The Evolution of the Community Pediatrician

Commentary From the Council on Community Pediatrics

The Council on Community Pediatrics (COCP) seeks to promote health justice and address the social and structural determinants of health by supporting community pediatricians in evidence-based clinical care, advocacy, education, and collaboration with families and communities. The COCP is interested in engaging innovative solutions that support children to flourish and recognizes location-based strategies as foundational and developmental approaches that address child health and well-being in the child’s environment. The COCP resides at the intersection of public health, social justice, child rights, and family-centered clinical care. 

The executive committee of the COCP contributed to the research, writing, and editing of this 75-year retrospective look at the role of the community pediatrician in recognizing the importance of the social environment on child health. 

The Evolution of the Community Pediatrician

Percita Ellis, MD, FAAP¹, Christopher Greeley, MD, MS, FAAP², Andrea Green, MDCM, FAAP³, Joyce Javier, MD, MPH, MS, FAAP⁴, Mala Mathur, MD MPH, FAAP⁵, Gerri Mattson, MD, MSPH, FAAP⁶, Rita Nathawad, MD, MSc-GHP, FAAP⁷, Chris Peltier, MD, FAAP⁸

Affiliations: ¹Rockbridge Area Health Center, Lexington, VA; ²Professor of Pediatrics, Division of Public Health, Baylor College of Medicine; ³Professor of Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT; ⁴Associate Professor of Clinical Pediatrics and Population and Public Health Sciences, Children’s Hospital Los Angeles, Keck School of Medicine at the University of Southern California; ⁵Department of Pediatrics, University of Wisconsin–Madison, Madison, WI; ⁶Adjunct Associate Professor, Department of Maternal and Child Health, University of North Carolina, Gillings Global School Of Public Health; ⁷Department of Pediatrics, University of Florida, College of Medicine-Jacksonville; ⁸Department of Pediatrics, University of Cincinnati College of Medicine

Highlighted Articles From Pediatrics

• Hubbard JP, Zibit S. Review of private practice; pediatricians and general practitioners. Pediatrics. 1948;1(3):379-386; doi:10.1542/peds-1-3-379
• May CD. Can the new pediatrics be practiced? Pediatrics. 1959;23(2):253-254; doi:10.1542/peds.23.2.253
• Haggerty RJ. Child health 2000: new pediatrics in the changing environment of children’s needs in the 21st century. Pediatrics. 1995;96(4):804-812
• Eisenberg L. Social context of child development. Pediatrics. 1981;68(5):705-712 doi:10.1542/peds.68.5.705
• Committee on Community Health Services. The pediatrician’s role in community pediatrics. Pediatrics. 1999;103(6):1304-1306; doi:10.1542/peds.103.6.1304
• Gorski PA, Kuo AA, Granado-Villar DC, et al. Community pediatrics: navigating the intersection of medicine, public health, and social determinants of children’s health. Pediatrics. 2013;131(3):623-628; doi:10.1542/peds.2012-3933

Since the advent of pediatrics as a distinct discipline, clinicians have appreciated the importance of a child’s environment on their long-term outcome. In 1904, Abraham Jacobi,^1,2 often cited as the father of American pediatrics, noted “it was not enough, however, to work at the individual bedside in the hospital.”³ He encouraged pediatricians to engage in the community to affect health beyond their 4 hospital walls. Currently, the pediatrician recognizes the impact of social, environmental, political, and historical experiences on child health to a degree that we believe would make Dr. Jacobi proud. This advancement of awareness of social drivers of health and the changing role of pediatricians in community is evident in the evolving literature of Pediatrics over the past 75 years.

Within the pages of Pediatrics, we see the growth and transformation of the practicing pediatrician over the past 75 years. We have witnessed the development and deployment of antibiotics, improvements in nutrition, and systematic advancements in sanitation. In 1948, pediatricians were largely urban practitioners, with one-third of all pediatricians living in 3 states (New York, New Jersey, and Pennsylvania), and half living in or near only 12 cities.⁴ Seventy-five percent of all pediatric care was not provided by pediatricians, but general practitioners.⁴ In this formative period, the first quarter century of Pediatrics, there was the beginning of the recognition that the diseases impacting children were changing away from historic afflictions “such as, diphtheria, dysentery, and the cholera infantum of summer months.”⁴ It was also at this time that we see recognition within the pages of Pediatrics that inequality in access to healthcare was apparent: “a city child of an indigent family may be just as isolated from good medical care as the child in an isolated rural county.”⁴ The role of the pediatrician was noted to need to change as well; “as these diseases have diminished in morbidity and severity, the pediatrician, and general practitioner, too, have given more time to the protection of health and less to the care of the sick.”⁴ The recognition of the shift created an existential crisis with what was noted in a 1959 Pediatrics editorial as “new pediatrics.”⁵ The concern was that the public would not find value in “comprehensive care,” which would usher in “the ‘shot and formula’ epoch” of child care.⁵ Prevention of disease was a new professional concept, and the fear was people would simply not buy it (both theoretically and financially). The result of the shifting practice patterns was a greater appreciation of the “art of medicine”; “As patterns of medical care have changed, the individual doctor-patient relation is being replaced by short-term encounters with numerous disparate specialists and other health workers.”⁶

From 1973 to 1998, articles in Pediatrics acknowledged the change in childhood morbidities from predominantly acute infectious disease and nutritional deficiencies to chronic conditions.⁷ The family structure was also changing: as more mothers were working outside the home, Pediatrics was exploring the impact of this cultural shift on child well-being. The practice of pediatrics began to move beyond the scope of solely treating children within the hospital and clinic and into new settings within their families, schools, and communities.^7,8 Specifically, pediatric practice began to build connections between parenting, social context, and child behavior. In 1975, Chamberlin described how often a mother plays with her child and praises her child is related to a “friendly outgoing pattern of child behavior,” which alludes to how parenting behavior is related to child behavior.⁹ In 1981, Eisenberg described that the social context of mothers being employed in the workforce can impact bonding in early infancy.¹⁰ Runyan et al described that social capital, defined as “benefits that are derived from personal social relationships and social affiliations” have a great impact on children’s well-being as early as the preschool years.¹¹ Example indicators of social capital include having 2 parents or parent-figures in the home, social support of the maternal caregiver, neighborhood support, and regular church attendance. In 1981, Nader et al recognized that behavioral, educational, and social-family problems should be addressed through partnership with schools and community health care resources.¹² These shifting sands foreshadowed the progress of the next 25 years and highlighted the importance of positive parenting and policies that influence the social context of children and families in order to optimize child health.

These trends point to the need to redefine the pediatrician’s role in community pediatrics, which was described in a 1999 policy statement by the Committee on Community Health Services in Pediatrics.¹³ Articles from the most recent 25 years of Pediatrics have a renewed emphasis on the intersection between child health and well-being and social and environmental factors. The role of the community pediatrician was more clearly defined to include “a perspective that enlarges the pediatrician’s focus from one child to all children in the community.”¹³ The community pediatrician must collaborate with organizations such as schools, health departments, and social agencies. “Greater communication, collaboration, and partnership between pediatricians and the public health sector have the potential to improve individual- and population-level…outcomes.”¹⁴ Over the past 25 years, Pediatrics literature has advanced the “understanding of the mechanisms and impact of biological, behavioral, cultural, social, and physical environments on healthy development.”¹⁵ The Adverse Childhood Experiences Study has confirmed the ill effects of stress on development and physiology and promoted strategies such as trauma responsive care and resilience building. Children in the 21st century not only face health risks associated with poverty, food, and housing insecurity, or limited access to health and education, but are impacted by societal burdens including racism and other forms of discrimination, climate change, and violence. Despite efforts to promote the health and well-being of all children, many have remained invisible, including children of minority communities, youth in the juvenile justice or foster care systems, and human trafficking victims. Efforts to “see” these groups and identify pathways to optimal outcomes are ongoing. To address the root cause of these disparities, pediatricians must integrate the principles and practice of child health equity (children’s rights, social justice, and human capital investment).¹⁶ Moving into the future, it is clear that optimizing child well-being requires an investment in communities and recognition of the importance of child-friendly social policies. Research, education, and advocacy around building policy that respects child rights and child-friendly health promoting environments will be critical for children to flourish. ¹⁶

Jacobi noted, “The young are the future makers and owners of the world.”³ As medicine modernized (antibiotics, sanitation, nutrition, hygiene), the diseases afflicting children likewise changed, becoming more community-embedded and team-based. Robert Haggarty, a luminary in the transformation of community-based pediatrics, in 1975 coined the term “new morbidities.” The new framing recognized that the threats to children were no longer the historic morbidities but newer, more modern scourges (educational failure, mental and behavioral health, poverty, violence).¹⁷ As the understanding of the value of the social context in which a child is born, grows, is educated, and thrives has evolved, so has the recognition that pediatricians need to be part of a team. In Pediatrics in 1995, Haggerty wrote, “we must become partners with others, or we will become increasingly irrelevant to the health of children.”⁷ This was (as noted earlier) emphasized by the Council on Community Pediatrics in 2018. Pediatrics continues to evolve and the role of the pediatrician changes along with it.

References

1. Burke EC. Abraham Jacobi, MD: the man and his legacy. Pediatrics. 1998;101(2):309-312; doi:10.1542/peds.101.2.309
2. Haggerty RJ. Abraham Jacobi, MD, respectable rebel. Pediatrics. 1997;99(3):462-466; doi:10.1542/peds.99.3.462
3. Jacobi A. The history of pediatrics and its relation to other sciences and arts. Amer Med. 1904;8(19):795-805
4. Hubbard JP, Zibit S. Review of private practice; pediatricians and general practitioners. Pediatrics. 1948;1(3):379-386; doi:10.1542/peds-1-3-379
5. May CD. Can the new pediatrics be practiced? Pediatrics. 1959;23(2):253-254; doi:10.1542/peds.23.2.253
6. Korsch BM, Gozzi EK, Francis V. Gaps in doctor-patient communication. 1. Doctor-patient interaction and patient satisfaction. Pediatrics. 1968;42(5):855-871; doi:10.1542/peds.42.5.855
7. Haggerty RJ. Child health 2000: new pediatrics in the changing environment of children's needs in the 21st century. Pediatrics. 1995;96(4):804-812
8. Burnett RD, Bell LS, Frank DJ, et al. Concepts of school health programs. Pediatrics. 1975;55(1):140-141; doi:10.1542/peds.55.1.140
9. Chamberlin RW. Parental use of “positive contact” in child-rearing: its relationship to child behavior patterns and other variables. Pediatrics. 1975;56(5):768-773 doi:10.1542/peds.56.5.768
10. Eisenberg L. Social context of child development. Pediatrics. 1981;68(5):705-712; doi:10.1542/peds.68.5.705
11. Runyan DK, Hunter WM, Socolar RR, et al. Children who prosper in unfavorable environments: the relationship to social capital. Pediatrics. 1998;101(1):12-18; doi:10.1542/peds.101.1.12
12. Nader PR, Ray L, Brink S. The new morbidity: use of school and community health care resources for behavioral, educational, and social-family problems. Pediatrics. 1981;67(1):53-60; doi:10.1542/peds.67.1.53
13. Committee on Community Health Services. The pediatrician’s role in community pediatrics. Pediatrics. 1999;103(6):1304-1306; doi:10.1542/peds.103.6.1304
14. Kuo AA, Thomas PA, Chilton LA, et al. Pediatricians and public health: optimizing the health and well-being of the nation’s children. Pediatrics. 2018;141(2):e20173848; doi:10.1542/peds.2017-3848
15. Gorski PA, Kuo AA, Granado-Villar DC, et al. Community pediatrics: navigating the intersection of medicine, public health, and social determinants of children’s health. Pediatrics. 2013;131(3):623-628. doi:10.1542/peds.2012-3933
16. Council on Community Pediatrics, Committee on Native American Child Health. Health equity and children’s rights. Pediatrics. 2010;125(4):838-849; doi:10.1542/peds.2010-0235
17. Haggerty RJ, Roghmann KJ, Pless IB. Child Health and the Community. Piscataway, NJ: Transaction Publishers; 1975