At pediatric Grand Rounds on a cool September morning in 2016, Tina Cheng presented a sweeping range of challenges facing faculty and staff members of Johns Hopkins Children’s Center. She cited new and shifting epidemics, like childhood obesity and opioid addiction, increases in adverse childhood experiences and inner-city violence, a widening gap between the rich and the poor.

The United States, she noted, ranks 26th out of 29 developed countries in child well-being. With her pediatrician’s eye on the horizon during a national election year, Cheng anticipated declin­ing biomedical research dollars, dramatic changes in health insur­ance for families and potential cuts in federal support of health care spending for children. “How do we address it all?” Cheng asked the residents and faculty members packing the auditorium.

Then Cheng reiterated in multiple ways the institution’s mission and reputation as the birthplace of modern pediatric medicine and its great achievements in pediatric research that have led to increased survival and improved quality of life for children. She noted emerging new concepts of pediatric care like life course theory—treating the whole child, the whole family, the whole community to influence health across the life span—and treating children in the context of their lives. She talked about the “three-generation continuum,” in which pediatricians are urged to focus not only on the parents and the child but the next generation to come to optimize their health and wellness. She cited terms like precision medicine, population health and “big data,” as though within them lie solutions to improving child health. By reaching out into the community and identifying social determinants of health, like education, employment, food and housing, and their impact on families, Cheng emphasized, pediatricians could actually reduce or prevent their need for health care services: “Pediatri­cians can do more than care for children. They have the power to change their lives—to pre-empt injury and illness.”

It seemed Cheng would take a breath, slow down or end this talk. Instead, she posed a challenge: “Some people have said our strategic plan is kind of bland, that we don’t have a North Star. I think for us our North Star is pretty clear—it is the children and the families we serve and what is in their best interest. I think our future is very bright, but it’s up to us to create that future.”

There was the slightest pause of si­lence in the auditorium, punctuating a growing impression that Cheng, Johns Hopkins’ new pediatrician-in-chief and co-director of Johns Hopkins Children’s Center, could steer its faculty members and staff to the answers, to the North Star and beyond. The ovation was impressive.

“The way she expresses her vision of the future of pediatrics is inspiring to me and, I think, to most people who hear it,” says pediatrics faculty member Maggie Moon. “And she has the focus and skills to help us move in that direction.”

“There are a lot of data around health disparities in Baltimore, which is a real challenge we have to face,” says fellow faculty member Maria Trent. “Tina’s un­derstanding of that will allow her to not only uphold the mission and vision of the larger Johns Hopkins institution but really make a difference for the people who live here.”

From Iowa to Baltimore

In the wake of her Grand Rounds presen­tation, a sense of Tina Cheng emerged—she seldom stands still. As observed by others, her mode of operation is envision, assess, solicit, collaborate, implement and—core to that formula—innovate. She constantly looks forward, then moves ahead thoughtfully, a mindset that dates back almost a half-century to a Coralville, Iowa, elementary school classroom where Cheng wrote “ENT doctor” in her school yearbook, in response to the question, “What do you want to be when you grow up?” She was 6.

“I had a lot of nose bleeds as a kid and a lot of visits to the ENT doctor,” Cheng explains. “The following year, I wrote pediatrist—I meant pediatrician—after reading some books about kids who had illnesses, and one I remember had os­teogenesis imperfecta. I was really taken with the fact that I wanted to help peo­ple and be a doctor.”

One vision led to another, and Cheng, breaking the mold that encouraged young women in the Midwest to attend schools near home, enrolled at Brown University’s combined undergrad-medical school pro­gram: “I can’t say I knew very much about Brown. I just ended up there.”

The child of immigrant Chinese par­ents—her father was a biochemist, her mother, a kindergarten teacher—and one of only three Asians in her high school class, Cheng feels she may have been searching for her own identity in selecting a diverse northeastern cam­pus. Diversity she also found in Brown’s curriculum as a biology major, which allowed her the flexibility to take elec­tives like international relations, history and literature. Brown and a wider world stimulated her, though she would not stray far from medicine. She did, how­ever, reconsider pediatrics.

“People said women should not go into pediatrics. I didn’t want to be ste­reotyped, so in medical school I wasn’t thinking I would be a pediatrician,” says Cheng. “When my colleagues said to take the rotation you think you don’t want first, I selected pediatrics. But I loved it and saw great potential to in­fluence kids and their health behaviors early in life.”

The next several years were founda­tional. In medical school at Brown and a pediatrics residency at the University of California, San Francisco, she found taking care of patients extremely reward­ing, but she wanted to make more of a difference. The public health scientist in Cheng emerged: “I loved seeing patients one on one, but I also thought about how we could make a bigger impact across populations.”

That vision led her to a preventive medicine residency and a graduate degree in public health at the University of California, Berkeley, followed by a research fellowship at the University of Massachusetts. Working with underserved populations and studying injury prevention and child health disparities deeply resonated with her and became her next quest, which she found at Children’s National Health System in Washington, D.C. Eight years later, she got a call from Julia McMillan, head of a search committee for a new director of the Division of General Pediatrics and Adolescent Medicine at Johns Hopkins Children’s Center. Was she interested?        Initially, Cheng thought no. She considered herself too early in her aca­demic career to be a division director. Also, while Cheng could cite worthy ac­complishments at Children’s National, including founding the Generations Clinic in Washington, D.C., a clinic for teen mothers and their children recog­nized as an evidence-based practice in reducing rapid repeat pregnancy in ado­lescents, she was not yet a full professor. And, as her mentor warned, “looking can be dangerous.”         But Johns Hopkins had reached out to her, Cheng figured, and if the institu­tion’s goals were in sync with hers, she could take some giant steps in her calling to improve the health of children, noting the division’s strong collaboration with the Johns Hopkins Bloomberg School of Public Health: “I think I had a smaller view of what was possible. Hopkins just has incredible people resources and a culture of striving for excellence.”

Meanwhile, McMillan and former division Director Modena Wilson saw the same determination in Cheng. As a leader, hands-on clinician, accomplished researcher and teacher, and passionate ad­vocate for children, she certainly met the criteria for the job. While they agreed she was junior in age, her achievements were much greater than her age would suggest.

“Tina has a nice way of understating her own accomplishments, but there is a confidence about her,” says McMillan. “I had an impression that if she assessed the situation and believed she could do it, then she could do it. Also, we were looking for a strong leader vested in re­search, and she had this robust record of research in injury prevention and youth violence. Modena thought we’d be lucky to get her.”

Former Pediatrician-in-Chief George Dover agreed, citing Cheng’s advocacy: “Tina emphasized that all children should be exposed to all possible medical care in pediatrics, and that should absolutely be the highest priority in this country.”

Still, not having been groomed by Johns Hopkins, Cheng felt a bit intimidated. Also, she had concerns about whether she would find Johns Hopkins “stuffy” or “supportive.” After she took the division chief post in 2002, she found the latter in abundance.

“I quickly discovered that if you had an idea and a plan,” Cheng says, “Hopkins would provide a platform to take it to the next step.”

And steps she took.

 Forging an Agenda

First off as division director, Cheng saw the urgent need for Johns Hopkins’ pedi­atric primary care clinic—the Harriet Lane Clinic—and subspecialty clinics to be under one outpatient roof. Harriet Lane had limited space within the hospital, and pediatric subspecialists were holding their clinics across campus in an outpatient building designed primarily for adults. The $20 million David M. Rubenstein Child Health Building did not exist when Cheng stepped into her new role, so immediately she began to work with Johns Hopkins leadership and architects to make it hap­pen, which it did in 2007.

In concert with building the new pedi­atric outpatient building, Cheng focused on improving access to care. Another pri­ority was continuing the type of violence prevention research she had conducted in Washington, D.C. Prior to her arrival at Johns Hopkins, adolescents who came into the pediatric Emergency Department (ED) with assault or fight-related injuries were stitched up and sent home. Cheng added a case management violence pre­vention intervention with the patients and families to identify and address the root causes of the injuries.

“What caused the fight? How could it be prevented in the future?” she asked.

This pre-emptive approach resulted in an increase in referrals to commu­nity services, such as mentoring and afterschool programs, bullying preven­tion, conflict resolution and substance use programs. It also led Cheng and pediatric ED physician Leticia Ryan to a violence prevention collaboration in Baltimore and Philadelphia called Take Charge, in which ED patients are re­ferred to a mentoring volunteer with Big Brothers Big Sisters to learn how to solve problems without violence. Cheng’s pre­vious research, says Ryan, shows that a prior violent injury is a strong risk fac­tor for future assault-related injuries and homicide.

“Early results of the Take Charge program have been promising, with participating youth showing improved self-efficacy in avoiding violence, de­creased aggression and problem behav­ior,” says Ryan. “Before this program, we had very little to offer youth who came to the ED with fight-related injuries to help them prevent future injuries.”

In another mentoring and parenting intervention called Healthy Futures, Cheng and her colleagues leveraged the strengths of the youth and families and employed career counseling and tech­niques, like motivational interviewing, to prompt kids to plan for their futures to improve educational, employment and health outcomes.

“If you have more of a sense of your future and how to get there, you’re more likely to move in that direction and not get involved in risky healthy behaviors,” says Cheng.

Her work resonated with faculty members and residents. As an intern inspired by Cheng’s studies targeting families whose health was compromised by poverty, Devan Jaganath proposed an initiative called Financial Futures for Families, in which Harriet Lane Clinic case managers connect families with community resources related to their financial needs, whether that means help getting a job or opening a savings account. In the six months prior to the initiative’s launch in January, Jaganath, now a third-year resident, detected a high number of failed connections for families due to barriers like transportation. But at the end of January, there was a significant rise in successful linkages, showing that having the service in the clinic really reduced some potential barriers.

“The ultimate goals are to see whether integrating financial services in a clinic-based practice increases patients’ and families’ access to services, and results in higher employment, higher income and hopefully better health,” explains Jaganath.

Indeed, as effective services were iden­tified, Cheng and Harriet Lane Clinic Director Barry Solomon incorporated them into an expanding medical home model in the clinic. To help reduce the risk of teen pregnancy and remove barri­ers to preconception care for low-income women, for example, the Preconception Women’s Health in Pediatrics Initiative was added to the menu of clinic services. Today, 14 years after Cheng was named division director, the clinic features nu­merous wraparound services not typi­cally found in a pediatric primary care clinic, including nutrition and lactation services, screening for family social needs and risks, services for mothers experienc­ing depression and intimate partner vio­lence, injury prevention counseling, and a community help desk.

“All of these services and nontradi­tional programs, and our thinking now about the continuum of care, life course theory and the whole child in the fam­ily and the community have been influ­enced by Tina,” says Solomon. “It really comes back to social determinants—people can’t take care of themselves if they don’t have the basics.”

“Tina has broadened the definition of what a medical home should be—a program that addresses multiple needs, from housing and mental health to the health of parents,” adds Dover. “I don’t think anyone will ever create a medical home that has all of the resources Tina has brought to bear, which has become a phenomenal multidimensional approach to optimizing the health of children.”

The clinic is an important point of contact, notes Cheng, but through her lens it cannot solve all the challenges facing families in impoverished com­munities. Her answer? “To appropriately address health disparities, we have to go beyond the clinic and go where the kids are—in the schools.”

In 2014, Cheng and pediatrics fac­ulty member Sara Johnson did just that in a big way. Acting on evidence that students’ access to school-based health services improves attendance and aca­demic performance, they founded the Ruth and Norman Rales Center for the Integration of Health and Education. By supplementing the school nurse model with a medical team that includes a pe­diatrician and pediatric nurse practitio­ner who can diagnose, treat and screen schoolwide for asthma, dental and vision issues, as well as keep immunizations up to date, the center is helping to control chronic diseases like asthma, keeping students in class and out of the ED.

“Tina’s vision has helped promote the idea that by providing comprehensive health services in schools, we can reduce health and educational disparities at the same time,” says Johnson.

In another tack, Cheng looked across the street, leveraging pediatrics’ close alignment with faculty members in the Johns Hopkins Bloomberg School of Public Health to improve the health of Baltimore’s children. Cheng, Johnson and Solomon, among other pediatrics faculty members, have joint appoint­ments in the Bloomberg School of Pub­lic Health’s Department of Population, Family and Reproductive Health, which holds that families remain a fundamen­tal influence on early, lifelong health.

“One of Tina’s strengths was her abil­ity to closely align with leaders at the school of public health, find common ground and collaborate on training and community programs,” says Dover.

For Cheng, these were all pieces of the puzzle in implementing a whole child, whole family, community approach em­phasizing early determinants of health. Meanwhile, through her prolific re­search—Cheng is the author of over 150 publications—speaking at various national conferences and serving in leadership positions with groups like the American Academy of Pediatrics, Cheng was further evolving into a nationally recognized administrator and scholar.

That was a history Johns Hopkins Medicine leadership was well-familiar with when searching for a new chair of pediatrics at Johns Hopkins Bayview Medical Center, a position vacated by Jonathan Ellen after he was named pres­ident, CEO and physician-in-chief for Johns Hopkins All Children’s Hospital in St. Petersburg, Florida. Like Cheng, Ellen subscribed to a health disparities approach in treating children: “Tina and I share the belief that many pediatric problems are socially determined, and if you do not do work outside the clinical setting in the community, you will not reduce the overwhelming causes of mor­bidity and mortality in children.”

But if Cheng was going to accept the post, which she did, she knew she’d have to quickly scale the learning curve of providing care for Latino children, who comprise 75 percent of patients at Bayview Medical Center’s primary care clinic. That led to Cheng—with pedia­tricians Lisa DeCamp and Sarah Polk, and adult internists Kathleen Page and Adriana Andrade—founding the Center for Salud/Health and Opportunity for Latinos, or Centro SOL.

“We felt Latinos were a unique population with unique needs, and that it was important to have a center focus on the clinical issues facing fami­lies, as well as research and advocacy,” says Cheng. “With the support of a generous donor and matching funding from the institution, it has been amaz­ing to see the reach of that center in a relatively short time.”

The success of this program wasn’t lost among leaders of Johns Hopkins Medicine three years later in look­ing for a replacement for George Dover as its next pediatrician-in-chief.

Creating the Future

As noted in her first Grand Rounds presentation as pediatrician-in-chief, there was no shortage of challenges fac­ing Cheng, faculty and staff members when she stepped into her new leader­ship role. The landscape of health care was rapidly changing, with fewer small pediatric practices and more group practices and systems of care, posing the need to work even more closely with community pediatricians, sub­specialists and hospitals to help them and their patients navigate the Johns Hopkins system. Continuing to build a network throughout the region was another task, as was developing new evidence-based ways to provide health care for children. Internally, adding a chief medical officer to the pediatrics leadership team, a first for the department, was another pri­ority, as was recruiting, training and mentoring the next generation of pe­diatricians to be innovators.

But in these endeavors and oth­ers, Cheng would not be flying solo. In her latest promotion, Cheng was also named co-director of Johns Hop­kins Children’s Center with Pediatric Surgeon-in-Chief David Hackam, who also has a strong research record and a vision—the development of six pediatric surgical centers. Cheng and Hackam complement each other’s strengths and perspectives, and any tricky issues are usually settled over a bag of potato chips, their shared addiction.

“We both find that potato chips allow us to think more broadly,” says Hackam. “And it’s a challenge to see who can eat the fewest. I usually lose.”

Hackam smiles, then adds: “Tina is incredibly inviting and encouraging of ideas, and respectful of other opinions and thoughts. And she puts up with a surgeon, which takes tremendous amounts of patience.”

Others also cite Cheng’s calm-in-a-storm demeanor, though her mantra is more about being proactive than pa­tient, innovative rather than compla­cent. For instance, writing about the seven great achievement in pediatric research over the past 40 years wasn’t enough (Pediatric Research, Septem­ber 2016), so as this magazine was being printed, “The Next Seven Great Achievements in Pediatric Research,” with Cheng as lead author, was being published in the May 2017 issue of Pediatrics. Among her predictions: the development of pediatric immuniza­tions to prevent emerging diseases, such as Zika and Ebola virus disease; advances in cancer immunotherapy; and genomic screening prenatally and in pediatrics that will greatly enhance pediatricians’ ability to diagnose and prevent diseases early.

There is no question Cheng is a forward-thinking scholar and perhaps an evidence-based prophet of sorts for pediatricians too. She sees what’s ahead because she is constantly looking around corners searching for answers for children, something she is not shy about expressing.

“What I am passionate about is fo­cusing on where child health care is going and how we innovate to provide the best clinical care, education and research to make sure we do the best for kids and families,” says Cheng. “We can’t just sit back and wait for things to change around us; we need to be proactive and create the future.”