The changing role of the paediatrician in the 21st century

We expect most physicians and families are aware of Norman Rockwell's painting of the paediatrician: a kindly older gentleman in a shirt, tie and three-piece suit listening with his stethoscope to a doll's heart, the doll held up by a young Caucasian girl with a hat, scarf and brown leather shoes. So much has changed since that painting. First of all, most paediatricians are women and dress exactly like our families. Second, our patients come from all over the world and many have a chronic illness or a disability, or are thin or pale or with alopecia from chemotherapy, or are overweight and not physically fit. Not all paediatricians will fit the same mold; our roles have changed considerably. We have acquired new skills, and most importantly, our patients and the care they require have changed. For paediatricians who are subspecialists, we seem to know more about our subspecialty but perhaps less about other areas of child health. Most subspecialists work in tertiary care centres surrounded and supported by other experts. The problems now are not only diagnostic medical problems, but also problems of collaborating with other health care professionals, of managing a team in a time of limited resources, of communicating with patients and families with other health professionals, and of communicating and making useful the knowledge from our research. For paediatricians in the community, we continue to balance caring for the few patients who need hospitalization with the much larger number of ambulatory patients, many of whom have a chronic illness, such as asthma, complications of prematurity, genetic diseases, developmental disabilities, autism or school difficulties, to name just a few of the many conditions general paediatricians must deal with. We have developed new skills of communication with families, other health professionals and community leaders. Increasingly, we must advocate for our patients who need special resources and services, or advocate for children in a nation that seems to ignore children, especially those who are marginalized, live in poverty, are First Nations or new immigrants, or have mental health issues. We must focus more on prevention of illness in adult life. Our patients are no longer like the young healthy girl in Norman Rockwell's famous painting. For paediatricians in the 21st century, it is often more difficult to know what is the ethical and professional thing to do. In Norman Rockwell's time, Canadian society appeared more homogeneous and the doctor ‘knew’ what was the best thing to do and most people accepted the physician's paternalistic role. But now we are faced with helping patients and their families make decisions in a much more complex multicultural society with changing values. We now share decision making with all the complexity that it entails, yet it is often unclear what is the best thing for some children. Paediatricians should also be scholars. We may not all do research, but we must base our recommendations and decisions on evidence produced by research and presented in the medical literature. We need to keep up with the rapidly expanding medical knowledge and discoveries. We must be able to critically appraise the relevant literature and what other experts proclaim as the truth. We are also teachers, whether it is the doctors and paediatricians of the future, our patients and families or our own children. We need to know how to teach and communicate effectively. The articles in the present issue arise from an international workshop and symposium held in November 2006, “Child health in the 21st century: The role of the paediatrician in an inter-professional environment” (http://www.caphc.org/partnerships_21century.html). Four major themes were discussed at the symposium: meeting the needs of our diverse and/or vulnerable populations; meeting the needs of children and youth with chronic health conditions; child and youth health human resources; and education and training: addressing the future needs of child and youth health. The symposium led to 19 recommendations based on promoting and improving the best health care services for all infants, children and youth in Canada, particularly those who are disadvantaged, and to do this through interdisciplinary cooperation and collaboration. The recommendations are a tall order but at least outline the challenges for where paediatrics should be going in the 21st century. So are we going in the right direction? Do we have the correct skills and tools? Do we know who we are travelling with and are we working well together? The articles that follow in this special issue of Paediatrics & Child Health address many of the recommendations emanating from the symposium and pose challenges for all of us involved in child and youth health. Saleem Razack (pages 287–289) highlights the social determinants of health and briefly describes the vulnerable populations of children and the devastating and often ignored effects of poverty. Donald Spady (pages 290–292) urges us to consider and act on the enormous challenges that environmental degradation and global warming pose for our children and youth. Robert Armstrong (pages 293–294) reminds us that there are many professionals and nonprofessionals involved in providing child and youth health care, of which paediatricians continue to be a critical member of the health care team. Nevertheless, the future needs are poorly defined and as models of care evolve, the number of health care providers will need to be appropriately determined. Frank Gavin (pages 295–297), founding Chair of the Canadian Family Advisory Network, writes eloquently about the need for excellent communication between physicians and parents, and especially the importance of engagement of parents in true partnership with professional caregivers. Henry Ukpeh (pages 299–302) articulates a personal perspective about the critical role of the community paediatrician and the need to address the issues of medial education, human resources and remuneration, parental engagement and mental health. The education of paediatricians and other child health providers was the focus of many of the recommendations. Susan Bannister, Harish Amin and Burke Baird (pages 303–309) outline some of the changes in training, which are relevant to the recommendations, and the need for continued improvement in medical education to better meet the needs of children and youth. Astrid Guttmann, Eyal Cohen and Charlotte Moore (pages 310–314) propose that human resource planning should be based on maximizing health-related outcomes for mothers, children and youth. They review some innovative models of care that have been successfully used for particular patient groups. Stan Kutcher, Simon Davidson and Ian Manion (pages 315–318) briefly review the magnitude of the child and youth mental health problems, some new models of care, and the importance of research and translating the results of that research into practice. The articles in the present issue are about changes taking place for the new century. These are exciting, but they also remind us that we need to constantly evaluate whether changes are really improving the health and lives of Canadian children and youth. Are our children and youth healthier, happier and achieving their full adult potential to live productive and meaningful lives? Only time will tell. We encourage all to read the articles in the present issue and consider how we can best move forward to address the changes in paediatric care, which have taken place since Rockwell produced his famous painting and which must take place to meet the future needs of children and youth. Looking again at Rockwell's painting of the paediatrician, although we have changed a lot and our patients have changed considerably, there is still something about the painting that we hope rings true. There is a smile on the paediatrician's face, a sense that he is enjoying the interaction with his young patient and a sense of empathy, caring and compassion for his young patient. We hope that will never change with paediatricians in the 21st century. We and the Board of the Canadian Paediatric Society look forward to receiving your thoughts, comments and suggestions about how we can work together to advance the future of Canada's children and youth.

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