State of the Art Pediatrics: The Demise of Pediatric Subspecialty Health Care in America

Column Author: Christopher M Oermann, MD | Director, Cystic Fibrosis Cente

Column Editor: Amita Amonker, MD, FAAP | Physician Advisor, Care Management and Utilization Review

Professional societies representing pediatric subspeciality physicians have voiced concerns about the sustainability of their workforces for decades. A large body of literature discusses a wide variety of issues for all pediatric subspecialities. The parable of the blind men and the elephant has seemed to fit, as the causes of the poor fill-rates of most training programs have been theorized to include inadequate exposure of early-stage learners, like or dislike of certain disease types, financial disincentives related to fellowship training, the duration of training, attrition during fellowship, the research requirement, an aging workforce in some subspecialties, among others. The “cause” of the problem very much depends upon the lens through which the problem is viewed, with divergent opinions among pediatric specialties, academic versus private practice, and clinical care versus scholarship versus education. As a result, a multitude of approaches to remedy the workforce shortage have been suggested and have largely failed.

The Initiative on Subspecialty Clinical Training and Certification (SCTC) project, sponsored by the American Board of Pediatrics (ABP), was one of the earliest attempts to broadly assess the workforce concerns across all boarded pediatric subspecialties.  An entire supplement of Pediatrics was dedicated to multiple aspects of fellowship training and board certification.²  The project reports on a wide spectrum of fellowship training issues with data generated through a series of surveys completed by the ABP.  Of note, some concerns are shared among subspecialties but there are also significant differences in fellowship-related issues as outlined by Freed in one of the articles and online data supplements.³  Subsequent work published by many of the same authors expands our understanding of the complexity of the workforce challenge and indicates that a single solution will likely not address concerns across all subspecialties.^4,5 

A 2024 supplement to Pediatrics takes a second look at pediatric subspecialty workforce concerns and uses a model to try to predict the adequacy of the workforce between 2020 and 2040.⁶  The introductory article for the supplement provides some stark data regarding disparity among pediatric subspecialties.  As an example, there are 5319 neonatologists active in the US, with 3128 critical care physicians, 3096 cardiologists, and 3017 emergency medicine physicians compared to 363 child abuse pediatricians, 508 rheumatologists, and 580 adolescent physicians.  The second manuscript in the supplement addresses the methodologies for the project but also provides insights into the profound geographic maldistribution of pediatric subspecialty care in the US.  Additional information on this subject can be found on the ABP and AAP websites.^7-8  The series of articles concludes with the following: “Although each subspecialty has unique characteristics, commonalities include (1) the changing demographics and healthcare needs of children, including mental health; (2) poor outcomes for children experiencing adverse social drivers of health, including racism; and (3) dependence on other subspecialties. Common healthcare delivery challenges include (1) physician shortages for some subspecialties; (2) misalignment between locations of training programs and subspecialists and areas of projected child population growth; (3) tension between increasing further subspecialization to address rare diseases and general subspecialty care; (4) the need to expand clinical reach through collaboration with other physicians and advanced practice providers; (5) the lack of parity between Medicare, which funds much of adult care, and Medicaid, which funds over half of pediatric subspecialty care; and (6) low compensation of pediatric subspecialists compared with adult subspecialists. Overall, subspecialists identified the lack of a central authority to monitor and inform child healthcare provided by pediatric subspecialists as a challenge. Future research on the pediatric subspecialty workforce and the children it serves will be necessary to ensure these children’s needs are met.  Together, these articles provide overarching and subspecialty-specific recommendations to improve training, recruitment, and retention of a diverse workforce, implement innovative models of care, drive policy changes, and advise future research.”⁹  Several of these conclusions echo issues addressed by the National Academies of Sciences, Engineering, and Medicine (NASEM) consensus study report, The Future Pediatric Subspecialty Physician Workforce: Meeting the Needs of Infants, Children, and Adolescents (2023). 

This report represents a comprehensive assessment of the status of the pediatric subspecialty workforce and paints a grim portrait of the future.  The original report, 385 pages, is augmented by a highlights document and four policy briefs available through the NASEM website.  The highlights include issues related to access to care, issues related to fellowship education and training, influences impacting decisions to pursue a career in a pediatric subspecialty, the primary care – subspecialty care interface, and financial aspects of children’s healthcare.  The policy briefs include efforts to enhance recruitment and retention of subspecialty trainees, collaboration between primary and subspecialty care, supporting the physician-scientist pathway, and, most importantly, reducing financial disincentives to pursuing pediatric subspecialty training.  These documents suggest that major changes in multiple areas will be needed to maintain an adequate pediatric subspecialty workforce. 

Even more alarming are the results of the 2024 pediatric match.¹¹  The National Residency Match Program reported that pediatrics offered 3,139 positions but filled only 2,887 (92%) compared to 97% in 2023. There were 252 pediatrics positions unfilled, up from 164 in 2023. The match rate in pediatrics for graduating medical students was 47.6 percent, down 7.2% from 2023.  These data do not bode well for the future of pediatrics and pediatric subspecialties. 

The unfortunate reality is that the bulk of workforce concerns in pediatrics and pediatric subspecialties are financial in nature.  The marked disparity between Medicare and Medicaid reimbursement drives specialty choices and disparity between pediatric subspecialty compensation drives subspecialty choices.  On average, Medicaid reimburses the exact same services at 72% (range 37% to 118%) of Medicare rates.  As a result, internal medicine subspecialty salaries are significantly higher than pediatric subspecialty salaries.  Until there is parity between Medicaid and Medicare reimbursement, pediatric subspecialty healthcare will be severely disadvantaged.  Until there is parity between compensation for internists and pediatricians, fewer and fewer medical school graduates will become pediatricians.  If there aren’t any pediatricians, there aren’t going to be any pediatric subspecialists other than those which are highly compensated.  The ABP referenced data above indicate large numbers of neonatologists, critical care physicians, cardiologists, and emergency medicine physicians compared to much smaller numbers of other subspecialists.⁶  Until the scales are balanced children will continue to have inadequate access to most pediatric subspecialty healthcare. 

References

1. Oermann CM, Lahiri T, Peterson-Carmichael SL, Weiss P. The history of workforce concerns in pediatric pulmonary Medicine. Pediatr Pulmonol. 2023 Mar;58(3):683-689. doi: 10.1002/ppul.25094. Epub 2020 Oct 12. PMID: 32986316.
2. https://publications.aap.org/pediatrics/issue/133/Supplement_2
3. Freed et. al. Specialty specific comparisons regarding perspectives on fellowship training.   2014;133:S76–S77. doi.org/10.1542/peds.2013-3861F. 
4. Freed GL, Moran LM, Van KD, et al. Current workforce of pediatric subspecialists in the United States. 2017;139(5):e20163604. 
5. Freed GL. The pediatric subspecialty workforce is more complex than meets the eye.  JAMA Pediatr. 2021;175(10):1006-1008.  doi:10.1001/jamapediatrics.2021.1909
6. https://publications.aap.org/pediatrics/issue/153/Supplement%202
7. https://www.aap.org/en/advocacy/pediatric-subspecialty-shortages-fact-sheets/?srsltid=AfmBOopi5pjycW0zbsWoYxxb6vqmCiKSwNfBLVJ2NVXDdhZ21Bo8Fmsc
8. https://www.abp.org/content/data-and-workforce
9. Orr CJ, McCartha E, Vinci RJ, Mink RB, Leonard MB, Bissell M, Gaona AR, Leslie LK. Projecting the Future Pediatric Subspecialty Workforce: Summary and Recommendations. Pediatrics. 2024 Feb 1;153(Suppl 2):e2023063678T. doi: 10.1542/peds.2023-063678T. PMID: 38300012.
10. https://nap.nationalacademies.org/catalog/27207/the-future-pediatric-subspecialty-physician-workforce-meeting-the-needs-of
11. National Resident Matching Program, Results and Data: 2024 Main Residency Match®. National Resident Matching Program, Washington, DC. 2024. https://www.nrmp.org/match-data/