The changing tides of the U.S. pediatric anesthesiology workforce
Alan Jay Schwartz, MD, MSEd, Justin L Lockman, MD, MSEd, and Aditee P Ambardekar, MD, MSEd
"Indeed, seven years of great plenty will come throughout all the land of Egypt. But after them, seven years of famine will arise, and all the plenty will be forgotten in the land of Egypt. The famine will deplete the land." Genesis 41:29-32
Sound familiar? As recently as 2018, Muffly et al.1 predicted that the growth in pediatric anesthesia fellowship trained physicians would surpass the growth of the pediatric population and the number of inpatient procedures performed in the United States. Simply stated, we were producing too many pediatric fellowship-trained anesthesiologists, and this overabundance would limit job opportunities for graduates. Slow forward 7 years and a “growing workforce shortage of pediatric anesthesiology physicians threatens the future of the subspecialized care for pediatric surgical patients demanding an urgent reassessment of recruitment, training, and retention strategies.”2
In today’s PAAD, Carullo et al.3 and its accompanying editorial2 that, even in the face of this famine, OK shortage, we have forgotten the years of plenty and is being compounded by a noticeable decline in the number of anesthesiology residents choosing to specialize in pediatric anesthesiology. I’ve asked our education team to review these articles for you. Myron Yaster MD
Original article
Carullo P, Khan S, Nause-Osthoff R, Gupta R, Xie J, Azamfirei R, Tran L, Wang T. Understanding Pediatric Anesthesiology Fellowship Interest: A National Survey of the Resident Experience. Paediatr Anaesth. 2025 Mar;35(3):223-231. doi: 10.1111/pan.15049. Epub 2024 Dec 7. PMID: 39644206.
Editorial
Salik I, Doherty T, Abramowicz AE. The Pediatric Anesthesiology Workforce in the United States: How to Curb the Crisis? Paediatr Anaesth. 2025 Mar;35(3):196-198. doi: 10.1111/pan.15056. Epub 2024 Dec 17. PMID: 39688202.
First things first! The three of us have PASSION for quality education AND pediatric anesthesiology. If you are interested in why, we (JLL and AA) wrote several articles about it as highlighted in a PAAD from February 13, 2024. (https://ronlitman.substack.com/p/you-have-chosen-wisely). We applaud all of you reading today’s PAAD, as well as that prior one, for your personal passion for pediatric anesthesiology.
An important question is: How can we share our passion for pediatric anesthesiology with trainees? The annual surgical population of pediatric patients requiring anesthesia care exceeds 3.9 million patients.4 In 1997, Rockoff and Hall provided a clear rationale for subspecialty training in pediatric anesthesiology.5 To state the obvious, you wouldn’t take your car to a hairdresser to have new brakes installed; we believe you shouldn’t take high acuity pediatric patients, with unique anatomic, physiologic and pharmacologic differences to be cared for by anesthesiologists with only basic education in pediatric anesthesiology and infrequent exposure to the care of such patients. But the reality of surgical care for children is that there simply are not enough pediatric anesthesiologists to care for them all.
In 2018, when Muffly et al predicted an oversupply of subspecialty trained pediatric anesthesiologists, residents, especially those with significant training debt, feared limited economic earning potential due to difficulty finding practice opportunities. The economic pressure was one major reason fewer residents chose pediatric anesthesiology as their career path forward. And after the COVID-19 pandemic, market forces raised private practice salaries to new heights, pushing many residents away from fellowship training altogether.
Carullo and colleagues3 asked about the drivers in the decision process for residents contemplating fellowship training in pediatric anesthesiology. The authors utilized a survey, sent in 2023 to members of the Pediatric Anesthesia Leadership Council, the Education Committee within the Society for Pediatric Anesthesia, and anesthesiology residency program directors, who subsequently forwarded the survey to residents in training (there were >1,600 anesthesiology residents in 2023). They received responses from 201 residents, including 182 (11% of residents in training) who completed more than 80% of the survey.
Among respondents, 12% were PGY1, 23% were CA1, 31% were CA2, and 35% were CA3. Respondents were all aware of the critical shortage of pediatric anesthesiologists and the low number of fellowship applicants. A majority (79%) of respondents had access to a pediatric anesthesiology fellowship at their institution and half (49%) had access to pediatric cardiac anesthesiology fellowship, as well.
The anesthesiology fellowship preferences of the respondents were highest for both cardiac and pediatric anesthesia, at 20%. Exposure to high-acuity cases and advanced procedures (placement of arterial lines, central lines, and nerve blocks) significantly increased the likelihood of planning to pursue pediatric anesthesiology fellowship. The factors most indicative of selecting pediatric anesthesiology fellowship included a desire for a collaborative working environment (71%), desire to care for medically complex patients (78%), desire to care for patients with congenital heart disease (53%), and desire to provide global healthcare (33%).
On the other hand, we were surprised to learn that residents’ perceptions of faculty teaching, mentor availability, planned future practice environment, and the presence of fellowship programs at the training institution were not significantly associated with intentions to pursue pediatric anesthesiology fellowship. Interestingly, free text survey responses exposed trainees’ concerns with compensation, working environment, patient demographics, and the emotional challenges in pediatric anesthesiology as reasons for not being interested in pursuing a fellowship.
On December 18, 2023, Lupa and Corridore’s PAAD, “Pediatric Anesthesia Fellowship (mis)Match” (https://ronlitman.substack.com/p/pediatric-anesthesia-fellowship-mismatch?utm_source=publication-search) reviewed the data that documented the number of pediatric anesthesiology fellowship positions available and subsequently filled in the match. In 2023, 60 fellowship programs sponsored 211 positions of which 125 were filled (59% of available positions). Thirty-nine programs (67%) were unfilled. This is in stark contrast to 2015 when 46 fellowship programs sponsored 185 positions of which 178 were filled (96% of available positions) and five programs (11%) were unfilled. Cladis and colleagues,6 in a prelude to today’s PAAD3, reflected on the increase in unmatched positions.
The editorial by Salik, Doherty, and Abramowicz that accompanied Carullo’s survey of resident training experience, attempted to define why fewer residents have a goal toward pediatric anesthesiology education and career practice. They highlight several considerations that drive resident decisions and cite the perceived opportunity cost of sacrificing a lucrative attending position for an extra year of training, competition with subspecialties offering a more favorable work-life balance, complicated healthcare workforce dynamics that challenge finding a purely pediatric practice, and the challenges of academic positions, some of which remain understaffed with longer work hours, lower reimbursement rates, and fewer opportunities for career advancement and scholarly productivity. However, as noted in our February 2024 PAAD, perception is not always reality and there are many amazing and highly rewarding (financially and otherwise) careers in pediatric anesthesiology - we (JLL and APA) work at and retired from (AJS) two such places!
Salik and colleagues suggest strategies that may tip the scale in favor of residents selecting pediatric anesthesiology fellowship training. They suggest considering the implementation of financial incentives and improved work-life balance. They recommend reassessing and redesigning the pediatric anesthesiology fellowship process to streamline training, especially for dual specialty trained residents or those who express interest early. They also suggest bolstering mentorship in our field and enhancing recognition of benefits to patients when pediatric anesthesiology is available through national awareness and advocacy efforts.
The take home message from the work of Carullo, Salik, Muffly, Rockoff, Cladis and many others is crystal clear. Thoughtful yeoman’s effort must be expended to prescribe “treatments” to cure the unpopularity of pediatric anesthesiology fellowship training. We owe it to our children to generate passion among young anesthesiology trainees for our superb subspecialty as a viable, rewarding, and desirable career path. Our children are depending upon us to solve this problem.
What are your recommendations to facilitate a match between residents and a future as a pediatric anesthesiologist? Send your recommendations to Myron Yaster who will share them in a future Friday Reader Response.
References
1. Muffly MK, Singleton M, Agarwal R, et al. The Pediatric Anesthesiology Workforce: Projecting Supply and Trends 2015-2035. Anesthesia and analgesia 2018;126(2):568-578. (In eng). DOI: 10.1213/ane.0000000000002535.
2. Salik I, Doherty T, Abramowicz AE. The Pediatric Anesthesiology Workforce in the United States: How to Curb the Crisis? Paediatric anaesthesia 2025;35(3):196-198. (In eng). DOI: 10.1111/pan.15056.
3. Carullo P, Khan S, Nause-Osthoff R, et al. Understanding Pediatric Anesthesiology Fellowship Interest: A National Survey of the Resident Experience. Paediatric anaesthesia 2025;35(3):223-231. (In eng). DOI: 10.1111/pan.15049.
4. Rabbitts JA, Groenewald CB. Epidemiology of Pediatric Surgery in the United States. Paediatric anaesthesia 2020;30(10):1083-1090. (In eng). DOI: 10.1111/pan.13993.
5. Rockoff MA, Hall SC. Subspecialty training in pediatric anesthesiology: what does it mean? Anesthesia and analgesia 1997;85(6):1185-90. (In eng). DOI: 10.1097/00000539-199712000-00001.
6. Cladis FP, Lockman JL, Lupa MC, et al. Pediatric Anesthesiology Fellowship Positions: Is There a Mismatch? Anesthesia and analgesia 2019;129(6):1784-1786. (In eng). DOI: 10.1213/ane.0000000000004431.