Saturday, July 26, 2008

Field of Pediatric2

Field of Pediatrics (Part 2)


Families facing economic, social, or political hardship have been forced to leave their land and homes in search of better opportunities; such migrations are often within a country or between neighboring countries. Both industrialized and developing countries experience these migrations.

In the United States, there are an estimated 3–5 million migrant and seasonal farmworkers and their families. The eastern migration is primarily from Florida, whereas the western migration comes from Texas, other border states, and Mexico. Many children travel with their parents and experience poor housing, frequent moves, and a socioeconomic system controlled by a crew boss who arranges the jobs, provides transportation, and often, together with the farm owners, provides food, alcohol, and drugs under a “company store” system that leaves migrant families with little money or in debt. Children often go without schooling; medical care is usually limited.

The medical problems of children of migrant farmworkers are similar to those of children of homeless families: increased frequency of infections (including HIV), trauma, poor nutrition, poor dental care, low immunization rates, exposures to animals and toxic chemicals, anemia, and developmental delays.

Among the most substantial migrant populations in the world is China's “floating population,” an estimated 100 million (almost 10% of China's population) of rural to urban migrants. The rapidly growing urban versus rural income gradient and a relaxation of restrictions on movement in the country has fueled this influx of rural residents who arrive in China's urban areas without health, education, or employment benefits for themselves or their children. Similar patterns are seen in many countries in Asia, Africa, and South America. In most of these countries there are few legal or social programs to aid the families or their children, spawning massive squatter settlements without provisions for water, sanitation, education, or basic health needs. Government policies vary worldwide, but frequently their response to such communities is to bulldoze the settlements and imprison or deport the residents.


Families with children are the fastest growing segment of the homeless population in the United States. Children make up about 25% of the homeless population, with an estimated 100,000 children living in shelters on a given night and about 500,000 homeless each year. Many homeless are not in shelters (living in the street or with extended families), and thus these figures are low estimates. The population of homeless children has been increasing as a consequence of more families with children living in poverty or near poverty, fewer available affordable dwellings for these families, decreasing public assistance programs for the non-elderly poor, and the rising prevalence of substance abuse.

Homeless children have an increased frequency of illness, including intestinal infections, anemia, neurologic disorders, seizures, behavioral disorders, mental illness, and dental problems, as well as increased frequency of trauma and substance abuse. Homeless children are admitted to U.S. hospitals at a much higher rate than the national average. They have higher school failure rates, and the likelihood of their being victims of abuse and neglect is much higher. In one study, 50% of such children were found to have psychosocial problems, such as developmental delays, severe depression, or learning disorders. The increased frequency of maternal psychosocial problems, especially depression, in homeless households has a significant untoward impact on the mental and physical health of these children. Because families tend to break apart under the strain of poverty and homelessness, many homeless children end up in foster care. If their families remain intact, frequent moves make it very difficult for them to receive continuity of medical care.

Homelessness exists worldwide. There are an estimated 3 million people in the 15 countries of the European Union who do not have a permanent home. In Toronto, Canada, 6,500 people stayed in emergency shelters on a typical night in late 1997, a 66% increase over the previous year. In some nations in Latin America, Asia, and Africa, the distinction between rural-to-urban migrants and homelessness is blurred.

Provision of adequate housing, job retraining for the parents, and mental health and social services are necessary to prevent homelessness from occurring. Physicians can have an important role in motivating society to adopt the social policies that will prevent homelessness from occurring by educating policy-makers that these homeless children are at greater risk of becoming burdens both to themselves and to society if their special health needs are not met.


The number of runaway and thrown-away children and youths in the United States is estimated at about 500,000; several hundred thousand of these children have no secure and safe place to stay. Teenagers make up most of both groups. The usual definition of a runaway is a youth younger than 18 yr who is gone for at least 1 night from his or her home without parental permission. Most runaways leave home only once, stay overnight with friends, and have no contact with the police or other agencies. This group is no different from their “healthy” peers in psychologic status. A smaller but unknown number become multiple or permanent “runners” and are significantly different from the one-time runners.

Thrown-aways include children told directly to leave the household, children who have been away from home and are not allowed to return, abandoned or deserted children, and children who run away but whose caretakers make no effort to recover them or do not appear to care if they return. The same constellation of causes common to many of the other special-risk groups is characteristic of permanent runaways, including environmental problems (family dysfunction, abuse, poverty) and personal problems of the young person (poor impulse control, psychopathology, substance abuse, or school failure). Thrown-aways experience more violence and conflicts in their families.

In the United States, it is a minority of runaway youths who become homeless street people. These youths have a high frequency of problem behaviors, with 75% engaging in some type of criminal activity and 50% engaging in prostitution. A majority of permanent runaways have serious mental problems; more than 33% are the product of families who engage in repeated physical and sexual abuse. These children also have a high frequency of medical problems, including hepatitis, sexually transmitted infections, and drug abuse. Although runaways often distrust most social agencies, they will come to and use medical services. Medical care may become the point of re-entry into mainstream society and the path to needed services. U.S. parents who seek a physician's advice about a runaway child should be asked about the child's history of running away, the presence of family dysfunction, and personal aspects of the child's development. If the youth contacts the physician, the latter should examine the youth and assess his or her health status, as well as willingness to return home. If it is not feasible for the youth to return home, foster care, a group home, or an independent living arrangement should be sought by referral to a social worker or a social agency. Although legal considerations involved in the treatment of homeless minor adolescents may be significant, most states, through their “Good Samaritan” laws and definitions of emancipated minors, authorize treatment of homeless youths. Legal barriers should not be used as an excuse to refuse medical care to runaway or thrown-away youths.

The issue of runaway youths is very complex in many developing nations, where in many instances the youth may be orphaned and/or leaving situations of forced sex or other abusive situations. In 2003, there were an estimated 15 million HIV orphans in Africa, an increase of 3.5 million in 2 yr. This number is estimated to grow to 18 million by 2010. With school attendance <50% st="on">Africa, children who are orphaned are 17% less likely to attend school. Humanitarian and international organizations have begun to focus on this very vulnerable group of youths across the globe. Rates are often uncertain, and in many countries, these children have not even been recognized as an at-risk group, so great is the social chaos and so massive are the unmet needs.


By age 20–30 yr, many children in the United States and other developed countries who were at special risk will have made moderate successes of their lives. Teenage mothers and children who were born prematurely or in poverty demonstrate that, by this age, the majority have made the transition to stable marriages and jobs and are accepted by their communities as responsible citizens. As the numbers of risk factors increases for an individual, however, the odds for a successful adulthood decline.

Certain biologic characteristics are associated with success, such as being born with an accepting temperament. Avoidance of additional social risks is even more important. Premature infants or preadolescent boys with conduct disorders and poor reading skills, who must also face a broken family, poverty, frequent moves, and family violence, are at much greater risk than children with only 1 of these risks. Perhaps most important are the protective buffers that have been found to enhance children's resilience because these can be aided by an effective health care system and community. Children generally do better if they can gain social support, either from family members or from a nonjudgmental adult outside the family, especially an older mentor or peer. Providers of medical services should develop ways to “prescribe” supportive “other” persons for children who are at risk. Promotion of self-esteem and self-efficacy is a central factor in protection against risks. It is essential to promote competence in some area of these children's lives. Prediction of the consequences of risk is never 100% accurate. However, the confidence that, even without aid, many such children will achieve a good outcome by age 30 yr does not justify ignoring or withholding services from them in early life.

A team is needed because it is rare for 1 individual to be able to provide the multiple services needed for high-risk children. Successful programs are characterized by at least 1 caring person who can make personal contact with these children and their families. Most successful programs are relatively small (or are large programs divided into small units) and nonbureaucratic but are intensive, comprehensive, and flexible. They work not only with the individual, but also with the family, school, community, and at broader societal levels. Generally, the earlier the programs are started, in terms of the age of the children involved, the better is the chance of success. It is also important for services to be continued over a long period.


Concerns about the aforementioned problems of children throughout the world have generated 3 sets of goals. The 1st set includes that all families have access to adequate perinatal, preschool, and family-planning services; that international and national governmental activities be effectively coordinated at the global, regional, national, and local levels; that services be so organized that they reach populations at special risk; that there be no insurmountable or inequitable financial barriers to adequate care; that the health care of children have continuity from prenatal through adolescent age periods; and that every family ultimately have access to all necessary services, including developmental, dental, genetic, and mental health services. A 2nd set of goals addresses the need for reducing unintended injuries and environmental risks, for meeting nutritional needs, and for health education aimed at fostering health-promoting lifestyles. A 3rd set of goals covers the need for research in biomedical and behavioral science, in fundamentals of bioscience and human biology, and in the particular problems of mothers and children.

The unfinished business in the quest for physical, mental, and social health in the community is illustrated by the disparities with which deaths due to disease, injuries, and violence are distributed among white, black, and Hispanic children in the United States and between and within nations. Homicide is a major cause of adolescent deaths and has increased in rate among the very young, in whom the increase may, in part, represent the more accurate identification of child abuse. Among adolescents, homicide may reflect unresolved social tensions, substance abuse (cocaine, crack), and an unhealthy preoccupation with violence in our society (see Part III and Chapters 35, 112, and 113 [Chapter 35] [Chapter 112] [Chapter 113] ).


In 2002, children younger than 18 yr made ≈232 million patient visits to U.S. physicians' offices and hospital outpatient departments. This represents 320 visits per 100 children per year, up from 275 in 1995. Pediatricians report an average of 50 preventive care visits per week, 33% for infants. The visits average 17 to 20 min, increasing in length as children become adolescents. The principal diagnoses, accounting for ≈40% of these visits, are well child visits (15%), middle-ear infections (12%), and injuries (10%). Ambulatory visits by children and youth decrease with age. The opposite occurs with adults. Nonwhite children are more likely than white children to use hospital facilities (including the emergency room) for their ambulatory care; the number of well child visits annually is almost 80% higher among white infants than black infants. Children with private insurance are more likely than children with public insurance who, in turn, are more likely than uninsured children to receive non–emergency room care. Insurance coverage increases outpatient utilization and receipt of preventive care by approximately 1 visit per year for children.

In 2002, there were 80 hospitalizations per 1,000 children, down from 1997 (91/1,000 children), but up from 2000 (76 per 1,000 children). White children are less likely to be hospitalized than black or Hispanic children, but more likely than Asian children. Poor children are nearly twice as likely as non-poor children to be hospitalized. Insurance coverage also appears to reduce hospital admissions that are potentially manageable in an ambulatory setting.

Health care utilization differs significantly among nations. In most countries, however, hospitals are sources of both routine and intensive child care, with medical and surgical services that may range from immunization and developmental counseling to open heart surgery and renal transplantation. In most countries, clinical conditions and procedures requiring intensive care are also likely to be clustered in university-affiliated centers serving as regional resources—if these resources exist.

In the United States, the hospitalization rates for children (excluding newborn infants) are less than those of adults younger than 65 yr of age, except in the 1st yr of life. The rate of hospitalization and lengths of hospital stay have declined significantly for children and adults in the past decade. Children represent <8%>

Patterns of health care vary widely around the globe, reflecting differences in the geography and wealth of the country, the priority placed on health care vs other competing needs and interests, philosophy regarding prevention vs curative care, and the balance between child health and adult health care needs. The significant declines in infant and child mortality enjoyed in many of the developing countries in the past 3 decades have occurred in the context of support from international agencies like UNICEF, WHO, and the World Bank, bilateral donors (the aid provided from one country to another), and nongovernmental agencies to develop integrated, universal primary pediatric care with an emphasis on primary (vaccination) and selected secondary (oral rehydration solution [ORS], treatment of pneumonia and malaria) prevention strategies.


Through much of the 20th century, pediatricians were primarily focused on the treatment and prevention of physical illness and disorders. Currently, physicians caring for children, especially those in developed countries, have been increasingly called on to advise in the management of disturbed behavior of children and adolescents or problematic relationships between child and parent, child and school, or child and community. They are increasingly concerned with problems of mental, social, and societal health. The medical problems of children are often intimately related to problems of mental and social health. There is also an increasing concern about disparities in how the benefits of what we know about child health reach various groups of children. In both developed and developing nations, the health of children lags far behind what it could be if the means and will to apply current knowledge were focused on the health of children. The children most at risk are disproportionately represented among ethnic minority groups. Pediatricians have a responsibility to address these problems aggressively.

Linked with these views of the broad scope of pediatric concern is the concept that access to at least a basic level of quality services to promote health and treat illness is a right of every person. Among children in the United States, having health insurance is strongly associated with access to primary care. The failure of health services and health benefits to reach all children who need them has led to re-examination of the design of health care systems in many countries, but unresolved problems remain in most health care systems, such as the maldistribution of physicians, institutional unresponsiveness to the perceived needs of the individual, failure of medical services to adjust to the need and convenience of patients, and deficiencies in health education. Efforts to make the delivery of health care more efficient and effective have led imaginative pediatricians to create new categories of health care providers, such as pediatric nurse practitioners in industrialized nations and trained birth attendants in developing countries, and to participate in new organizations for providing care to children, such as various managed care arrangements.

New insights into the needs of children have reshaped the child health care system in other ways. Growing understanding of the need of infants for certain qualities of stimulation and care has led to revision of the care of newborn infants and of procedures leading to an adoption or to placement with foster families. For handicapped children, the massive centralized institutions of past years are being replaced by community-centered arrangements offering a better opportunity for these children to achieve their maximum potential.


Adverse health outcomes are not evenly distributed among all children, but are concentrated in certain high-risk populations. At-risk populations may require additional, targeted, or special programs designed to be effective with unique populations. All nations, regardless of wealth and level of industrialization, have subgroups of children at particular risk, requiring additional services.

In the United States, the largest vulnerable group is children living in poverty, representing about 14% of U.S. children. Substantial proportions of children in other industrialized countries are also living in poverty. The approach to addressing the needs of this group in the United States has been the establishment of a targeted insurance program, Medicaid, which became law in 1965 as a jointly funded cooperative venture between the federal and state governments to assist states in the provision of adequate medical care to eligible needy persons. The federal statute identifies >25 different eligibility categories for which federal funds are available. These statutory categories can be classified into 5 broad coverage groups: children, pregnant women, adults in families with dependent children, individuals with disabilities, and individuals ≥65 yr old. Pediatric care in the United States is highly dependent on Medicaid; however, only a relatively small proportion of the Medicaid funds actually go to child health, with the remainder serving older adults. Following broad national guidelines, each state establishes its own eligibility standards; determines the type, amount, duration, and scope of services; sets the rate of payment for services; and administers its own program. Although Medicaid has made great strides in enrolling low-income children, significant numbers of children remain uninsured. From 1988 to 1998, the proportion of children insured through Medicaid increased from 15.6% to 19.8%, but the percentage of children without health insurance increased from 13.1% to 15.4%. Minority children were disproportionately among those without insurance. The Balanced Budget Act of 1997 created a new children's health insurance program called the State Children's Health Insurance Program (SCHIP). This program gave each state permission to offer health insurance for children, up to age 19 yr, who are not already insured. SCHIP is a state-administered program and each state sets its own guidelines regarding eligibility and services. There is great variation by state, but in many states, the SCHIP program has begun to reduce racial inequities in access to health care for children.

Many industrialized nations have adapted different “safety net” systems to assure adequate coverage of all youth. Many of these programs provide health insurance for all children, regardless of income, hoping to avoid problems with children losing insurance coverage and access to health care due to changes in eligibility by providing a single form of insurance that all providers accept. The response of developing countries to the issue of universal access to care for children has been uneven, with some providing no safety net, but many having limited universal or safety net services.

To address the special needs of Native Americans in the United States, the Indian Health Service, established in 1954, has been the responsibility of the Public Health Service, but the 1975 Indian Self-Determination Act gave tribes the option of managing Native American health services in their communities. The Indian Health Service is managed through local administrative units, and some tribes contract outside the Indian Health Service for health care. Much of the emphasis is on adult services: treatment for alcoholism, nutrition and dietetic counseling, and public health nursing services. There are also >40 urban programs for Native Americans, with an emphasis on increasing access of this population to existing health services, providing special social services, and developing self-help groups. In an effort to accommodate traditional Western medical, psychologic, and social services to the Native American cultures, such programs include the “Talking Circle,” the “Sweat Lodge,” and other interventions based on Native American culture. The efficacy of any of these programs, especially those to prevent and treat the sociopsychologic problems particular to Native Americans, has not been determined.

Recognizing the health needs of migrants in the United States, the U.S. Public Health Service initiated in 1964 the Migrant Health Program to provide funds for local groups to organize medical care for migrant families. Many migrant health projects, which were staffed initially by part-time providers and were open for only part of the year, have been transformed into community health care centers that provide services not only for migrants, but also for other local residents. In 2001, the ≈400 Migrant Health Centers served >650,000 migrant and seasonal farmworkers; >85% were people of color. Health services for migrant farmworkers often need to be organized separately from existing primary care programs because the families are migratory. Special record-keeping systems that link the health care provided during winter months in the south with the care provided during the migratory season in the north are difficult to maintain in ordinary group practices or individual physicians' offices. Outreach programs that take medical care to the often remote farm sites are necessary, and specially organized Head Start, early education, and remedial education programs should also be provided. Approaches in other countries have also focused on business initiatives for migrant populations to enable them to overcome the cycle of financial dependency on their migratory lifestyle.

The United States has spent > $10 billion through the 1987 McKinney Act to provide emergency food, shelter, and health care; to finance help for young runaways; to aid homeless people in making their way back into the housing market; and to place homeless children in school. Mobile vans, with a team consisting of a physician, nurse, social worker, and welfare worker, have been shown to provide effective comprehensive care, ensure delivery of immunizations, link the children to school health services, and bring the children and their families into a stable relationship with the conventional medical system. Special record-keeping systems have been introduced to enhance continuity and to provide a record of care once the family has moved to a permanent location. Because of the high frequency of developmental delays in this group, linkage of preschool homeless children to Head Start programs is an especially important service. The Runaway Youth Act, Title III of the Juvenile Justice and Delinquency Prevention Act of 1974 (Public Law 93–414) and its amended version (Public Law 95–509) have supported shelters and provide a toll-free 24 hr telephone number (1-800-621-4000) for youths who wish to contact their parents or request help after having run away.

In Belgium, Finland, the Netherlands, Portugal, and Spain, the right to housing has been incorporated into the national constitutions. The Finnish government has devised a multifaceted response to the problem, including house building, social welfare and health care services, and the obligation to provide a home of minimum standards for every homeless person. The number of homeless in Finland has been reduced by 50%.


The growth of high technology, the increasing number of people older than 65 yr, the redesign of health institutions (particularly with respect to the needs for and the uses of personnel), the public's demand for medical services, the increase in administrative bureaucracies, and the manner in which the costs of health care are paid have driven the costs of health care in the United States up to a point at which they represent a significant proportion of the gross national product. Although children (0–18 yr) represent about 25% of the population, they account for only about 12% of the health care expenditures, or about 60% of adult per capita expenditures. Efforts to contain costs have led to revisions of the way in which physicians and hospitals are paid for services. Limits have been set on the fees for some services, capitated prepayment and various managed care systems flourish, a program of reimbursement (diagnosis-related groups [DRGs]) based on the diagnosis rather than on the particular services rendered to an individual patient has been implemented, and a relative value scale for varying rates of payment among different physician services has been instituted. These and other changes in the system of financing health services raise important ethical, quality of care, and professional issues for pediatricians to address.

Health care costs have been better contained in most other industrialized nations, the majority of which also enjoy lower childhood mortality rates than does the United States.


The shaping of health care systems to meet the needs of children and their families requires accurate statistical data and difficult decisions in setting priorities. Along with growing concerns about the design and cost of health care systems and the ability to distribute health services equitably has come increasing concern about the quality of health care and about its efficiency and effectiveness. There are large local and regional variations among similar populations of children in the rates of use of procedures and technology and of hospital admissions. These variations require continuing evaluation and explanation in terms of the actual impact of medical and surgical services on health status and the outcome of illness.

The Institute of Medicine (IOM) issued a report, “Crossing the quality chasm: A new health system for the 21st century” in 2001. This report, challenging American physicians to renew efforts to focus not just on access and cost, but also on quality of care, has been furthered in several pediatric initiatives, including but not limited to: specific initiatives for monitoring child health outlined in the IOM report “Children's Health, the Nation's Wealth,” challenge/demonstration grants funded by the Robert Wood Johnson Foundation, the National Initiative for Children's Healthcare Quality, and training initiatives by the Federation of Pediatric Organizations. Importantly, each of these initiatives is calling for the establishment of measurable standards for assessment of quality of care and for the establishment of routine plans for periodic reassessment thereof. Efforts have been initiated at some medical centers to establish evidence-based clinical pathways for disorders (such as asthma) where there exists sound evidence to advise these guidelines. Pediatricians have developed tools to evaluate the content and delivery of pediatric preventive “anticipatory guidance,” the cornerstone of modern pediatrics.

Increased attention has been focused during residency training and as part of continuing education on the importance of providing pediatricians with the skills to communicate effectively with parents and patients. These efforts are having an impact, with evidence that 66% of children are receiving good or excellent preventive care with no disparities according to race or income level. The increased focus on quality improvement in pediatric practice is reflected in the pediatric residency training competency requirements of practice-based learning and improvement- and system-based practice.


The 20th century witnessed the formation of professional societies of pediatricians around the globe. Some of these societies, such as the American Board of Pediatrics (ABP), are concerned with education and the awarding of credentials certifying competence as a pediatrician and/or a pediatric subspecialist. At the beginning of 2004, the ABP reported that there were ≈79,000 board-certified pediatricians. Among those presenting for 1st time certification to the ABP in 2003, 80% were American Medical Graduates (20% were International Medical Graduates) and 63% were women. Other societies are primarily concerned with organizing members of the profession in their country or region to dedicate their efforts and resources toward children. In the United States, the American Academy of Pediatrics (AAP), formed in 1930, currently has a membership of ≈60,000 child health specialists in both academic and private practice. Most general pediatricians in the United States enter private practice; ≈66% are in group practices, 5% enter solo practice, and 5% work in a health maintenance organization. The AAP provides a variety of continuing educational services to pediatricians in multiple national and regional settings and tracks the professional activities and practices of its members. A comparable group in India, the Indian Academy of Pediatrics, was formed in 1963, and now has >13,000 members and 16 subspecialty chapters. Likewise, the Pakistani Pediatrics Association is >35 years old, the Malaysian Pediatric Association was started about 25 years ago, and the Canadian Pediatric Society was founded in 1922. These societies represent but a few of the many national and regional pediatric professional organizations around the world.

The amount of information relevant to child health care is rapidly expanding, and no person can become master of it all. Physicians are increasingly dependent on one another for the highest quality of care for their patients. About 25% of pediatricians in the United States claim an area of special knowledge and skill, including 15,000 who have board certification in 1 of the 13 pediatric subspecialties with board certification. Each year about 10% of the ≈3,000 pediatric residents training in the United States are enrolled in a dual residency training program that will lead to eligibility for board certification in both pediatrics and internal medicine.

The growth of specialization within pediatrics has taken a number of different forms: interests in problems of age groups of children have created neonatology and adolescent medicine; interests in organ systems have created pediatric cardiology, neurology, child development, allergy, hematology, nephrology, gastroenterology, child psychiatry, pulmonology, endocrinology, and specialization in metabolism and genetics; interests in the health care system have created pediatricians devoted to ambulatory care, emergency care, and intensive care; and, finally, multidisciplinary subspecialties have grown up around the problems of handicapped children, to which pediatrics, neurology, psychiatry, psychology, nursing, physical and occupational therapy, special education, speech therapy, audiology, and nutrition all make essential contributions. This growth of specialization has been most conspicuous in university-affiliated departments of pediatrics and medical centers for children.

In the United States, most subspecialists practice in academic settings or children's hospitals. Likewise, specialists are growing in number in other industrialized countries and in developing nations that are becoming industrialized.


The explosion of information has also created new challenges for continuing education. In earlier years, new information in any field of medicine was easily accessible through a relatively small number of journals, texts, or monographs. Today, relevant information is so widely dispersed among the many journals that elaborate electronic data systems are necessary to make it accessible. The Internet has dramatically improved access to information by physicians and patients, but judgment about the quality, clinical significance, accuracy, bias, and appropriate use of such information is a challenge. In 2002, 95% of pediatricians surveyed reported using a computer in the office; 50% reported accessing the Internet daily, most for medical information. One third used a personal digital assistant, most frequently for scheduling and for access to pharmacology references. Only 14% reported using email to communicate with patients, although about 50% would accept prescription refill requests by email. The American Board of Pediatrics and the American Academy of Pediatrics have arranged for close linkage of continuing education of pediatricians to recertification in pediatrics.

Whereas the Internet is important in the United States, it is revolutionizing access to medical knowledge in developing and transitional countries. Previously, medical schools in these settings were highly dependent on slow and often unpredictable mail systems to connect them with medical advances, new directions in medical practice, and medical colleagues in general. Now, many of the same schools have immediate access to hundreds of journals and their professional counterparts across the globe.

There is no touchstone through which physicians can ensure that the process of their own continuing education will keep them abreast of advancing knowledge in the field, but they must find a way to base their decisions on the best available scientific evidence if they are to discharge their responsibility to their patients. An essential element of this process may be for physicians to take an active role, such as participating in medical student and resident education. Efforts in continuing self-education will also be fostered if clinical problems can be made a stimulus for a review of standard literature, alone or in consultation with an appropriate colleague or consultant. This continuing review will do much to identify those inconsistencies or contradictions that will indicate, in the ultimate best interest of patients, that things are not what they seem or have been said to be. Physicians still learn most from their patients, but this will not be the case if they fall into the easy habit of accepting their patients' problems casually or at face value because the problems appear to be simple.

The tools that physicians must use in dealing with the problems of children and their families fall into three main categories: cognitive (up-to-date factual information about diagnostic and therapeutic issues, available on recall or easily found in readily accessible sources, and the ability to relate this information to the pathophysiology of their patients in the context of individual biologic variability); interpersonal or manual (the ability to carry out a productive interview, execute a reliable physical examination, perform a deft venipuncture, or manage cardiac arrest or resuscitation of a depressed newborn infant); and attitudinal (the physician's unselfish commitment to the fullest possible implementation of knowledge and skills on behalf of children and their families in an atmosphere of empathic sensitivity and concern). With regard to this last category, it is important that children participate with their families in informed decision-making about their own health care in a manner appropriate to their stage of development and the nature of the particular health problem.

The workaday needs of professional persons for knowledge and skills in care of children vary widely. Primary care physicians need depth in developmental concepts and in the ability to organize an effective system for achieving quality and continuity in assessing and planning for health care during the entire period of growth. They may often have little or no need for immediate recall of esoterica. On the other hand, consultants or subspecialists not only need a comfortable grasp of both common and uncommon facts within their field and perhaps within related fields, but also must be able to cope with controversial issues with flexibility that will permit adaptation of various points of view to the best interest of their unique patient.

At whatever level of care (primary, secondary, or tertiary) or in whatever position (student, pediatric nurse practitioner, resident pediatrician, practitioner of pediatrics or family medicine, or pediatric or other subspecialists), professional persons dealing with children must be able to identify their roles of the moment and their levels of engagement with a child's problem; each must determine whether his or her experience and other resources at hand are adequate to deal with this problem and must be ready to seek other help when they are not. Among the necessary resources are general textbooks, more detailed monographs in subspecialty areas, selected journals, access to Internet materials, audiovisual aids, and, above all, colleagues with exceptional or complementary experience and expertise. The intercommunication of all these levels of engagement with medical and health problems of children offers the best hope of bringing us closer to the goal of providing the opportunity for all children to achieve their maximum potential.