33 They often see patients independently and can prescribe a limited number of medications. China has no available national statistics on subspecialization.
In the United States, 62.5% of pediatricians and >70% of pediatric residents in the past decade have been women.32 In China, there are no national data on pediatrician sex, but survey data indicate ∼70% of pediatricians are women.34 In the United States, minority-background pediatricians are seriously underrepresented. Despite approximately one-half of American children belonging to minority racial or ethnic groups, there was only a modest increase in African American, Hispanic, and Native American pediatricians from 9% to 14% between 2003 and 2019.35,36,42 Ethnicity data are not available for the Chinese pediatric workforce.
Career Satisfaction and Workload:
A longitudinal cohort study of early-career American pediatricians documents that 97% to 98% of respondents continued working in pediatrics over the past decade. They reported high satisfaction with overall career (83%) and life (71%), although 30% reported experiencing burnout.43–45 Respondents to the AAP Periodic survey in 2021 averaged 42.7 hours per week (primary care: 40.9 hours, subspecialists: 48.7 hours) and, in 2019, cared for a mean of 69.5 patients per week (primary care: 81.1, subspecialists: 49.6), down from 74 in 2012.36
In China, Zhang documented that 12.6% of pediatricians had left practice in the past 3 years.33 Other surveys corroborate this finding and suggest that turnover is highest among younger pediatricians with low salaries and high workloads.5,34 Zhang found workload to be highest in tertiary children’s hospitals. Although this represents only a subset of pediatricians, they are each typically responsible for 80 to 100 visits per day, averaging >50 work hours per week.33
In the United States, 25% of general pediatricians and 10% of subspecialty pediatricians worked part-time as of 2013.35,37,38 There is a growing trend toward part-time work for both sexes and across age groups.35 Although doctors are allowed to conduct multisite practices, part-time clinical work is exceedingly rare in China.
The US nurse-to-physician ratio is 3:1 compared with 1:1 in China. The United States has >5 times the number of nurses per capita as China.46–48 The United States also has a significant number of advanced practice clinicians (APCs). As of 2019, 18 000 pediatric nurse practitioners and 4700 certified physician assistants worked in pediatrics.49,50
Pediatrician Competence
In the United States, pediatric organizations, including the ABP, the Association of Pediatric Program Directors, and the American Academy of Pediatrics (AAP) are dedicated to ensuring the competence of pediatricians. Passage of licensure or certification examinations is now augmented by Entrustable Professional Activities, continuing education, and documented practice improvement efforts.51–53 Such efforts are aimed to align training with evolving child health needs, exemplified by the Entrustable Professional Activities on racism and health inequities.54 However, American pediatrics lags in equipping trainees with tools to address the mental health and substance use disorder crises.55–57 Existing training requirements and financial barriers slow the evolution of training.58 In addition, some pediatric subspecialties continue to face shortages (notably developmental and behavioral pediatrics and adolescent and child psychiatry).2,59
Chinese teaching hospitals have established pediatric residency programs for many years, but national standards for pediatric training were just developed in 2014.47 China has not yet adopted competency-based training, due to a lack of agreement on evaluation. Medical education is organized through the Ministry of Education, which complicates coordination with teaching hospitals overseen by the National Health Commission. Better linkage could focus educational programs on clinical needs. Similar to other specialties, China’s pediatric training emphasizes attaining higher academic degrees. Some (especially tertiary) hospitals require PhDs for clinical work. Because the evaluation of clinical skill is not yet well established, physician promotions often largely focus on academic publications. The recent development of training standards opens new opportunities to better align training and incentives for pediatricians with China’s child health needs.
Pediatrician Accessibility
In both countries, the density of pediatricians per 1000 children is higher in areas with higher population density (children per square mile), but distribution is more uneven in the United States than in China. (Fig 1) China’s pediatrician density is 3 times higher in the Eastern coastal provinces than in Western inland provinces and twice the density in urban versus rural areas.33 In the United States, states with large coastal urban areas have the highest density of pediatricians. Massachusetts’s highest density (2.07 pediatricians/1000 children) is almost 4 times higher than Wyoming’s (0.54 pediatricians/1000 children).32
Pediatrician density per 1000 children versus child population density by state/province.
* USA data sources: Pediatricians include US diplomats, including subspecialists currently certified in general pediatrics, aged ≤70 years. American Board of Pediatrics Workbook 2019–20. Children included ages 0 to 17 years. State land area data from US Census Bureau, 2010: https://www.census.gov/geographies/reference-files/2010/geo/state-area.html.
** China data sources: Pediatricians include licensed pediatricians and assistant pediatricians per national study.33 Number of licensed Provincial land area and child populations from provincial government websites. Children included ages 0 to 17 years for Liaoning province and Shanghai, 0 to 15 years for Jilin, Zhejiang, Jiangxi, Hunan, Shanxi, and Ningxia, and 0 to 14 years for the rest of the provinces.
Pediatrician density per 1000 children versus child population density by state/province.
* USA data sources: Pediatricians include US diplomats, including subspecialists currently certified in general pediatrics, aged ≤70 years. American Board of Pediatrics Workbook 2019–20. Children included ages 0 to 17 years. State land area data from US Census Bureau, 2010: https://www.census.gov/geographies/reference-files/2010/geo/state-area.html.
** China data sources: Pediatricians include licensed pediatricians and assistant pediatricians per national study.33 Number of licensed Provincial land area and child populations from provincial government websites. Children included ages 0 to 17 years for Liaoning province and Shanghai, 0 to 15 years for Jilin, Zhejiang, Jiangxi, Hunan, Shanxi, and Ningxia, and 0 to 14 years for the rest of the provinces.
Employment Arrangements and Practice Patterns
In the United States, 55% of general pediatricians work in independent or private practice, including group practices and health maintenance organizations, with fewer in community hospitals (16%) or university hospitals/medical schools (11%).37 Conversely, 44% of subspecialty pediatricians work in university hospitals or medical schools, 17% in community hospitals, and 23% in independent or private practice.38 Most acute care visits occur in outpatient settings, and general pediatricians predominantly provide outpatient care.37
In China, 99% of pediatricians are employed by government-run hospitals and provide both inpatient and ambulatory specialty and acute care.33,39 China’s system consists of parallel hospital tiers designated as primary, secondary, and tertiary.60 Tertiary hospitals are concentrated in urban areas (85%) and eastern China (44%), whereas primary hospitals predominate in rural areas (77%) and western China (40%).33 There is no formal referral system between hospitals. This coordination and access limitation leads to families seeking care in higher-tier hospitals even for simple problems.61 Preventive care largely occurs in a separate Maternal Child Health (MCH) system of health centers and hospitals.60
Hospitalizations in Pediatrics
In the United States, in 2016, there were 2.6 million hospital admissions (excluding births) for children aged 0 to 17 (3.6 hospitalizations per 100 child years), a 21% decrease from 2010.62,63 Children’s hospitals provide an increasing proportion of pediatric hospitals beds, up to 27% in 2018.64,65 (Table 2) The proportion of children referred to larger centers after presenting to hospitals has been increasing.66,67 This regionalization is likely reducing access to care in rural areas.68
Pediatric Inpatient Beds, United States and China
. | United States . | China . |
---|---|---|
Child population (aged 0–17 in the US, 0–14 in China) | 73 106 000 (2020)a | 253 383 938 (2020)b |
Beds for pediatric patients | 131 685 beds (2016)c or1.80 beds/1000 children | 559 696 beds (2019)39 or 2.21 beds/1000 children |
Number of freestanding children’s hospitals | 64 (2019) up from 50 in 201264 | 141 in 2019 up from 72 in 201039 |
Proportion of total inpatient pediatric beds in children’s hospitals | 27.4% in 2018 up from 21.5% in 200864 | 7.8% in 2019 up from 7.5% in 201039 |
. | United States . | China . |
---|---|---|
Child population (aged 0–17 in the US, 0–14 in China) | 73 106 000 (2020)a | 253 383 938 (2020)b |
Beds for pediatric patients | 131 685 beds (2016)c or1.80 beds/1000 children | 559 696 beds (2019)39 or 2.21 beds/1000 children |
Number of freestanding children’s hospitals | 64 (2019) up from 50 in 201264 | 141 in 2019 up from 72 in 201039 |
Proportion of total inpatient pediatric beds in children’s hospitals | 27.4% in 2018 up from 21.5% in 200864 | 7.8% in 2019 up from 7.5% in 201039 |
2020 US National Census data, 0–17 population.
2020 China National Census data, 0–14 population.
Chien AT, Pandey A, Lu S, et al. Pediatric hospital services within a one-hour drive: a national study. Pediatrics. 2020;146(5).
In China, between 2010 and 2018, pediatric hospitalizations increased significantly, with 63% more annual hospital discharges (to 24 million).39 The estimated hospitalization rate of 9.5 per 100 child years is substantially higher than in the United States, although methodologic differences impair direct comparison. The number of Chinese children’s hospitals has almost doubled in the past decade. (Table 2) Although they provide <8% of all pediatric beds, they care for a growing proportion of pediatric visits, and employ 12.6% of pediatricians, as of 2019.39
Payment Mechanisms for Pediatric Care
In the United States, 95% of children had health insurance, as of 2021, with 35.9% of children covered by the Children’s Health Insurance Program or Medicaid.69 However, a substantial proportion of American pediatricians (up to 15% in 2017) do not accept Medicaid patients, likely because of low reimbursement.70–73 There are significant disparities and variations in child health insurance coverage between different states.74–76
In China, near-universal health insurance coverage has been achieved with 2 major public insurance programs, New Rural Cooperative Medical System and Urban Residents Basic Medical Insurance System.60 Coverage is limited with emphasis on inpatient care. Free preventive care is provided by local health clinics through the National Essential Public Health Program. Although the majority of hospitals are public, most of their operational revenue is derived from a fee-for-service model with limited government funding. Although physicians all take public insurance programs in China, access is still limited by caps on coverage that vary by province.
Out-of-pocket medical expenditures are significantly higher in China (29%) than in the United States (9%).77,78 Financial pressures likely impact family care seeking in China, as evidenced in a multicenter study revealing high rates (13%) of very preterm infants discharged against medical advice.79 There is no similar experience of discharge against medical advice in the United States.
Pediatrician Roles and Child Health Systems
We examined American and Chinese pediatricians’ roles on the basis of a framework of systems for preventive, acute, and chronic care proposed by the National Academy of Medicine (Table 3), with attention to the contexts and teams in which they work.80
Pediatrician Roles in Child Health Care Teams in United States and China
Care . | Country . | System . | Clinical Team Members . | Location . |
---|---|---|---|---|
Preventive | United States | Screening, anticipatory guidance and immunizations are provided by primary care provider integrated into well child visits often with Bright Futures guidelines. | Primary care team: general pediatrician or family physician working with APCs and nurses; may integrate other clinicians, including school nurses. | Primarily outpatient settings (offices, clinics) |
Some screenings and health education done through schools. | Newborn home visits rare and for high-risk populations | |||
Schools with school nurses or clinics | ||||
China | MCH system provides preventive care such as screenings, health education, and immunizations based on national guidelines. | MCH team: Pediatricians working alongside nurses and “Child Preventive Health Doctors” trained in public health. | Two-thirds of MCH facilities are hospitals, the remainder are health centers or health stations. | |
Home visits universally provided for newborns. Some schools have MCH providers or school nurses. | ||||
Low Acuity | United States | Low acuity care by primary care provider in medical home model: first contact, longitudinal, coordinated care. | Primary care team: general pediatrician or family physician working with APCs and nurses. May consult with outpatient subspecialists. | Outpatient settings including offices, clinics, urgent care centers |
Occasional school-based clinics | ||||
China | Community-based accessible clinics and primary hospitals provide low acuity care, but do not generally provide longitudinal care or care coordination. | Primary care team: Primarily general practitioners or “assistant pediatricians” in rural locations. | Urban community health centers, rural township hospitals | |
Outpatient clinics of hospitals also provide acute care. | Hospital team: Pediatricians working with nurses. | Outpatient clinics based at general hospitals | ||
TCM provides acute and chronic care as alternative to western treatment. | TCM team: TCM trained and licensed physicians. | TCM hospitals/clinics or TCM department integrated into Western hospital | ||
High Acuity | United States | Emergency department or hospital. | Hospital team: Increasingly led by pediatric subspecialists: hospitalists, emergency physicians and intensivists or subspecialists working with APCs, nurses, and other clinicians. | Hospitals |
China | Emergency department or hospital. | Hospital team: General pediatricians working with nurses and other clinicians; pediatricians rotate between inpatient and outpatient services. Pediatricians may have some subspecialty training. | Hospitals | |
Chronic | United States | Care coordinated by primary care provider in medical home model: first contact, longitudinal, coordinated care. | Primary care team and subspecialty team: Primary general pediatrician or family physician working with APCs and nurses including school nurses. Often consulting with outpatient subspecialists. | Primarily outpatient settings (offices, clinics) |
Multidisciplinary centers may coordinate care for some chronic diseases (eg, cystic fibrosis). | Subspecialty teams: Subspecialists may consult or may coordinate much of the care with APCs and nurses. | |||
China | Provide disease specific care (such as oncology) both inpatient and outpatient. | Hospital team and/or subspecialty centers: Pediatricians often with nonstandardized training in subspecialty. | Hospital-based clinics, TCM hospitals, and private clinics or TCM department integrated into Western hospital. | |
TCM provide chronic care as alternative to western treatment. | TCM team: TCM trained and licensed physicians. |
Care . | Country . | System . | Clinical Team Members . | Location . |
---|---|---|---|---|
Preventive | United States | Screening, anticipatory guidance and immunizations are provided by primary care provider integrated into well child visits often with Bright Futures guidelines. | Primary care team: general pediatrician or family physician working with APCs and nurses; may integrate other clinicians, including school nurses. | Primarily outpatient settings (offices, clinics) |
Some screenings and health education done through schools. | Newborn home visits rare and for high-risk populations | |||
Schools with school nurses or clinics | ||||
China | MCH system provides preventive care such as screenings, health education, and immunizations based on national guidelines. | MCH team: Pediatricians working alongside nurses and “Child Preventive Health Doctors” trained in public health. | Two-thirds of MCH facilities are hospitals, the remainder are health centers or health stations. | |
Home visits universally provided for newborns. Some schools have MCH providers or school nurses. | ||||
Low Acuity | United States | Low acuity care by primary care provider in medical home model: first contact, longitudinal, coordinated care. | Primary care team: general pediatrician or family physician working with APCs and nurses. May consult with outpatient subspecialists. | Outpatient settings including offices, clinics, urgent care centers |
Occasional school-based clinics | ||||
China | Community-based accessible clinics and primary hospitals provide low acuity care, but do not generally provide longitudinal care or care coordination. | Primary care team: Primarily general practitioners or “assistant pediatricians” in rural locations. | Urban community health centers, rural township hospitals | |
Outpatient clinics of hospitals also provide acute care. | Hospital team: Pediatricians working with nurses. | Outpatient clinics based at general hospitals | ||
TCM provides acute and chronic care as alternative to western treatment. | TCM team: TCM trained and licensed physicians. | TCM hospitals/clinics or TCM department integrated into Western hospital | ||
High Acuity | United States | Emergency department or hospital. | Hospital team: Increasingly led by pediatric subspecialists: hospitalists, emergency physicians and intensivists or subspecialists working with APCs, nurses, and other clinicians. | Hospitals |
China | Emergency department or hospital. | Hospital team: General pediatricians working with nurses and other clinicians; pediatricians rotate between inpatient and outpatient services. Pediatricians may have some subspecialty training. | Hospitals | |
Chronic | United States | Care coordinated by primary care provider in medical home model: first contact, longitudinal, coordinated care. | Primary care team and subspecialty team: Primary general pediatrician or family physician working with APCs and nurses including school nurses. Often consulting with outpatient subspecialists. | Primarily outpatient settings (offices, clinics) |
Multidisciplinary centers may coordinate care for some chronic diseases (eg, cystic fibrosis). | Subspecialty teams: Subspecialists may consult or may coordinate much of the care with APCs and nurses. | |||
China | Provide disease specific care (such as oncology) both inpatient and outpatient. | Hospital team and/or subspecialty centers: Pediatricians often with nonstandardized training in subspecialty. | Hospital-based clinics, TCM hospitals, and private clinics or TCM department integrated into Western hospital. | |
TCM provide chronic care as alternative to western treatment. | TCM team: TCM trained and licensed physicians. |
Primary Care
In the United States, pediatrics is considered a primary care specialty anchored in principles of “first contact, longitudinal responsibility, integration of services and family orientation.”81 The AAP advocates for the “Medical Home,” which is characterized by care that is “accessible, continuous, comprehensive, family centered, coordinated, compassionate and culturally effective.”82 However, only 50% of parents of children with disabilities endorsed having a fully functioning medical home, with lower rates among racial and ethnic minorities, non-English-speaking, and uninsured children.83,84 Nurse practitioners also have an increasing role in the provision of primary care.85 Family physicians continue to provide primary care to more than one-fifth of pediatric patients, particularly in rural areas, although some data indicate that a declining percentage of family physicians see children (68% saw patients aged <5 years in 2018).86–88
China’s primary care system refers to a network of urban community health centers, rural township hospitals, and private clinics, which provided an estimated 55% of the total population outpatient care and 18% of inpatient care in 2016.89 This system is designed to be community-based and accessible, but successful models for longitudinal care and integration of services are lacking. A shift toward qualified general practitioners and away from historically less-qualified “primary care doctors” is underway. However, the ambiguous role of Chinese general practitioners, with a heavy focus on older adult chronic illness care and episodic care for minor ailments without continuity of care, differs significantly from the role of US family physicians.
Preventive Care
In the United States, preventive care is included in the role of pediatricians as primary care providers. Screenings and anticipatory guidance are incorporated into annual well checks. Bright Futures has been a successful tool for systematically delivering age-appropriate pediatric preventive care.90 Unlike China, the United States does not have large cadres of health providers in the community or a strong public health program for children.91 School nurses in the United States fill a significant role, which has evolved to the management and prevention of a wide array of acute and chronic conditions.92
In 1949 China developed an MCH system to administer preventive child health care. This system is recognized for having contributed to the rapid reduction in infectious disease burden and under-5 mortality rates.93 The MCH system is a network of hospitals, health centers, and health stations that coordinates neonatal and early child health alongside maternal care and includes home visits to newborns, health education for parents, well checks with screenings, and scheduled immunizations, including in schools. The role of the MCH system is evolving and recently expanded to include neuropsychological screening, eye care, oral health care, hearing care, and screening for metabolic syndrome.94
In addition to pediatricians, the MCH system employs “Child Preventive Health Doctors” trained in preventive medicine or public health, who provide screening and health education but do not prescribe medications. Some of these providers work in schools and may manage minor ailments or emergencies. Despite these strengths, the lack of integration between the MCH system and primary care services or hospitals is a serious challenge.95
Hospital Teams
In the United States, hospital teams are increasingly led by hospitalists assisted by nurse clinicians and physician assistants who specialize in the care of the hospitalized child.96 Inpatient care for common disorders is increasingly protocolized with ongoing quality improvement initiatives. By contrast, in China, most inpatient care is supervised by pediatricians who carry both outpatient and inpatient responsibilities. Quality improvement methodology is just beginning to be employed.
Subspecialty Care
In the United States, pediatric subspecialists provide acute and chronic inpatient and outpatient care with organ- or disease-specific expertise. They often work in collaboration with primary care or hospital teams and direct hospital care for patients whose primary disorder is specific to their field.
In China, hospital-based subspecialists care for children with acute or chronic illnesses, but training for most subspecialists is not standardized. Only 2 pediatric subspecialties are nationally recognized (neonatology and anesthesiology) although individual provinces may recognize more. There is little capacity for the coordination of care when >1 specialty is required, although multidisciplinary team care is increasingly common in tertiary hospitals. Although the regionalization of care occurs with certain centers of excellence, there is no formal vertical integration of chronic disease management between primary, secondary, and tertiary hospitals or outpatient continuity of care.
Traditional Chinese Medicine (TCM) clinicians also care for children in China, with TCM hospitals providing 8% of pediatric hospital beds.97 Almost all primary health care institutions offer TCM, which may be integrated alongside Western medicine, or offer complementary treatments.89 In the United States, there are some offerings of complementary and integrative medicine in pediatrics, particularly for children with complex and painful medical conditions, but there is sparse integration of complementary medicine practitioners into the child health workforce.
Family-Centered Care
Most major pediatric organizations in the United States have endorsed family-centered care principles. Although families can join hospital advisory boards and assist in research design, studies of the medical home model and patient experience surveys document the need for even more family engagement.98,99 In China, despite formal endorsement by nursing organizations, there are few data on family-centered care. Families of most hospitalized children anecdotally do some of the tasks covered by nurses in the United States. However, limitations to parental visits are common in Chinese pediatrics and NICUs.100,101
Discussion
Our dialog highlighted significant strengths, pressing challenges, and serious deficiencies in both countries for the pediatric workforce and education. We identified several areas in which we could learn new approaches from each other. There were also areas in which the country-specific history and structure of health care delivery limited the usefulness of such a direct application. Nonetheless, the information from the dialog can be a foundation on which policymakers and academics in both the United States and China can consider reforms to pediatric training and child health systems to support a competent pediatric workforce empowered to respond to the contemporary health needs of our children and youth.
Areas in Which Continued Dialog Can Enhance Practice
Given the increased complexity of child health care, both countries would benefit from a more team-based approach to the child health workforce. China could increase the number of other clinicians to assist pediatricians with their tremendous workloads. Possibilities include increasing the quality of training and the number of nurses and introducing models of APCs. Such an approach may also allow for the introduction of models of care continuity, such as the Medical Home model. In the United States, a recent call for more robust public health infrastructure highlighted a needed role that in China is filled by “Child Preventive Health Doctors” but, in the United States, is filled by a patchwork of providers who are often not linked with one another.102
The United States can learn from China’s successful efforts in ensuring access to child health care at a community level. Policymakers in both the United States and China have sought to increase the availability of physicians in rural communities, but progress is incomplete in both countries.4,103,104 American efforts to address geographic maldistribution are primarily through the support of community and rural health centers, financial incentives such as the National Health Service Corps loan repayment, visa waiver programs, and rural training programs.105–108 Such efforts may be undermined by ongoing closures of pediatric beds in rural hospitals.66,68 China has less provincial variation in pediatrician density than American states do, possibly due to the distribution of its public hospitals, free tuition programs targeting medical students who commit to working for 3 years in rural health centers, and promotion criteria for physicians linked to service time in lower-tier hospitals or community health centers.109,110 Reimbursement for both hospitals and clinicians should ensure the provision of pediatric care is appropriately incentivized.
Areas of Continued Challenge to Providing Highest-Quality Care in Both Countries
In both countries, supporting child health care delivery by broader teams was seen as vital to reaching the most vulnerable children. Teams need racially, culturally, and ethnically diverse members, including the recruitment of diverse pediatricians. Teams must be inclusive of clinicians and nonclinicians, including school-based providers.42,111–113 Telehealth represents an opportunity to link teams and families but, if poorly designed and inaccessible, may risk exacerbating inequities104,114 When parents and caregivers are recognized as essential and equal members of the child health care team, the rest of the team members become more attuned to societal expectations, needs, and strengths, particularly for ethnically, racially, and geographically diverse populations in both countries.115–117
Other structural causes must be addressed to resolve inequities in access to quality care. The United States has greater geographic disparities in the distribution of pediatricians, but more standardized pediatric training. China’s distribution of pediatricians is more even but relies on rural coverage of assistant pediatricians, who have significantly less training. Both countries have made progress on insurance coverage; however, in the United States, a significant proportion of children remain uninsured. China provides universal coverage of basic health care needs, but higher out-of-pocket health costs remain. Continued policy changes and advocacy are needed to ensure the most vulnerable children in both countries can access health care.
Both countries face challenges to ensure that pediatric workforce training and health systems structures effectively evolve to address shifting epidemiology, including childhood chronic illnesses, disability, and mental and behavioral health disorders. Skills and structures are needed to understand and address the social, economic, and environmental conditions that affect children’s growth and development, and to guide government policies to improve children’s health and family wellbeing. The most effective workforce solutions are likely country-specific. For example, mental health care is being incorporated into primary care in the United States but may be better addressed through the MCH system or other systems in China.
Limitations
We recognize numerous limitations to the comparisons described in this report. National data were often not available or used different methodologies. We included assistant pediatricians in the tally of Chinese pediatricians, recognizing their independent practice, but did not similarly include American APCs given variations in independent practice by state. The ABP data on the pediatrician workforce does not account for pediatricians who did not achieve or maintain certification or pediatricians who retired before, or continue working after, age 70.
Conclusions
The FOC team noted many shared challenges and similar themes to opportunities in efforts to develop a child health workforce that provides access to quality care for existing and evolving health needs. Children with health concerns require increasingly complex care delivered most effectively by multidisciplinary teams. Reimagining pediatrics centered on the child and functioning in the context of the full health care team, including families, requires a leap of faith. The profession needs to have faith that the role of pediatricians would not dwindle but be augmented. The full team needs to have faith that the roles would be fairly reimbursed and that team members would all receive training appropriate to their roles. In the end, children rely on us to advocate for them and design systems that best meet the health needs of all our children.
Efforts should continue toward strengthening pediatric education and building a diverse multidisciplinary pediatric workforce that is accessible, competent, motivated, and empowered to deliver high-quality care that results in health equity for all children. Dialog among child health professionals from different countries allows for sharing of ideas and innovations to address the diverse causes of children’s ill health and develop systems that promote health, resilience, and equitable child health outcomes.
Acknowledgments
The authors would like to thank the China Medical Board and, especially, Lincoln Chen and Barbara Stoll for their steadfast support of this project, Professor Zonghan Zhu, Professor Meng Mao, and Professor Kunling Shen for their insights, and William Cull and Lynn Olson from the AAP for their assistance in workforce research.
Dr Russ conducted comparative analysis, designed figures, drafted the initial manuscript, and reviewed and revised the manuscript; Drs Gao, Lee, Stephens, Trimm, Yu, Jiang, and Palfrey and Ms Karpowicz contributed to comparative analysis and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: This project was funded by the China Medical Board, which is an independent American foundation. The China Medical Board facilitated logistics for one in-person meeting of the ‘For Our Children’ team but had no role in data collection, analysis, or manuscript preparation.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest relevant to this article to disclose.
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