AMA Journal of Ethics^®

The bounds of the patient-physician relationship are difficult to define in pediatrics because of the necessary involvement of the child's surrogate decision maker usually, the parent. The triadic relationship, patient-parent-physician, adds complexity because it often means considering both the child's best interests and what his or her parents see as the family's best interests. The literature has raised questions about the appropriate role of parental and family interests in clinical decision making for children.

In a recent report, the Task Force on Family of the American Academy of Pediatrics (AAP) has taken an interesting look at the patient-parent-physician relationship by examining the appropriate role for pediatricians in family decision making.¹ For example, what is the physician's role when parents divorce and a custody a battle ensues? Is it appropriate for a pediatrician to speak to a patient's parent about healthy parent-to-parent communication? A quarter of all pediatric office visits are associated with children's psychosomatic, social, or behavioral problems,² a fact which suggests that parents often turn to pediatricians to treat problems other than childhood illness and for assistance in raising socially integrated, well-adjusted children.

The AAP task force points out that the primary role of pediatricians is to treat illness and maintain child well-being, but it emphasizes that this must be done within the context of the family. This expansion on the traditional role of the pediatrician requires an understanding of the family's strengths and weaknesses and a push from the physician to promote the coherence and healthiness of the family structure because it is so closely linked to the child's well-being.

The task force suggests that it is necessary for pediatricians and family researchers to work together towards a greater understanding of how successful families function and of how to improve weaker families and teach them to be more supportive. The report stresses the need for physicians to recognize the diversity among families and to encourage resilience within families. The report calls for closer alliance not only between family researchers and pediatricians but also between pediatricians and parents, by suggesting it is appropriate for pediatricians to take on the role of the parents' coach in learning how to be better caregivers.

In formulating its policy recommendations, the task forces considered both pragmatic and philosophical issues. For example, are current reimbursement practices sufficient for pediatricians to extend clinical encounter time to family concerns? What does society see as an appropriate role for nonfamily members, such as physicians, in child rearing?

Despite pragmatic challenges and perhaps some societal objections, the task force believes that the importance of families to children's well-being makes it imperative that pediatricians take a more active role in encouraging healthy families. Although the AAP has acknowledged in the past the role of families in the practice of pediatrics, this report calls for pediatricians as a group, as well as individual physicians, to more diligently and consistently advocate for the promotion of child health by supporting their patients' families.

The report offers 80 recommendations, which can grouped into 4 categories. The first category covers educational recommendations for both residency programs and continuing medical education, such as requiring residents to be able to explain the value of a father's involvement in the home and assist families in understanding the problems and risks associated with stepfamilies and live-in partners. The AAP also advocates that continuing medical education for pediatricians should include, for example, a course that examines both the impact of a child's health problem on the family and the impact of the family's problems on the child's health. Second, the task force recommends that the AAP advocate both publicly and internally for policies and education programs that "encourage, support, promote, and help to sustain healthy marriages."³ While the report finds value in the traditional 2-parent family, it also stresses the need for pediatricians to help families of all varieties to understand and meet the needs of the family's children.

The third category encompasses practice-directed recommendations such as pediatricians helping parents understand and fulfill their roles as the primary caregivers to their children's physical, emotional, and social well-being. For example, it is appropriate, according to the report, for pediatricians to discuss such issues with parents as daily child care arrangements, parental choices concerning work schedules, and how much time they choose to allocate to their children, as well as other family members' tobacco or alcohol use and how it may affect the children in the home. Finally, the report makes a number of recommendations for future research such as studying how best to support single-parent families and how best to involve absentee or adolescent fathers in the lives of their children.