Growth and changes in the pediatric medical subspecialty workforce pipeline

Meeting the need for effective and standardized neonatology training: a pan-European Master's Curriculum

Neonatology is a pediatric sub-discipline focused on providing care for newborn infants, including healthy newborns, those born prematurely, and those who present with illnesses or malformations requiring medical care. The European Training Requirements (ETR) in Neonatology provide a framework for standardized quality and recognition of equality of training throughout Europe. The latest ETR version was approved by the Union of European Medical Specialists (UEMS) in April 2021. Here, we present the curriculum of the European School of Neonatology Master of Advanced Studies (ESN MAS), which is based on the ETR in Neonatology and aims to provide a model for effective and standardized training and education in neonatal medicine. We review the history and theory that form the foundation of contemporary medical education and training, provide a literature review on best practices for medical training, pediatric training, and neonatology training specifically, including educational frameworks and evidence-based systems of evaluation. The ESN MAS Curriculum is then evaluated in light of these best practices to define its role in meeting the need for a standardized empirically supported neonatology training curriculum for physicians, and in the future for nurses, to improve the quality of neonatal care for all infants. IMPACT STATEMENT: A review of the neonatology training literature was conducted, which concluded that there is a need for standardized neonatology training across international contexts to keep pace with growth in the field and rapidly advancing technology. This article presents the European School of Neonatology Master of Advanced Studies in Neonatology, which is intended to provide a standardized training curriculum for pediatricians and nurses seeking sub-specialization in neonatology. The curriculum is evaluated in light of best practices in medical education, neonatology training, and adult learning theory.

Physician workload and practice management in pediatric gastroenterology

OBJECTIVES

The pediatric gastroenterology workforce has grown in the last few decades. The North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) formed a task force to understand current pediatric gastroenterology organizations' practice structures.

METHODS

19-item electronic survey was distributed to NASPGHAN members who were clinical or academic division directors.

RESULTS

30% responded to the survey, all directors of academic practices. The median number of clinical sessions per week was seven sessions, and the median individual work relative value unit (wRVU) target for practices was 4000-4500. Healthcare team ratios compared to provider clinical full-time equivalent were reported as the following: Nursing 0.80, medical assistant 0.29, dietitian 0.29, social worker 0.14, and psychologist 0.13. Regarding compensation, 68.0% were salaried with bonus based on billing or director decision, 28.0% were salaried with no incentive pay, and 4.0% were salaried with a portion at risk if the target was not met, and a bonus was given if the target was met. Most practices participated in a wellness activity with the most common strategies being didactic lectures about physician burnout (80%), annual burnout check-ins (68%), and/or after-hours social activities (60%).

CONCLUSIONS

Pediatric gastroenterology practices vary regarding clinical sessions per week and annual wRVU targets with the median at seven sessions per week and an annual goal of 4000-4500 wRVUs, similar to reported national benchmark goals at the 50th percentile. Healthcare teams, including nursing, medical assistants, dietitians, social workers, and psychologists, had similar ratios of staff to providers for all sizes and types of practices. Most practices are engaging in wellness initiatives.

Diversity, Equity, and Inclusion, Child Health, and the Pediatric Subspecialty Workforce

Using multiple metrics, the diversity of the pediatric population in the United States is increasing. However, recent data suggest significant disparities in both the prevalence and management of child health conditions cared for by pediatric subspecialists. These inequities occur across multiple dimensions of diversity, including race and ethnicity, country of origin, socioeconomic status, sex and gender, and disability. Research also suggests that attending to diversity, equity, and inclusion in the medical workforce may positively affect health outcomes. High-quality pediatric subspecialty care thus requires knowledge of these data, attention to the effects of social drivers, including racism and discrimination, on health and wellbeing, and interventions to improve pediatric health equity through educational, practice, policy, and research innovations. In this article, we review data on the diversity of the pediatric population and pediatric subspecialty workforce, suggest potential strengths, weaknesses, opportunities, and threats of current diversity, equity, and inclusion initiatives in academic pediatrics, and provide recommendations across 4 domains: education and training, practice, policy, and future research. The ultimate goal of pediatrics is to improve health equity for all infants, children, adolescents, and young adults cared for in the United States by pediatric subspecialists.

Child Health Needs and the Pediatric Nephrology Subspecialty Workforce: 2020-2040

Pediatric nephrology is dedicated to caring for children with kidney disease, a unique blend of acute care and chronic longitudinal patient relationships. Though historically a small field, trainee interest has declined over the past 2 decades. This has led to growing alarm about the health of the pediatric nephrology workforce, although concerns have been hampered by a lack of available data to enable feasible projections. This article is part of a supplement that anticipates the future pediatric subspecialty workforce supply. It draws on existing literature, data from the American Board of Pediatrics, and findings from a model that estimates the future supply of pediatric subspecialists developed by the Carolina Health Workforce Research Center at the University of North Carolina Chapel Hill's Cecil G. Sheps Center for Health Services Research and Strategic Modeling Analytics & Planning Ltd. The workforce projections from 2020 to 2040 incorporate population growth, clinical effort, and geographic trends and model alternate scenarios adjusting for changes in trainee interest, clinical efforts, and workforce attrition. The baseline model predicts growth of clinical work equivalents by 26% by 2040, but further widening geographic disparities worsen the existing mismatch between supply, clinical need, and market demand. The worst-case scenario projects 13% growth by 2040 which, at best, maintains the status quo of an already strained workforce. The models do not account for many factors expected to heighten demand over the coming decades. Urgent reforms are necessary now. Proposed solutions require multipronged changes in education and training pathways, remuneration, clinical practice models, and government policy.

Forecasting the Future Supply of Pediatric Subspecialists in the United States: 2020-2040

Concerns persist about whether the United States has an adequate supply of pediatric subspecialists and whether they are appropriately distributed across the nation to meet children's health needs. This article describes the data and methods used to develop a workforce projection model that estimates the future supply of 14 pediatric subspecialities certified by the American Board of Pediatrics at the national and US census region and division levels from 2020 to 2040. The 14 subspecialties include adolescent medicine, pediatric cardiology, child abuse pediatrics, pediatric critical care medicine, developmental-behavioral pediatrics, pediatric emergency medicine, pediatric endocrinology, pediatric gastroenterology, pediatric hematology-oncology, pediatric infectious diseases, neonatal-perinatal medicine, pediatric nephrology, pediatric pulmonology, and pediatric rheumatology. Hospital medicine was excluded because of the lack of historical data needed for the model. This study addresses the limitations of prior models that grouped adult and pediatric physician subspecialty workforces together and aggregated pediatric subspecialties. The model projects supply at national and subnational levels while accounting for geographic moves that pediatric subspecialists make after training and during their career. Ten "what if" scenarios included in the model simulate the effect of changes in the number of fellows entering training, the rate at which subspecialists leave the workforce, and changes in hours worked in direct and indirect clinical care. All model projections and scenarios are available on a public, interactive Web site. The model's projections can also be examined with other data to provide insight into the possible future of the pediatric subspecialty workforce and offer data to inform decision-making.

Child Health Needs and the Pediatric Cardiology Workforce: 2020-2040

This article evaluates the pediatric cardiology (PC) workforce and forecasts its future supply. Produced as part of a supplement in Pediatrics, this effort represents a collaboration among the American Board of Pediatrics Foundation, the University of North Carolina at Chapel Hill's Carolina Health Workforce Research Center, the Strategic Modeling and Analysis Ltd., and members of the pediatric subspecialty community. PC is a complex subspecialty including care from fetal life through adulthood and in practice settings that range from the outpatient clinic to procedural settings to the cardiac ICU. Complex subdisciplines include imaging, electrophysiology, heart failure, and interventional and critical care. Using American Board of Pediatrics data, US Census Bureau data, and data from the modeling project, projections were created to model the subspecialty workforce through 2040. Across all modeling scenarios considered, there is considerable projected growth in the supply of pediatric cardiologists by 2040. However, there is significant regional variation in the projected supply of trainees relative to demand in terms of local population growth, with evidence of a likely mismatch between areas surrounding training centers versus areas of greatest workforce need. In addition, this article highlights areas for future focus, including efforts to attract more residents to the subspecialty in general, particularly underrepresented minority members; increased support, more part-time career options, and improved academic career advancement for women in PC; and the development of better "real-time" workforce data to guide trainees and training programs in decisions regarding sub-subspecialty job availability.

Child Health and the US Pediatric Subspecialty Workforce: Planning for the Future

This article opens a multi-article Pediatrics supplement that provides a rigorous analysis of the projected pediatric subspecialty workforce in the United States. Congenital variations, epigenetics, exposures, lifestyle, preventive care, and medical interventions from conception through young adulthood set the stage for health and wellbeing in adulthood. Although care provided by pediatric subspecialists is associated with better outcomes and lower costs compared with adult providers, the authors of recent articles in the lay and medical literature have questioned the capacity of pediatric subspecialists to meet children's health care needs. This article highlights that, despite numerous advances in prevention, diagnosis, and treatment, the last decade has witnessed increasing numbers of children with acute or chronic physical and mental health disorders, including medical complexity, obesity, type 2 diabetes, anxiety, depression, and suicidality, all of which are exacerbated by poverty, racism, and other social drivers of health. In this article, we then describe the variability in the demographics, practice characteristics, and geographic distribution of the 15 core pediatric subspecialties certified by the American Board of Pediatrics. We then discuss the rationale and approach to the development of a pediatric subspecialty workforce model that forecasts subspecialist supply from 2020 to 2040 for 14 subspecialties at the national and subnational levels (not including the newest subspecialty, pediatric hospital medicine), accounting for US Census Bureau child population projections. The model does not account for the unique physical and mental needs of individual children, nor does it address the increasingly precarious commitment to, and financing of, pediatric subspecialty care in the US health care system impacting market demand.

Child Health and the Pediatric Pulmonology Workforce: 2020-2040

There is concern as to whether the supply of pediatric pulmonology (PULM) subspecialists will be adequate to meet future demand. As part of an American Board of Pediatrics (ABP) Foundation-sponsored supplement investigating the future of the pediatric subspecialty workforce, this article assesses the current PULM clinical workforce and estimates the clinical workforce supply in the United States through 2040. The current workforce was assessed using ABP certification and Maintenance of Certification data, and a workforce supply model evaluating population growth, clinical effort, and geographic trends was developed after incorporating ABP data. Findings demonstrate that the number of pediatric pulmonologists has gradually increased over the past decade, and the ratio of subspecialists to children is likely to increase another 20% to 40% over the next 2 decades, although absolute numbers remain small. Geographic variation in access will persist in some regions. The proportion of women in the discipline has increased, but the proportion of pediatric pulmonologists from underrepresented in medicine backgrounds still lags behind the general population. Based on current trends, the PULM clinical workforce appears equipped to meet both population growth and the modest increase in demand for clinical services speculated to occur because of changes in the subspecialty's clinical portfolio. However, several factors could inhibit growth, and geographic maldistribution may continue to impact care access. Efforts to address variation in access and demographic diversity in the field are warranted. This article concludes by discussing the training, clinical practice, policy, and future workforce research implications of the data presented.

Projecting the Future Pediatric Subspecialty Workforce: Summary and Recommendations

This article summarizes the findings of a Pediatrics supplement addressing the United States workforce for 15 pediatric subspecialties. It includes results from a microsimulation model projecting supply through 2040; growth is forecasted to be uneven across the subspecialties with worsening geographic maldistribution. 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 subsubspecialization 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.

Interdisciplinary fetal neurology care: Current practice, challenges, and future directions

As the field of fetal-neonatal neurology has expanded over the past 2 decades with increasingly complex diagnoses, multidisciplinary collaboration with many subspecialties including genetics, neonatology, obstetrics, maternal fetal medicine, surgical sub-specialties, cardiology, radiology, palliative care, and ethics has needed to evolve to strive to offer optimal patient care. While comprehensive care delivery with an inter-disciplinary approach is preferred, there are often barriers based on numerous health disparities especially in resource limited settings. Even in the context of comprehensive care, diagnostic and prognostic uncertainty lead to challenges for providers during fetal neurology consultations. We present a case that highlights advantages of a comprehensive multi-disciplinary team in caring for the medical and social challenges of patients faced with a fetal neurologic diagnosis. Inter-disciplinary training focusing on maternal, fetal, neonatal, and childhood neurodevelopmental course and collaboration among the numerous stakeholders that contribute to fetal neurology practice is needed to provide optimal counseling and care for families faced with a fetal neurological diagnosis.

The Relationship Between Regional Growth in Neonatal Intensive Care Capacity and Perinatal Risk

BACKGROUND

The supply of US neonatal intensive care unit (NICU) beds and neonatologists is known to vary markedly across regions, but there have been no investigation of patterns of recent growth (1991-2017) in NICUs in relation to newborn need.

OBJECTIVE

The objective of this study was to test the hypothesis that greater growth in NICU capacity occurred in neonatal intensive care regions with higher perinatal risk.

RESEARCH DESIGN

A longitudinal ecological analysis with neonatal intensive care regions (n=246) as the units of analysis. Associations were tested using linear regression.

SUBJECTS

All US live births ≥400 g in 1991 (n=4,103,528) and 2017 (n=3,849,644).

MEASURES

Primary measures of risk were the proportions of low-birth weight and very low-birth weight newborns and mothers who were Black or had low educational attainment.

RESULTS

Over 26 years, the numbers of NICU beds and neonatologists per live birth increased 42% and 200%, respectively, with marked variation in growth across regions (interquartile range: 0.3-4.1, beds; neonatologists, 0.4-1.0 per 1000 live births). A weak association of capacity with perinatal risk in 1991 was absent in 2017. There was no meaningful (ie, clinical or policy relevant) association between regional changes in capacity and regions with higher perinatal risk or lower capacity in 1991; higher increases in perinatal risk were not associated with higher capacity growth.

CONCLUSION

The lack of association between newborn medical needs and the supply of NICU resources raises questions about the current effectiveness of newborn care at a population level.

Perceptions of the stressful job search for pediatric hematology/oncology fellows

The pediatric hematology and oncology (PHO) workforce landscape has been evolving over the past decades, with concern for waning interest in the subspecialty. We aimed to evaluate the impact of the initial PHO job search on fellow stress and anxiety, in addition to perceptions of the job search experience and potential areas of improvement. An anonymous survey consisting of demographics, emotional health impacts such as stress and anxiety, and job search experiences was developed and distributed to program leadership at all 74 PHO fellowship programs. At least one representative from 49 (66%) programs responded. Faculty were less likely than fellows to perceive that fellows are struggling to find jobs (p = .0198). However, faculty were more likely than fellows to perceive that fellows are either "extremely stressed" or "stressed" due to job search (p = .0003). By June 2021, 30 of 44 (68%) candidates had been offered a position, and 80% of those had accepted. There were no significant associations between fellow stress level and job offering, proximity to their ideal goals, or change in career type. Common barriers to the job search included geographic constraints and partner employment. Respondents identified centralized job listings, formal training on career development strategies, introduction to various career paths, and more transparency about the search as needed interventions. The perception of difficulty and stress regarding the job search is endorsed by most, identifying a need for more interventions to improve the experience. These data also highlight unmet mentorship and educational needs among PHO fellows in preparing for the job search.

Voices of Pandemic Care: Perspectives from Pediatric Providers During the First SARS-CoV-2 Surge

Pediatric providers were called on to care for adult patients well beyond their typical scope of practice during the first surge of the SARS-CoV-2 pandemic. Here, the authors share novel viewpoints and innovations from the perspective of providers, consultants, and families. The authors enumerate several of the challenges encountered, including those faced by leadership in supporting teams, balancing competing responsibilities to children while caring for critically ill adult patients, preserving the model of interdisciplinary care, maintaining communication with families, and finding meaning in work during this unprecedented crisis.

Assessing the pediatric subspecialty pipeline: it is all about the data source

BACKGROUND

National Resident Match Program (NRMP) data are often used to identify the pediatric subspecialty pipeline. Other data sources may provide greater accuracy.

METHODS

Analysis of data from the NRMP and the American Board of Pediatrics (ABP) for 14 pediatric subspecialties from 2008 to 2020. We calculated, within each subspecialty, the annual number of first-year fellowship positions offered, the NRMP match rate, the actual number of fellows entering training (ABP data) relative to the number of positions in the match (fill rate), and the actual number of matriculating first-year fellows each year.

RESULTS

For all subspecialties and years, the fill rate was greater than the match rate. All subspecialties had an increase in the relative and absolute number of first-year fellows, with the largest increases seen in emergency medicine (73.3%) and critical care (68.9%). Except for adolescent medicine, all subspecialties had an absolute increase in the number of positions offered, with the largest increase in pulmonology (32.1%).

CONCLUSIONS

NRMP data underestimate the actual number of first-year fellows entering subspecialty training. For all subspecialties, the number of first-year fellows has increased over time, indicating continued expansion in the pipeline for most. However, there remains great variation across subspecialties.

IMPACT

Perceptions of the pipeline for the pediatric subspecialty workforce vary depending on the data source. The use of NMRP match data alone underestimates the number of matriculating trainees. The number of unmatched fellowship positions has created a perception of a diminishing number of pediatric subspecialty fellows. This study uses multiple data sources to better understand the actual number of fellows entering pediatric subspecialty training and demonstrates that the NRMP match rate alone underestimates the pipeline of the pediatric subspecialty workforce.

Providing a Primary Care Medical Home for Children and Youth With Cerebral Palsy

Cerebral palsy (CP) is the most common motor disorder of childhood, with prevalence estimates ranging from 1.5 to 4 in 1000 live births. This clinical report seeks to provide primary care physicians with guidance to detect children with CP; collaborate with specialists in treating the patient; manage associated medical, developmental, and behavioral problems; and provide general medical care to their patients with CP.

Association Between Workforce Gender Distribution and Lifetime Earning Potential in the Pediatric Subspecialties

OBJECTIVE

Examine the relationship between the gender distribution of the pediatric subspecialty workforce and lifetime earning potential.

METHODS

We estimated lifetime earning potential for pediatric academic subspecialists using mean debt and compensation data from national physician surveys for 2019 to 2020 and examined the relationship between the workforce gender composition and lifetime earning potential across the pediatric subspecialties using linear regression analysis.

RESULTS

Subspecialties with a higher proportion of women had lower lifetime earning potential (-$55,215 in lifetime earning potential/1% increase in the percentage of female subspecialists; P value .002, 95% CI -$24,429 to -$86,000). Similarly, a higher proportion of female first-year fellows was associated with lower lifetime earning potential (-$61,808 in lifetime earning potential/1% increase in the percentage of female first-year fellows; P value .026, 95% CI -$9,210 to -$114,405).

CONCLUSIONS

Consistent with patterns seen in other areas of adult medicine and surgery, pediatric subspecialties with higher proportions of women, such as adolescent medicine and endocrinology, tended to have lower lifetime earning potentials than subspecialties with higher proportions of men, such as cardiology and critical care. Lower earning subspecialties also tended to train higher proportions of women, suggesting that this trend may worsen over time as pediatrics in general and individual subspecialties in particular become increasingly female predominant.

Residents' Perspective on Need for Point-of-Care Ultrasound Education During Pediatric Residency

OBJECTIVES

Many medical disciplines incorporate point-of-care ultrasound (POCUS) into their practice. Despite well-defined applications, POCUS has not been widely adopted in pediatrics and is not commonly taught during residency. Our objective was to profile the current state of POCUS education in pediatric residency training from the resident perspective.

METHODS

We surveyed pediatric trainees about their POCUS education, general opinions about POCUS, and perceived barriers to POCUS training in residency. We distributed the survey to a random sample of Ohio pediatric residents, stratified by program size and training level. Descriptive statistics were used to characterize responses.

RESULTS

We sampled 66.4% of the population (371 of 559) of Ohio pediatric residents and achieved a response rate of 59.3%. Only 15% of respondents received POCUS training during residency, with 85% having never performed a POCUS scan. Most (86%) desired POCUS education and 67% believed it should be required during residency. Residents felt that POCUS would be useful for procedural guidance (95%), clinical diagnosis (94%), and patient safety (74%). Most residents (61%) believed POCUS education would benefit their careers, particularly those planning on subspecialization. Barriers to POCUS education included lack of an established curriculum (75%), competing educational priorities (58%), and a shortage of qualified instructors (52%).

CONCLUSIONS

Although Ohio pediatric residents do not receive formal POCUS education in residency, they desire such training and believe it would benefit their future practice. Consensus on scope of practice, development of a standardized curriculum, and increased faculty training in POCUS may help address this educational gap.

Addressing Social Determinants of Health and Mitigating Health Disparities Across the Lifespan in Congenital Heart Disease: A Scientific Statement From the American Heart Association

Despite the overall improvement in life expectancy of patients living with congenital heart disease (congenital HD), disparities in morbidity and mortality remain throughout the lifespan. Longstanding systemic inequities, disparities in the social determinants of health, and the inability to obtain quality lifelong care contribute to poorer outcomes. To work toward health equity in populations with congenital HD, we must recognize the existence and strategize the elimination of inequities in overall congenital HD morbidity and mortality, disparate health care access, and overall quality of health services in the context of varying social determinants of health, systemic inequities, and structural racism. This requires critically examining multilevel contributions that continue to facilitate health inequities in the natural history and consequences of congenital HD. In this scientific statement, we focus on population, systemic, institutional, and individual‐level contributions to health inequities from prenatal to adult congenital HD care. We review opportunities and strategies for improvement in lifelong congenital HD care based on current public health and scientific evidence, surgical data, experiences from other patient populations, and recognition of implicit bias and microaggressions. Furthermore, we review directions and goals for both quantitative and qualitative research approaches to understanding and mitigating health inequities in congenital HD care. Finally, we assess ways to improve the diversity of the congenital HD workforce as well as ethical guidance on addressing social determinants of health in the context of clinical care and research.

Moving the Needle Toward Fair Compensation in Pediatric Nephrology

Remuneration issues are a substantial threat to the long-term stability of the pediatric nephrology workforce. It is uncertain whether the pediatric nephrology workforce will meet the growing needs of children with kidney disease without a substantial overhaul of the current reimbursement policies. In contrast to adult nephrology, the majority of pediatric nephrologists practice in an academic setting affiliated with a university and/or children's hospital. The pediatric nephrology service line is crucial to maintaining the financial health and wellness of a comprehensive children's hospital. However, in the current fee-for-service system, the clinical care for children with kidney disease is neither sufficiently valued, nor appropriately compensated. Current compensation models derived from the relative value unit (RVU) system contribute to the structural biases inherent in the current inequitable payment system. The perceived negative financial compensation is a significant driver of waning trainee interest in the field which is one of the least attractive specialties for students, with a significant proportion of training spots going unfilled each year and relatively stagnant growth rate as compared to the other pediatric subspecialties. This article reviews the current state of financial compensation issues plaguing the pediatric nephrology subspecialty. We further outline strategies for pediatric nephrologists, hospital administrators, and policy-makers to improve the landscape of financial reimbursement to pediatric subspecialists. A physician compensation model is proposed which aligns clinical activity with alternate metrics for current non-RVU producing activities that harmonizes hospital and personal mission statements.

Essentials of Neonatal-Perinatal Medicine Fellowship: careers in Neonatal-Perinatal Medicine

The clinical and academic landscape of Neonatal-Perinatal Medicine (NPM) is evolving. Career opportunities for neonatologists have been impacted by shifts in compensation and staffing needs in both academic and private settings. The workforce in NPM is changing with respect to age and gender. Recruiting candidates from backgrounds underrepresented in medicine is a priority. Developing flexible positions and ensuring equitable salaries is critically important. Professional niches including administration, education, research, and quality improvement provide many opportunities for scholarly pursuit. Challenges exist in recruiting, mentoring, funding, and retaining physician-scientists in NPM. Creative solutions are necessary to balance the needs of the NPM workforce with the growing numbers, locations, and complexity of patients. Addressing these challenges requires a multi-faceted approach including adapting educational curricula, supporting trainees in finding their niche, identifying novel ways to address work/life integration, and attracting candidates with both diverse backgrounds and academic interests.

Association of Lifetime Earning Potential and Workforce Distribution Among Pediatric Subspecialists

IMPORTANCE

Differences in lifetime earning potential between pediatric subspecialties may contribute to shortages in the subspecialty workforce.

OBJECTIVES

To evaluate the association between lifetime earning potential and workforce distribution and to investigate the potential role of a pediatric subspecialist-specific loan repayment program (LRP) in workforce expansion.

DESIGN, SETTING, AND PARTICIPANTS

This study was performed on publicly available mean debt and compensation data from national physician surveys from 2018 to 2019 of pediatric subspecialists in academic practice. Linear regression analysis was used to evaluate the association between lifetime earning potential and measures of workforce distribution in 2019, including distance to subspecialists, percentage of hospital referral regions with a subspecialist, and ratio of subspecialists to the regional child population as well as between lifetime earning potential in 2018 to 2019 and mean subspecialty fellowship fill rates between 2014 and 2018. The association between the change in lifetime earning potential from 2007 to 2018 and the change in workforce distribution metrics from 2003 to 2019 was also examined. The potential role of a pediatric subspecialist-specific LRP was modeled.

EXPOSURES

Lifetime earning potential by subspecialty.

MAIN OUTCOMES AND MEASURES

Measures of workforce distribution and fellowship fill rates.

RESULTS

This study included mean compensation data representing 7539 pediatric subspecialists, workforce distribution data representing 24 375 pediatric subspecialists, and fellowship fill rates representing a mean of 1344 pediatric subspecialty fellows per year. Higher lifetime earning potential was associated with shorter distance to subspecialists (-0.59 miles/$100 000 increase in lifetime earning potential; 95% CI, -1.10 to -0.09), higher percentage of hospital referral regions with a subspecialist (+1.17%/$100 000 increase in lifetime earning potential; 95% CI, 0.34-2.00), and higher ratio of subspecialists to regional child population (+0.11 subspecialists/100 000 children/$100 000 increase in lifetime earning potential; 95% CI, 0.04-0.19). The subspecialties for which lifetime earning potential increased the least between 2007 and 2018 experienced the least growth in the ratio of subspecialists to regional child population from 2003 to 2019 (+0.11 subspecialists/100 000 children/$100 000 increase in lifetime earning potential; 95% CI, 0.07-0.16). Higher lifetime earning potential was associated with higher mean fellowship fill rates (+0.96% spots filled/$100 000 increase in lifetime earning potential; 95% CI, 0.15-1.77). Implementing a pediatric subspecialist-specific LRP could increase fellowship fill rates and improve workforce distribution.

CONCLUSIONS AND RELEVANCE

Lifetime earning potential based on subspecialty may contribute to imbalances in both the current and future pediatric subspecialty workforce. Pediatric subspecialist-specific LRPs, especially for underfilled subspecialties, are potential tools for policy makers to target workforce shortages.