The sky really is falling: supply and demand of the Pediatric workforce
Myron Yaster MD, David G. Nichols MD MBA, and William J. Greeley MD MBA
“No matter what anyone says, it’s always about money” Mark Rogers MD
I trained in the 1970s and early 80s and was one of the first to do residencies in both Pediatrics (Children’s Hospital of Pittsburgh) and Anesthesiology (University of Pennsylvania) and Fellowships in Pediatric Anesthesiology and Critical Care Medicine (Children’s Hospital of Philadelphia), under the legendary leadership of the late Dr. John (Jack) Downes. Pediatric Critical Care was a new field. Most early programs were run by and staffed by pediatric anesthesiologists like Dr. Downes and Dr. Alan Conn of the University of Toronto. Neither Dr. Downes nor Dr. Conn were formally trained or boarded in Pediatrics. By the time I entered the field, the most common pathway to becoming a pediatric intensivist was via residencies in Pediatrics plus Anesthesiology. Fellowships in both Pediatric Anesthesia and Critical Care Medicine were new and not ACGME-approved. Furthermore, Anesthesiology residencies were only 2 years, and most (pediatric) Anesthesia fellowships were 3-12 months. At the time, Pediatric residencies were 3 years EXCEPT if one was going to do a fellowship, which, at the time, was 2 years in duration. If one was committed to a fellowship in any subspecialty of Pediatrics, the initial Pediatric residency was cut to 2 years, making the entire training period 4 years instead of the current 6. Wow, what a difference from today AND college and medical school costs were peanuts compared to today! Thus, I was able to complete my entire training, Pediatrics, Anesthesiology, Pediatric Anesthesiology and Pediatric Critical Care Medicine in 5 years.
At that time, there was a significant financial incentive for those trained in Pediatrics to do the additional 2 to 3 years of training in Anesthesiology and a fellowship in Pediatric Anesthesia / Critical Care Medicine. Upon completion of all this training, one would start out at salary level of anesthesiologist, and not a pediatrician; the $100–200,000 starting salary differential annually easily paid back on this additional training investment. Today, the same training takes 9-11 years! A duration of time that is unsustainable in the face of current educational debt and the current work/life balance needs of our graduates.
As discussed in last week’s PAADs, there is a supply/demand crisis in Pediatric Anesthesiology (and in Pediatrics). Fewer anesthesia residency graduates are entering the subspecialty while demand for our services is increasing. There are many reasons for this but ultimately it comes down to money. Medical school graduates have enormous debt upon graduation. They are forgoing Anesthesia subspecialty fellowships because they are offered large salaries after residency graduation, and there is no bump in salary for completing a Pediatric Anesthesia subspecialty fellowship. Indeed, compared to people going directly into practice from their basic Anesthesia residencies, at the completion of a pediatric anesthesia fellowship, graduates may earn LESS than if they went directly into an adult practice. Thus, many new Anesthesiology graduates, simply cannot afford to do a pediatric anesthesia fellowship.
The crisis is even worse in Pediatrics in the words of a recent National Academy of Medicine report: “In 2024, approximately 30 percent of pediatric training programs failed to fill their available residency slots, leaving 252 positions vacant — a notable increase from just 88 vacant spots in the previous year.” 1 Why are medical school graduates not going into Pediatrics and Pediatric subspecialties?2 Well, the simple answer, as my mentor, Dr. Rogers always said, “it is always about money!”
I’ve asked my good friends, Dr. David Nichols and Dr. Bill Greeley to assist me with today’s PAAD. Both ran large pediatric anesthesia and critical care divisions and both have MBAs. Dr. Nichols has unusual insight into this problem. He is board certified in Pediatrics, Anesthesiology, Pediatric Anesthesiology and Pediatric Critical Care Medicine, was the former division chief of Pediatric Anesthesiology, Critical Care Medicine, and Pain Management at the Johns Hopkins Children's Hospital, and was the Vice-Dean of Education at Hopkins. Further, he recently retired as the President of the American Board of Pediatrics. Dr. Greeley was the former chief of Pediatric Anesthesiology and Critical Care Medicine at the Children’s Hospital of Philadelphia and was a former President of the Society for Pediatric Anesthesia. Dr. Greeley, recently Co-chaired the SPA Task Force on Pediatric Anesthesia Graduate Medical Education which addressed and made recommendations on 1) current and future workforce needs, 2) the development of additional subspecialty training in such areas as pediatric cardiac anesthesia, pediatric pain medicine, and critical care medicine, and 3) evaluate the current state of Fellowship training in pediatric anesthesiology.. Myron Yaster MD
Opinion article
Carroll AE. Why It’s So Hard to Find a Pediatrician These Days. New York Times July 1, 2024. https://www.nytimes.com/2024/07/01/opinion/pediatrician-shortage.html?smid=nytcore-ios-share&referringSource=articleShare&sgrp=c-cb
National Academies of Sciences, Engineering, and Medicine. 2023. The Future Pediatric Subspecialty Physician Workforce: Meeting the Needs of Infants, Children, and Adolescents. Washington, DC: The National Academies Press. https://doi.org/10.17226/27207. ISBNs: Paperback: 978-0-309-70840-1 Ebook: 978-0-309-70843-2
Why are medical school graduates not going into Pediatrics AND Pediatric subspecialties? The principal reasons have been clear for some time. Pediatricians are amongst the lowest paid medical specialists in the United States and medical school educational debt continues to rise. “Increasing indebtedness among early career pediatricians is a concerning trend. Of those residents graduating from pediatric residency reporting any educational debt, the average debt increased from $156,500 in 1997 to $261,00 in 2023 (after adjusting for inflation). In fact, half of all residents in 2023 reported $200,000 or more in debt.”2 When one considers the large educational debt AND the typically lower earning potential for Pediatrics and Pediatric subspecialists (compared to their internal medicine counterparts), why should anyone be surprised about the falling numbers of medical school graduates going into Pediatrics? In the face of large indebtedness, the pediatrician’s earnings potential is limited compared to other medical specialties. The overall mean income among subspecialists in the larger pediatric subspecialties (e.g., neonatology, cardiology, critical care, emergency medicine, gastroenterology, and hematology/oncology) averaged $231,930, while pediatricians in the smaller subspecialties (all other pediatric medical subspecialties) averaged an annual income of of $168,245.2,3 General pediatricians earned $180,250 annually on average.
The NASEM report further highlights that board-certified pediatric subspecialties represented 8 of the 20 lowest paying specialties in American medicine, and the 5 specialties with the lowest compensation were all pediatric subspecialties (i.e., pediatric endocrinology, pediatric infectious disease, pediatric rheumatology, pediatric hematology and oncology, and pediatric nephrology.2 Further, a 2021 study introduced the concept of the lifetime return on investment (ROI) of subspecialty training. Compared to going into practice after a general Pediatrics residency, 12 out of 15 Pediatric subspecialties had a negative ROI, i.e. continuing in fellowship training after a Pediatrics residency actually subtracts from one’s lifetime income potential. Only Pediatric cardiology, critical care, and neonatology had a positive lifetime ROI.”2-4
Today’s PAAD discusses one of the 8 articles from the National Academies of Sciences, Engineering, and Medicine (NASEM) 2023 report. The Future Pediatric Subspecialty Physician Workforce: Meeting the Needs of Infants, Children, and Adolescents. Washington, DC: The National Academies Press. https://doi.org/10.17226/27207. All 8 articles are impressive in their thoughtful review of the healthcare needs of children and the specialty of Pediatrics. It is beyond the scope of a PAAD to review all of the issues found in the NASEM report However, we would urge you to review the entire NASEM report to get a better understanding of the challenges facing the pediatric workforces. Indeed, we think it may be worth a joint journal club!
Below are some thoughts on possible solutions to these challenges.
Overall length of education and training
As discussed in our previous PAADs on Pediatric Anesthesia and subspecialty training, the length of training in Pediatrics and its subspecialties coupled with enormous educational debt is not sustainable. We argue that the current model of 4 years of undergraduate training, 4 years of medical school, 3 years of Pediatric residency, and 3 years of subspecialty training can be condensed, particularly at the residency and fellowship levels. Using competency-based medical education methodologies would assure faculty and the public that students and trainees were attaining the necessary competencies in a shorter curriculum.5
The American Board of Pediatrics already offers an Accelerated Research Pathway (ARP) with 2 years of general pediatrics residency and 4 years of fellowship. Rather than the exception, the ARP model should become the norm for those targeting a research career. At a policy level, the ABP is open to 2-year fellowships for those interested in a clinical career as a pediatric subspecialist. However, the subspecialty societies and other stakeholders would need to reach a consensus and then petition the ABP.
The SPA task force recommended a more efficient and thorough training for double board certification (anesthesiology and pediatric) and double fellowship, sub-certification (pediatric anesthesia and pediatric critical care medicine) to 7 - 8 years instead of the current 9 - 11 years of training. They recommended convening a work group of stakeholders to include but not limited to the president of the ABA or designee, the president of the ABA or designee, the president of the SPA or designee, and a liaison member of the SPA task force to evaluate pathways for dual training in PCCM/pediatric anesthesiology. Also, using Delphi methodology to generate consensus among the stakeholder community (program directors, Service chiefs, practicing pediatric anesthesiologist), this Task Force concluded that the current one year fellowship in pediatric anesthesiology is a strength and should be maintained. Using new support tools such as AI, a standardize, nationally available, virtual curriculum for trainees could be developed to improve training in order to ensure the health, quality and vitality of subspecialty training into the future.
Scholarship and Loan Repayment Programs
The level of education (undergraduate + medical school) debt is staggering and drives medical school graduates into the most lucrative and highest paying fields of medicine, like Anesthesiology but not Pediatric Anesthesiology. While more are needed, there are debt repayment options such as the National Health Service Corps, the Pediatric Specialty Loan Repayment Program, the NIH Loan Repayment Programs, and the J-1 Visa Waiver Program.
Workforce and influences on lifestyle
Money is NOT the only driver influencing career choice. Whether one is discussing Pediatrics or any other medical specialty, “in general, lifestyle, work–life balance, and spousal considerations are among the factors that have the most influence on medical students and residents’ choice of specialty and career path.”2,6 Indeed, “general Pediatrics residents as well as Pediatric subspecialists specifically expressed the importance of lifestyle on their career paths. One study of pediatric hematologist/oncologists showed that they preferred a balance of direct patient care, inpatient service and office-based outpatient care, and non-clinical time and that they specifically sought jobs in settings that supported that balance, which were more likely to be larger medical centers with greater concentrations of subspecialists who could share the on-call burden.”2,7
As you all know, more than 50% of all medical school graduates and more than 70% of Pediatricians are women. The NASEM report states that “women prioritize lifestyle factors and interest in flexible work hours as compared to men. Female early-career Pediatricians typically spend more time on household responsibilities and the care of their own children than male Pediatricians. In addition, one survey of new Pediatric subspecialists showed that women were more likely than men to be employed part-time and were more likely to foresee part-time work within the coming 5 years. However, the study also showed that about one-third of the respondents who reported working part-time were still working more than 40 hours per week. Powell et al.8 found that graduating female Pediatric residents were more likely to prioritize factors such as number of overnight calls per month, option to work part-time, length of parental leave, and availability of onsite childcare in positions after residency as compared with male residents.”2
Clinician Burnout
“The 2019 National Academies report Taking Action Against Clinician Burnout described burnout as “a syndrome characterized by high emotional exhaustion, high depersonalization (i.e., cynicism), and a low sense of personal accomplishments from work.”9 Pediatric subspecialists may be at greater risk of burnout because of pressure to work longer hours (as a result of workforce shortages) and lower reimbursement compared with adult practice physicians.10 As noted by Dr. Sallie Permar, Nancy C. Paduano Professor and chair of pediatrics at Weill Cornell Medicine, , in one of the committee’s public webinars:
“The low [compensation] tied to the low reimbursement rate really does hold us back in terms of not only being able to recruit pediatricians throughout the pipeline from before medical school, in medical school, but also what I’ve found to be a problem also in preventing burnout and retaining our faculty in those roles. And we know that the burnout issue does face women and minorities more intensely.”2
A final thought from Myron on money and gender: More than 70% of Pediatricians are women and as we’ve discussed before, when the workforce tips to more than 50% women, pay and earnings fall for all including men.11,12 I’ve asked a noted economist and friend to find out more about this and I hope to return to this topic when he gets back to me in the next few weeks.
There is much more to this article and report. We would urge all of you to read it. Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Carroll AE. Why It’s So Hard to Find a Pediatrician These Days. New York Times2024.
2. National Academies of Sciences E, Medicine. The Future Pediatric Subspecialty Physician Workforce: Meeting the Needs of Infants, Children, and Adolescents. Washington, DC: The National Academies Press, 2023.
3. Catenaccio E, Rochlin JM, Simon HK. Differences in Lifetime Earning Potential Between Pediatric and Adult Physicians. Pediatrics 2021;148(2) (In eng). DOI: 10.1542/peds.2021-051194.
4. Catenaccio E, Rochlin JM, Simon HK. Differences in Lifetime Earning Potential for Pediatric Subspecialists. Pediatrics 2021;147(4) (In eng). DOI: 10.1542/peds.2020-027771.
5. Carraccio C, Englander R, Wolfsthal S, Martin C, Ferentz K. Educating the pediatrician of the 21st century: defining and implementing a competency-based system. Pediatrics 2004;113(2):252-8. (In eng). DOI: 10.1542/peds.113.2.252.
6. Newton DA, Grayson MS, Thompson LF. The variable influence of lifestyle and income on medical students' career specialty choices: data from two U.S. medical schools, 1998-2004. Acad Med 2005;80(9):809-14. (In eng). DOI: 10.1097/00001888-200509000-00005.
7. Frugé E, Margolin J, Horton T, et al. Defining and managing career challenges for mid-career and senior stage pediatric hematologist/oncologists. Pediatric blood & cancer 2010;55(6):1180-4. (In eng). DOI: 10.1002/pbc.22658.
8. Powell WT, Dundon KMW, Frintner MP, Kornfeind K, Haftel HM. Parenthood, Parental Benefits, and Career Goals Among Pediatric Residents: 2008 and 2019. Pediatrics 2021;148(6) (In eng). DOI: 10.1542/peds.2021-052931.
9. National Academies of Sciences E, Medicine, National Academy of M, Committee on Systems Approaches to Improve Patient Care by Supporting Clinician W-B. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington (DC): National Academies Press (US)
Copyright 2019 by the National Academy of Sciences. All rights reserved.; 2019.
10. Kumar G, Mezoff A. Physician Burnout at a Children's Hospital: Incidence, Interventions, and Impact. Pediatr Qual Saf 2020;5(5):e345. (In eng). DOI: 10.1097/pq9.0000000000000345.
11. Miller CC. As women take over a male-dominated field, the pay drops. New York Times2016.
12. Levanon A, England P, Allison P. Occupational Feminization and Pay: Assessing Causal Dynamics Using 1950–2000 U.S. Census Data. Social Forces 2009;88(2):865-891. DOI: 10.1353/sof.0.0264.