PROFESSIONALISM FOR PEDIATRICIANS

PROFESSIONALISM FOR PEDIATRICIANS

The American Board of Pediatrics adopted professional standards in 2000, as follows:

1. Honesty/integrity is the consistent regard for the highest standards of behavior and the refusal to violate one's personal and professional codes. Honesty and integrity imply being fair, being truthful, keeping one's word, meeting commitments, and being forthright in interactions with patients and peers and in all professional work, whether through documentation, personal communication, presentations, research, or other interactions. Maintaining integrity requires awareness of situations that may result in conflict of interest or that may result in personal gain at the expense of the best interest of the patient.


2. Reliability/responsibility means being responsible for and accountable to others. First, there must be accountability to one's patients, not only to children but also to their families. Second, there must be accountability to society to ensure that the public's needs are addressed. Third, the pediatrician must be accountable to the profession to ensure that the ethical precepts of practice are upheld. Inherent in this responsibility is reliability in completing assigned duties or fulfilling commitments. There also must be a willingness to accept responsibility for errors.


3. Respect for others is the essence of humanism, and humanism is central to professionalism. This respect extends to all spheres of contact, including, but not limited to, patients, families, other physicians, and professional colleagues, including nurses, residents, fellows, and medical students. The pediatrician must treat all persons with respect and regard for their individual worth and dignity. The pediatrician must be fair and nondiscriminatory and be aware of emotional, personal, family, and cultural influences on a patient's well-being, rights, and choices of medical care. It is also a professional obligation to respect appropriate patient confidentiality.


4. Compassion/empathy is a crucial component of the practice of pediatrics. The pediatrician must listen attentively and respond humanely to the concerns of patients and family members. Appropriate empathy for and relief of pain, discomfort, and anxiety should be part of the daily practice of pediatric medicine.


5. Self-improvement is the pursuit of and commitment to providing the highest quality of health care through lifelong learning and education. The pediatrician must seek to learn from errors and aspire to excellence through self-evaluation and acceptance of the critiques of others.


6. Self-awareness/knowledge of limits includes recognition of the need for guidance and supervision when faced with new or complex responsibilities. The pediatrician also must be insightful regarding the impact of his or her behavior on others and cognizant of appropriate professional boundaries.


7. Communication/collaboration is crucial to providing the best care for patients. Pediatricians must work cooperatively and communicate effectively with patients and their families and with all healthcare providers involved in the care of their patients.


8. Altruism/advocacy refers to unselfish regard for and devotion to the welfare of others. It is a key element of professionalism. Self-interest or the interests of other parties should not interfere with the care of one's patients and their families.

CHALLENGES OF PROFESSIONALISM

CHALLENGES OF PROFESSIONALISM

The inappropriate actions of a few practicing physicians, physician investigators, and physicians in positions of power in the corporate world, have created a societal demand to punish those involved and have led to the erosion of respect for the medical profession. These negative physician behaviors include the following:

• Abuse of power


• Sexual harassment and inappropriate sexual behavior


• Conflict of interest and inappropriate financial gain


• Professional arrogance and greed


• Physician impairment from drugs and alcohol


• Fraud in research and practice-misrepresentation


• Loss of conscientiousness in fulfilling responsibilities

The AAP, the American Board of Pediatrics, the American Board of Internal Medicine, the Liaison Committee on Medical Education, the Medical Student Objectives Project of the Association of American Medical Colleges, and the ACGME in their Outcomes Project have called for increasing attention to professionalism in the practice of medicine and in the education of physicians.

Professionalism

Professionalism

CONCEPT OF PROFESSIONALISM

Society provides a profession with economic, political, and social rewards. Professions have specialized knowledge, and when it is difficult to measure the quality of its work, a profession has the potential to maintain a monopoly on power and control, remaining relatively autonomous. The profession's autonomy can be limited by societal needs. A profession exists as long as it fulfills its responsibilities for the social good. In the past, simply being a physician was considered by many to be a sufficient measure of high-quality health care.

Today the medical professional's activities are subject to explicit public rules of accountability. Governmental and other authorities, whose function is to foster social and distributive justice and the public good, grant limited autonomy to the professional organizations and their membership. City and municipal government departments of public health establish and implement heath standards and regulations. At the state level, boards of registration in medicine, with powers to investigate physician impairment, establish the criteria for obtaining and revoking medical licenses. The federal government has an increasing role in funding direct medical care and regulating the standards of services, which include national programs such as Medicare and Medicaid and the Food and Drug Administration. The Department of Health and Human Services regulates physician behavior in conducting research with the goal of protecting human subjects. The Health Care Quality Act of 1986 authorized the federal government to establish The National Practitioner Data Bank, which began in 1990. This data bank contains information about physicians (and other healthcare clinicians) who have been disciplined by a state licensing board, a professional society (local or national), a hospital, or a health plan.

Practitioners who have been named in medical malpractice judgments or settlements also are included. Hospitals are required to review information in this data bank every 2 years as part of clinician recredentialing. There are accrediting agencies for medical schools (Liaison Committee on Medical Education) and postgraduate training (Accreditation Council for Graduate Medical Education [ACGME]). The ACGME includes establishing committees that review residency subspecialty training programs. At the individual physician level, the various specialty boards determine the criteria for competency for practice, including various examinations for board certification. Specialty certification is time limited, and physicians who wish to retain their certification are re-examined periodically. State boards of registration also adjudicate the question of the competence of the physician on an individual basis.

Historically, the most privileged professions have depended for their legitimacy on serving the public interest. The profession should be the guardian of social values emanating from that profession and negotiated with the public. A profession should not become more concerned about its own business, economics, and political interests than the interests of the people it serves. The public trust of physicians is based on the physician's commitment to altruism. The ACGME has established competency standards for its accreditation of residency programs. Among numerous required competencies is that of professionalism, which embodies altruism. Many medical schools include variations on the traditional Hippocratic oath as part of the commencement ceremonies as a recognition of a physician's responsibility to put the interest of others ahead of self-interest.

The core of professionalism is embedded in the daily healing work of the physician and encompassed in the patient-physician relationship. The goal in this relationship is to act in the best interest of the patient using all of the technologic, scientific, and humanistic experiences available. Professionalism includes an appreciation for the cultural and religious/spiritual health beliefs of the patient, incorporating the ethical and moral values of the profession and the moral values of the patient. Professionalism includes the family and the community as an important element of the healing perspective. The community perspective includes advocacy for the individual patient and advocacy for the community.

CULTURE

CULTURE

Culture is an active, dynamic, and complex process of the way people interact and behave in the world. Culture encompasses the concepts, beliefs, values (including nurturing of children), and standards of behavior, language, and dress attributable to people that give order to their experiences in the world, give sense and purpose to their interactions with others, and provide meaning for their lives. Culture requires an attempt to understand, from the patient and family perspective, questions such as: What is the nature of health? How does one keep healthy? What is the nature of illness? How does the illness work? Where does it come from (illness attribution, etiology)? What is the approach to treatment? and What is the expected outcome? An appropriate inquiry that addresses this realm includes open-ended questions such as: "What worries (concerns) you the most about your child's illness?" or "What do you think has caused your child's illness?" These questions facilitate the patient's or family's discussion of their thoughts and feelings about the illness and its causes. Cultural understanding also includes concepts and beliefs about how one interacts with health professionals and what one expects from health professionals. The spiritual and religious aspect of health and health care also can be viewed from this perspective. These differences in perspectives, values, or beliefs may affect the health of the child in an adverse way and may result in differences between the pediatrician and the patient and family. Significant conflicts may arise because religious or cultural practices may lead to the possibility of child abuse and neglect. In this circumstance, the pediatrician is required by law to report the suspected child abuse and neglect to the appropriate social service authorities (see Chapter 22).

Complementary and alternative medicine (CAM) practices constitute a part of the broad cultural perspective. It is estimated that 20% to 30% of all children use some CAM; 50% to 75% of adolescents use CAM. Of children with chronic illness, 30% to 70% use CAM therapies, especially for asthma and cystic fibrosis, whereas only 30% to 60% of children and families tell their physicians about their use of CAM. Therapeutic modalities for CAM include biochemical, lifestyle, biomechanical, bioenergetic, and homeopathy. Some modalities may be effective, whereas others may be ineffective or even dangerous.

By 2020, almost half of U.S. children will be of Latino, African American, Asian, or Native American ethnicity. In many states, this shift already has occurred. Currently, there are immigrants and refugees from Southeast Asia, eastern Europe, the Middle East, Asia, Africa, Central America, South America, and other parts of the world, with a variety of languages and health beliefs. Rapidly changing demographic shifts in populations make it likely that the pediatrician will encounter many different cultural identities. Understanding patient and family health beliefs and practices enables pediatricians to practice better health care.

CHANGING MORBIDITY

CHANGING MORBIDITY

Changing morbidity stresses the relationship between environmental, social, emotional, and developmental issues and child health status and outcome. This approach is based on significant interactions of biopsychosocial influences on health and illness and stresses that poverty and access to health care should be a major concern of pediatricians. These health issues include the following:

• School problems, learning disabilities, and attention problems


• Child and adolescent mood and anxiety disorders


• Adolescent suicide and homicide


• Firearms in the home


• School violence


• HIV


• The effects of media violence, obesity, and sexual activity


• Substance use and abuse by adolescents, especially the abuse of alcohol

Currently, 20% to 25% of children are estimated to have some mental health problem; 5% to 6% of these problems are severe. Pediatricians are estimated to identify only 50% of mental health problems. Data based on screening in pediatric office settings suggest an overall prevalence of psychosocial dysfunction of preschool and school-age children to be 10% and 13%, respectively. Children from poor families are twice as likely to have psychosocial problems as children from higher income families.

Other important influences on children's health include poverty, homelessness, single-parent families, parental divorce, domestic violence, both parents working, and adequate childcare. Related pediatric challenges include improving the quality of health care, social justice, equality in healthcare access, and improving the public health system. For adolescents, there are special concerns about sexuality, sexual orientation, substance use and abuse, violence, depression, and suicide (see Section XII).

HEALTH DISPARITIES IN HEALTH CARE FOR CHILDREN

HEALTH DISPARITIES IN HEALTH CARE FOR CHILDREN

Health disparities are defined as the differences that remain after taking into account patients' needs and preferences and the availability of health care. Social conditions, social inequity, discrimination, social stress, language barriers, and poverty are antecedents to and associated causes of health disparities. The disparities in infant mortality relate to poor access to prenatal care during pregnancy and the lack of access and appropriate heath services for women throughout their life span, such as preventive services, family planning, and appropriate nutrition and health care.

• Infant mortality increases as the mother's level of education decreases.


• Poorer children are less likely to be immunized at age 4 years and are less likely to receive dental care.


• Rates of hospital admission for treatable disease are higher for people who live in low-income areas.


• Children of ethnic minorities and children from poor families are less likely to have physician office or hospital outpatient visits and are more likely to have hospital emergency department visits.


• Access to care for children is easier for non-Hispanic whites and for children of higher income families than for minority and low-income families.

Other heath issues that represent challenges for pediatricians include the following:

• Although there was a decline in cigarette smoking in high school students from 36% in 1997 to 29% in 2001, more than a quarter of high school students still smoke.


• Among high school students, 38% of girls and 24% of boys do not engage in recommended amounts of moderate or vigorous physical activity.


• The prevalence of overweight children among those 6 to 11 years old doubled from 7% to 15% (1976-1980 to 1999-2000), and the prevalence of overweight adolescents among those 12 to 19 years old tripled from 5% to 16% during the same time. Obesity and its associated morbidities are a serious public health concern. It is estimated that 65% of U.S. adults are overweight or obese; this is associated with 300,000 deaths a year and at least $117 billion in healthcare costs.
  In 2000, it was estimated that $64.7 billion was spent treating injuries in the U.S., with injury-attributable medical expenses of $117.2 billion. For children up to 19 years old, the expenses for medical treatment were $24.4 billion, and attributed medical expenses were $29.1 billion. A significant percentage of injuries in adolescents are associated with alcohol abuse.


• In 1999-2000, the Head Start program served only 60% of eligible children. There were almost 13 million children in federal Title I reading programs, and greater than 6 million children qualified for disabilities under the Individuals with Disabilities Education Act.


• The school dropout rate for children was 14.5%.
  In 1999-2000, greater than 800,000 children were abused, approximately 500,000 children were in foster care, and 2.3 million were in the care of grandparents; 18.8% of children were living in poverty. In the same years, 1.7 million juveniles were arrested, 112,479 young people were in correctional institutions for juveniles, and 18.8% of these (21,130) were in adult prison facilities.

HEALTH STATUS OF AMERICAN CHILDREN

HEALTH STATUS OF AMERICAN CHILDREN

In 2002, there were slightly more than 4 million births. About 33.8% of these were to unmarried women. This percentage increased from 2001-2002 in non-Hispanic whites by 22.9%, in Hispanics by 43.4% and decreased in African Americans by 68%.
Of the current 72.2 million children (2002), 9.7 million children (13%) have no health insurance coverage for a full year. At any time, 24%, approximately 17 to 18 million children, go without health insurance. Insurance coverage under Medicaid, the State Child Health Insurance Plan (SCHIP), and private employer-based insurance varies by populations: 17% of white, 22% of African American, and 41% of Hispanic children had no health insurance at some time during a year. There is also variation by income: 10% of children with family incomes of 400% or greater above the poverty level had no health insurance, in contrast to 31% of all children with family incomes of 100% to 199% of poverty.

Access to primary care is a major goal for children. In 2000, 87% of all children were reported to have a primary care clinician, with most of this care provided by pediatricians. Ninety-one percent of whites and 75% of Hispanics reported a primary care provider; 93% of high-income families and 81% of poor families identified a primary care provider. The AAP advocates that all children have a medical home where their pediatrician and medical team provide needed preventive and curative services.
Prenatal care in the first trimester has increased by 11% since 1990, with 83.4% of all women receiving prenatal care. Whites (88.7%), Hispanics (76.8%), and African Americans (60.6%) begin prenatal care in the first trimester. Smoking has declined considerably, with only 12% of pregnant women reporting smoking in 2002. Cesarean sections have increased to 26.1% of all births. The incidence of preterm births has been increasing since the 1980s, with an increased rate in whites and a decreased rate in blacks. There has been an increase in low birth weight infants (<2500g [7.7% of all births]) and a steady rate of very low birth weight infants (<1500 g [1.5% of all births]) since the 1990s.

The national birthrate for adolescents has been steadily dropping since 1990, with more teenagers delaying their first sexual experience or using birth control (or both). There also was a 39% decrease in abortion in adolescents from 1990 to 1999. In 1999, however, there were approximately 487,000 live births to adolescents 19 years old and younger and 556,000 abortions.

There has been an overall decline in infant mortality by 46% since 1980, with equal declines in the rates for white and the nonwhite populations (see Section XI). The disparity between the ethnic groups has not changed. In 2001, the rates per 1000 live births were white, non-Hispanic, 5.7; Hispanic, 5.7; and African American, 14. In 2000, the U.S. ranked 25th in the infant mortality rate, below the Czech Republic, Cuba, Portugal, and Greece. Marked variations in infant mortality also exist by state. New Hampshire and Minnesota had the lowest infant mortality rates in the U.S., whereas West Virginia, Louisiana, and Mississippi had the highest, comparable to developing countries.

The overall causes of death in all children (1-19 years old) in the U.S. in 2001, in order of frequency, were injuries, assaults (homicide), malignant neoplasms, suicide, and congenital malformations (Table 1-1). For 2001, there were 25,757 deaths in children age 1 to 19 years. Of that total, 15,726 (61%) deaths of children were violence related secondary to injuries (11,196), homicide (2640), and suicide (1890). Many deaths are associated with alcohol abuse. Two thirds of child passengers (≤14 years old) die in automobile crashes in association with a drunk driver.

From 2000 to 2001, there were decreases in the rate of injuries in all ages, a decrease in malignant neoplasms, and a decrease in deaths from congenital malformations in the age group 5 to 14 years. There was an increase in the death rate from heart diseases and congenital malformations in the age group 1 to 4 years. Although there was a decrease in the rate of suicide for children (10 to 19 years), there was an increase in deaths caused by assaults and homicide in the age groups 1 to 4 years (35%) and 15 to 19 years (4.4%).

CURRENT CHALLENGES

CURRENT CHALLENGES

Current challenges in the care of children are access to health care; health disparities; children's social, cognitive, and emotional lives; congenital and genetic disorders; and environmental factors that affect optimal outcome of child health. Scientific advances in genetics are particularly relevant to pediatrics. With newer genetic technologies, pediatricians are able to diagnose diseases at the molecular level. Microarray genetic technology can identify the cluster of candidate genes associated with a variety of diseases; this technology is now used for the prognosis of diseases (e.g., cancer). Prenatal diagnosis of a variety of genetic diseases is now possible. Mandatory and recommended newborn screening for genetic and metabolic diseases has improved the accuracy of early diagnosis of these conditions, which, although rare, are often treatable. Giving folic acid to women of childbearing age reduces the risk of neural tube defects. The blood triple or quadruple screen during pregnancy and intrauterine ultrasound as a screening tool to detect fetal malformations and deformations provide information for diagnosis, prognosis, and clinical decision making. Functional magnetic resonance imaging allows a greater understanding of psychiatric and neurologic problems, such as dyslexia and attention-deficit/hyperactivity disorder.

The incidence of many serious bacterial and viral infections has been significantly reduced or eliminated by immunizations. Smallpox has been eliminated worldwide, and polio should be eliminated shortly. The overwhelming success of immunization programs in preventing many of the serious diseases seen in children in the last century has been associated with concerns about minor immunization side effects and rare complications. Pediatricians must continue to seek the safest vaccines possible, but they should oppose vigorously any attempts to limit the use of proven successful immunizations when the risk of complications is remote compared with the serious risk of clinical disease. The inappropriate claim of a causal association of autistic spectrum disorders and the measles vaccine has been disproved, and there have been numerous outbreaks of measles in unimmunized children.

There is increasing concern about environmental toxins in the food chain affecting children's growth and development and the ever-present problem of air pollution adversely affecting children's pulmonary function. Children are subject to physical, emotional, and sexual abuse; they also are victims of and bear witness to violence. Many immigrant families have seen death, destruction, terrorism, and war, all of which affect children's emotional development. Since the September 11, 2001, destruction of the World Trade Center, fear of terrorism has increased the level of anxiety for many families and children.

Pediatricians need to practice as part of an expanded healthcare team. Nurse practitioners provide well-child care and, in collaboration with pediatricians, care for common illnesses. Many pediatricians practice collaboratively with psychiatrists, psychologists, nurses, lawyers, and social workers. School health and school-based health clinics have improved access and outcomes for many common childhood and adolescent conditions.

Childhood antecedents of adult health conditions, such as alcoholism, depression, obesity, hypertension, and hyperlipidemias, are increasingly being recognized. There is an increase in the diagnosis of obesity and type 2 diabetes and a possible increase in the incidence of autistic spectrum disorders, although the latter may be secondary to improved diagnosis. Because of improved neonatal care, a greater percentage of preterm, low birth weight, or very low birth weight newborns are surviving, increasing the number of children with chronic medical conditions and developmental delays. Death from congenital malformations and malignant neoplasms is less common than previously, but these conditions remain the second and third most important causes of death after injuries in the 1- to 4-year-old population.

A BRIEF HISTORY OF PEDIATRICS

A BRIEF HISTORY OF PEDIATRICS

In England in 1769, Dr. George Armstrong established a dispensary for the poor children of London in the impoverished Red Lion Square district. Dr. Armstrong, a role model for today's socially conscious pediatricians, authored one of the first pediatric textbooks, Essay on Diseases Most Fatal to Infants.

During colonial times, there were a few physicians who were interested in children. Benjamin Rush (a signer of the Declaration of Independence) presented lectures specific to diseases of children. The first formal medical student courses about children's health were at Yale College (1813-1852). The first children's hospital in the English-speaking world was the Hospital for Sick Children on Great Ormond St. (GOS), London (1852). Charles Dickens lived within a few blocks of the hospital and raised money for GOS with readings from A Christmas Carol. The first children's hospital in the U.S. was founded by Dr. Francis W. Lewis, who visited GOS and then established the Children's Hospital of Philadelphia (1855). Dr. Abraham Jacobi was the founder of American pediatrics. He established the first children's clinic in the U.S. (1860), in New York City. The next two children's hospitals were Boston Children's Hospital (1869) and the Children's Hospital National Medical Center, Washington, D.C. (1870). Dr. Jacobi was a founding member of the Section of Pediatrics of the American Medical Association (AMA) and was the first president of the American Pediatric Society (1888). In 1897, Dr. L. Emmet Holt authored his classic American textbook The Diseases of Infancy and Childhood.

As the particular problems of children were identified, the federal government responded by accepting responsibility for the care of vulnerable children. In 1909, President Theodore Roosevelt convened the first of many White House conferences on the Care of Dependant Children. In 1912, the federal government established the U.S. Children's Bureau. In 1921, Congress passed the Sheppard-Towner Act, which authorized federal direct care for children. The AMA condemned the act as socialized medicine. When the Pediatric Section of the AMA House of Delegates endorsed the renewal of the Sheppard-Towner Act in 1929, the AMA House of Delegates rebuked the Pediatric Section and reversed the Section position, adopting a policy that prohibited any Section from taking any action without endorsement from the AMA House of Delegates. Key members of the Pediatric Section responded by recognizing the need for an independent professional organization and established the American Academy of Pediatrics (AAP) in 1930. The founders of the AAP declared that the core mission would be "to attain optimal physical, mental and social health and well being for all infants, children, adolescents and young adults." Through its many programs and projects, the AAP would seek to address " the needs of children, their families, and their communities… through advocacy, education, research, and service." The AAP remains the only national professional health organization whose goal is to serve and advocate for children and not just to serve the needs of its membership.

The Society for Pediatric Research was established for young basic science investigators in 1931. The Ambulatory Pediatric Association was founded in 1960 by a group of hospital outpatient directors interested in developing ambulatory care and health services research.

A BRIEF HISTORY OF PEDIATRICS

A BRIEF HISTORY OF PEDIATRICS

In England in 1769, Dr. George Armstrong established a dispensary for the poor children of London in the impoverished Red Lion Square district. Dr. Armstrong, a role model for today's socially conscious pediatricians, authored one of the first pediatric textbooks, Essay on Diseases Most Fatal to Infants.

During colonial times, there were a few physicians who were interested in children. Benjamin Rush (a signer of the Declaration of Independence) presented lectures specific to diseases of children. The first formal medical student courses about children's health were at Yale College (1813-1852). The first children's hospital in the English-speaking world was the Hospital for Sick Children on Great Ormond St. (GOS), London (1852). Charles Dickens lived within a few blocks of the hospital and raised money for GOS with readings from A Christmas Carol. The first children's hospital in the U.S. was founded by Dr. Francis W. Lewis, who visited GOS and then established the Children's Hospital of Philadelphia (1855). Dr. Abraham Jacobi was the founder of American pediatrics. He established the first children's clinic in the U.S. (1860), in New York City. The next two children's hospitals were Boston Children's Hospital (1869) and the Children's Hospital National Medical Center, Washington, D.C. (1870). Dr. Jacobi was a founding member of the Section of Pediatrics of the American Medical Association (AMA) and was the first president of the American Pediatric Society (1888). In 1897, Dr. L. Emmet Holt authored his classic American textbook The Diseases of Infancy and Childhood.

As the particular problems of children were identified, the federal government responded by accepting responsibility for the care of vulnerable children. In 1909, President Theodore Roosevelt convened the first of many White House conferences on the Care of Dependant Children. In 1912, the federal government established the U.S. Children's Bureau. In 1921, Congress passed the Sheppard-Towner Act, which authorized federal direct care for children. The AMA condemned the act as socialized medicine. When the Pediatric Section of the AMA House of Delegates endorsed the renewal of the Sheppard-Towner Act in 1929, the AMA House of Delegates rebuked the Pediatric Section and reversed the Section position, adopting a policy that prohibited any Section from taking any action without endorsement from the AMA House of Delegates. Key members of the Pediatric Section responded by recognizing the need for an independent professional organization and established the American Academy of Pediatrics (AAP) in 1930. The founders of the AAP declared that the core mission would be "to attain optimal physical, mental and social health and well being for all infants, children, adolescents and young adults." Through its many programs and projects, the AAP would seek to address " the needs of children, their families, and their communities… through advocacy, education, research, and service." The AAP remains the only national professional health organization whose goal is to serve and advocate for children and not just to serve the needs of its membership.

The Society for Pediatric Research was established for young basic science investigators in 1931. The Ambulatory Pediatric Association was founded in 1960 by a group of hospital outpatient directors interested in developing ambulatory care and health services research.

Population and Culture: The Care of Children in Society

Population and Culture: The Care of Children in Society

Many medical, developmental, and psychosocial issues challenge pediatricians and their patients in the U.S., which is a nation of cultural and ethnic diversity. We need to appreciate the prevalence of medical conditions and the social and environmental influences associated with such conditions, including health disparities and cultural issues, in providing pediatric care. We depend on the science of pediatrics to expand our ability to practice evidence-based medicine. New technologies and treatments help to improve morbidity, mortality, and the quality of life for children and their families, but also increase the costs of medical care. The challenge for pediatricians is to deliver care that is socially equitable and available for all children.