Access to pediatric subspecialty care for children and youth: possible shortages and potential solutions

Should neonatal-perinatal medicine move to two-year fellowships?

The duration of the majority of fellowships in pediatrics has been three-years. With increasing shortages of some outpatient-based pediatric subspecialists, shorter two-year fellowships are being considered for clinically oriented trainees not interested in a career based on research. Shortening the duration of fellowship may have some financial merits such as achieving a higher salary earlier after shorter training. However, we feel that continuing with a three-year duration for neonatology is more pragmatic at this time due to reductions in intensive care rotations during residency, time required to  achieve procedural excellence, the need for exposure to quality assurance methodology, proficiency in novel techniques such as bedside ultrasound, and to maintain the physician-scientist pipeline. The demand for neonatal fellowship continues to be high. Ongoing evaluation of the job market, training needs and fellowship curriculum is needed to determine if the duration of fellowship should be altered in the future.

The Utilization of Early Outpatient Care for Infants Following NICU Discharge among a National Sample

Outpatient care following discharge from a neonatal intensive care unit (NICU) is critical for streamlined transfer of care. Yet, information is lacking about the characteristics of early outpatient care. The objective of this secondary data analysis is to describe outpatient encounters (OPEs) within the first three months following the discharge of commercially insured infants admitted to NICUs in the MarketScan Research Database nationally from 2015 to 2017. Data were analyzed using descriptive statistics and logistic regression. A total of 22,214 NICU survivors were included, of whom half had an OPE within two days following discharge (quartiles 1, 3) and 90% within five days. The median number of OPEs in the first three months was five (quartiles 4, 7). A majority of first physician visits were with pediatricians (81.5%). A minority of infants with chronic conditions saw subspecialists. Term infants with delayed care had a lower risk of readmission. Spending was higher for preterm infants and those with chronic conditions. We conclude that most patients are seen shortly after discharge and by pediatricians; however, there is room for improvement. Frequent encounters and spending afflict high-risk groups with chronic conditions. Future work should examine the associations of early outpatient care with social determinants of health and other outcomes such as immunizations.

Access to Pediatric Eye Care by Practitioner Type, Geographic Distribution, and US Population Demographics

Importance

Investigating disparities in service coverage of pediatric optometrists and pediatric ophthalmologists in relation to patient demographics will illuminate vulnerable populations and inform future interventions.

Objective

To characterize the geographic distribution of pediatric eye care practitioners and analyze its association with population demographics.

Design, Setting, and Participants

In this cross-sectional study, 4 public databases were used to identify the addresses of pediatric optometrists and pediatric ophthalmologists in the US in April 2023. Addresses were geocoded, and population demographic data were collected. Pediatric optometrists and pediatric ophthalmologists listed in the public databases, as well as respondents to the 2020 US census, were included in this study. Data were analyzed from April to July 2023.

Exposures

Public databases and US census data of eye practitioners and their practice locations.

Main Outcomes and Measures

Geographic distribution of pediatric optometrists and pediatric ophthalmologists as listed in public databases and correlations between service coverage and US population demographics.

Results

A total of 586 pediatric optometrists (302 female [51.5%]) and 1060 pediatric ophthalmologists (590 male [55.7%]) were identified. Among US counties, 203 (6.5%) had at least 1 pediatric optometrist, and 308 (9.7%) had at least 1 pediatric ophthalmologist, showing substantial geographic overlap (odds ratio, 12.7; 95% CI, 9.4-17.4; P < .001). In the 2834 counties without pediatric ophthalmologists, 2731 (96.4%) lacked pediatric optometrists. There were more pediatric ophthalmologists per million people (3.3) compared with pediatric optometrists per million people (2.5) across all states (difference, 0.8; 95% CI, 0-1.9; P = .047). Among counties with practitioners, the median (IQR) number of pediatric optometrists per million people was 7.8 (0.4-245.0), surpassing the median (IQR) number of pediatric ophthalmologists per million people, 5.5 (1.0-117.0). Counties with pediatric ophthalmologists had higher mean (SD) household incomes than counties with pediatric optometrists ($76 126.87 [$21 879.23] vs $68 681.77 [$18 336.40]; difference, -$7445.10; 95% CI, $2519.51-$12 370.69; P = .003) and higher mean (SD) population with bachelor's degrees than counties with pediatric optometrists (79 016 [82 503] vs 23 076 [44 025]; difference, -55 940; 95% CI, -73 035 to -38 845; P < .001), whereas counties with neither specialist type had the lowest mean (SD) household income ($57 714.03 [$2731.00] vs $78 388.67 [$18 499.21]; difference, -$20 675.00; 95% CI, -$21 550.90 to -$19 799.10; P < .001) and mean (SD) population with bachelor's degrees (5113 [12 875] vs 167 015 [216 486]; difference, -161 902; 95% CI, -170 388.9 to -153 415.1; P < .001) compared with counties with practitioners.

Conclusions and Relevance

Geographic disparities in pediatric eye care access, compounded by socioeconomic differences, underscore the urgency of augmenting practitioner support in underserved areas.

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.

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.

Advocacy in neonatology: current issues and introduction to the series

Advocacy is an increasingly important skill for neonatologists. As social factors play a greater influence on short & long-term newborn outcomes, neonatal physicians must be attentive to policy factors and work to ensure they benefit the health of both patients and the specialty. In this article, we review advocacy issues of current relevance to neonatal practice, including the "Born Alive Executive Order," the "Newborn Screening Saves Lives Act," subspecialty loan repayment and legislation related to donor human milk, as well as introduce topics further discussed as part of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine Advocacy Series.

Pediatric Resident Confidence in Assessing Neurological Cases: A Nationwide Survey

BACKGROUND

A relative shortage of pediatric neurologists in proportion to estimated neurological disorders often results in general pediatricians evaluating and treating children with complex neurological conditions. Dedicated rotations in pediatric neurology are not mandated during medical school or pediatric residency. We evaluated the perceptions of a large cohort of pediatric residents and program directors (PDs) regarding child neurology training.

METHODS

Using an online tool, surveys were sent to pediatric residents and pediatric and pediatric neurology PDs.

RESULTS

Response rates were 41% from pediatric residency programs, yielding 538 resident responses; 31% from pediatric PDs; and 62% from pediatric neurology PDs. Only 27% of the surveyed residents reported completing a neurology rotation during residency, 89% of whom expressed a subjective improvement in confidence with neurological assessments. Factors affecting comfort with eliciting a neurological history included exposure to a neurology rotation during residency, year of training, duration of neurology rotation in medical school, and inpatient exposure to neurological patients, whereas those associated with examination additionally included program size and postresidency plans. Overall, 80% of surveyed residents, 78% of pediatric PDs, and 96% of pediatric neurology PDs acknowledged the potential value of a mandatory pediatric neurology rotation during residency.

CONCLUSION

We suggest that a mandatory pediatric neurology rotation will boost the confidence of current and future pediatric trainees in assessing common neurological conditions of childhood.

The Pediatrician Workforce in the United States and China

From 2019 to 2022, the For Our Children project gathered a team of Chinese and American pediatricians to explore the readiness of the pediatric workforce in each country to address pressing child health concerns. The teams compared existing data on child health outcomes, the pediatric workforce, and education and combined qualitative and quantitative comparisons centered on themes of effective health care delivery outlined in the World Health Organization Workforce 2030 Report. This article describes key findings about pediatric workload, career satisfaction, and systems to assure competency. We discuss pediatrician accessibility, including geographic distribution, practice locations, trends in pediatric hospitalizations, and payment mechanisms. Pediatric roles differed in the context of each country's child health systems and varied teams. We identified strengths we could learn from one another, such as the US Medical Home Model with continuity of care and robust numbers of skilled clinicians working alongside pediatricians, as well as China's Maternal Child Health system with broad community accessibility and health workers who provide preventive care.In both countries, notable inequities in child health outcomes, evolving epidemiology, and increasing complexity of care require new approaches to the pediatric workforce and education. Although child health systems in the United States and China have significant differences, in both countries, a way forward is to develop a more inclusive and broad view of the child health team to provide truly integrated care that reaches every child. Training competencies must evolve with changing epidemiology as well as changing health system structures and pediatrician roles.

The Behavioral Health Needs of Youth With Preexisting Psychiatric Disorders in the Aftermath of COVID-19

Children and adolescents with psychiatric disorders are a sizable population of children and youth with special health care needs. While the capabilities of behavioral health resources to meet these youth's needs were already strained, the Coronavirus Disease 2019 (COVID-19) pandemic extended resource limitations just as this subgroup of children and youth with special health care needs faced new stressors and potential exacerbations of their underlying psychiatric illnesses. In this article, we provide a brief narrative review of the factors' manifestations with an emphasis upon their disproportionate impact upon children of color and their families and particularly those from disadvantaged communities. We proceed to provide policy proposals for addressing these disparities. These include raising reimbursement for behavioral health services, increasing telehealth care delivery, reducing inter-state licensing requirements, increasing community-based services, and addressing social determinants of health. Conclusions and directions for strengthening behavioral health service delivery capabilities and addressing systemic injustices are made.

Evaluation of new instruments for screening and diagnosis of tics and tic disorders in a well-characterized sample of youth with tics and recruited controls

Tics and tic disorders can significantly impact children, but limited screening tools and diagnostic challenges may delay access to care. The current study attempted to address these gaps by evaluating sensitivity and specificity of the Motor or Vocal Inventory of Tics (MOVeIT), a tic symptom screener, and the Description of Tic Symptoms (DoTS), a brief diagnostic assessment for tic disorders. Children (n=100, age 6-17 years old) with tic disorders attending a Tourette specialty clinic and a community-recruited sample without tics completed a gold-standard assessment by a tic expert; these evaluations were compared to child self-report and parent and teacher report versions of the MOVeIT, and child and parent versions of the DoTS. The parent and child MOVeIT met or exceeded pre-specified 85% sensitivity and specificity criteria for detecting the presence of tics when compared to a gold-standard tic expert diagnosis. The Teacher MOVeIT had lower sensitivity (71.4%) but good specificity (95.7%) for identifying any tic symptoms compared to gold standard. For determination of the presence or absence of any tic disorder, sensitivity of both parent and child DoTS was 100%; specificity of the parent DoTS was 92.7% and child DoTS specificity was 75.9%. More work may be needed to refine the teacher MOVeIT, but it is also recognized that tic expression may vary by setting. While the MOVeIT and DoTS parent and child questionnaires demonstrated adequate sensitivity and specificity for determining the presence of tics and tic disorders in this well-defined sample, additional testing in a general population is warranted.

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.

Skipping the Line: Inequality in Access to Developmental-Behavioral Care

CASE

The mother of an 18-month-old boy contacted the developmental and behavioral pediatrics clinic to request an evaluation because of concerns that her son is not using any words and only recently began walking. The child's mother became upset when she was notified that the clinic policy requires receipt of a formal request for evaluation from the primary care physician and that the first available appointment was in 9 months. Later that day, the child's grandmother contacted the clinic and reported that she is a member of the Donor Society affiliated with the university/medical system. Membership in the Donor Society is granted to individuals who have met specific philanthropic thresholds benefiting the university. One benefit to members of the Donor Society is the ability to access subspecialty medical services for themselves and their family members, across all disciplines, within 5 business days of their request.After confirming the details of the Donor Society promise with the philanthropic department of the hospital, a small committee of professionals within the clinic gathered to discuss the implications of this promised benefit to Donor Society members. This clinic is the only source for specialized, multidisciplinary developmental-behavioral health care that accepts public insurance within a 200-mile radius. The current waitlist for evaluation is 9 to 15 months depending on the reason for referral, and approximately 75% of patients on the waitlist receive some form of public assistance and/or live in a rural or underserved area. During the discussion, it was noted that there are 2 developmental-behavioral pediatric clinicians who practice within a cash-based private practice setting in the community. The waitlist for that practice was recently reported to be 3 to 6 months depending on the reason for evaluation, but that practice also requires a referral from the primary care physician before scheduling an initial evaluation.How would you recommend that the clinicians in the developmental and behavioral pediatrics clinic respond to the request to fulfill the promises made by the university to members of the Donor Society? How does a promise such as this one made to the Donor Society affect structural inequalities within the health care system and what strategies could be used to mitigate further inequalities that may result?

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.

Growth and changes in the pediatric medical subspecialty workforce pipeline

BACKGROUND

To inform discussions of pediatric subspecialty workforce adequacy and characterize its pipeline, we examined trends in first-year fellows in the 14 American Board of Pediatrics (ABP)-certified pediatric medical subspecialties, 2001-2018.

METHODS

Data were obtained from the ABP Certification Management System. We determined, within each subspecialty, the annual number of first-year fellows. We assessed for changes in the population using variables available throughout the study period (gender, medical school location, program region, and program size). We fit linear trendlines and calculated χ² statistics.

RESULTS

The number of first-year pediatric medical subspecialty fellows increased from 751 in 2001 to 1445 in 2018. Fields with the growth of 3 or more fellows per year were Cardiology, Critical Care, Emergency Medicine, Gastroenterology, Neonatology, and Hematology Oncology (P value <0.05 for all). The number of fellows entering Adolescent Medicine, Child Abuse, Infectious Disease, and Nephrology increased at a rate of 0.5 fellows or fewer per year. Female American Medical Graduates represented the largest and growing proportions of several subspecialties. Distribution of programs by region and size were relatively consistent over time, but varied across subspecialties.

CONCLUSIONS

The number of pediatricians entering medical subspecialty fellowship training is uneven and patterns of growth differ between subspecialties.

IMPACT

The number of individuals entering fellowship training has increased between 2001 and 2018. Growth in the number of first-year fellows is uneven. Fields with the greatest growth: Critical Care, Emergency Medicine, and Neonatology. Fields with limited growth: Adolescent Medicine, Child Abuse, Infectious Disease, and Nephrology. Concerns about the pediatric medical subspecialty workforce are not explained by the number of individuals entering the fellowship.

INteractive Virtual Expert-Led Skills Training: A Multi-Modal Curriculum for Medical Trainees

Background: Internationally, pediatric depression and suicide are significant issues. Additionally, in the context of the COVID-19 pandemic, pediatric mental health needs are rising astronomically. In light of Child & Adolescent Psychiatrist (CAP) subspecialist shortages in the United States (US), there is an increasing call for primary care physicians in Family Medicine and Pediatrics to address an increasingly broad variety of patient needs. Here we report on the development and preliminary evaluation of medical student and resident perceptions on the "INteractive Virtual Expert-led Skills Training" (INVEST) medical education curriculum, a virtual synchronous CAP curriculum employing active learning strategies, including expert-led discussion and video modeling, and discussion designed to meet those priorities. Methods: In a standardized 60-min training format, our curriculum leverages audience response system polling, video modeling of key clinical skills, and interactive discussion with an expert subspecialist, over a virtual video conferencing platform. The primary educational strategy relies on use of video modeling to demonstrate best practice with CAP led group discussion to solidify and explain important concepts. Five waves of medical students and residents (N = 149) participated in the INVEST curriculum and completed pre- and post-training surveys regarding knowledge and comfort in the management of pediatric patients with depression and suicidality. Results: Trainee participants reported significant positive gains in perceived likelihood of encountering pediatric suicidality as well as knowledge/comfort with depression screening and suicidality assessment in a primary care setting. Across some competency areas, there was an effect of medical learner level. Learners at lower levels generally reported the highest benefit. Medical students reported significant increases in their comfort interpreting and discussing positive depression screens and evidenced the greatest relative benefit in comfort with discussing suicidality. Conclusion: To our knowledge, INVEST is the first fully virtual, multimodal curriculum led by expert CAP subspecialists. Our findings suggest that INVEST shows promise for equipping medical learners with baseline knowledge for caring for patients with pediatric depression and suicidality. This synchronous, virtually delivered curriculum allows for critical training delivered to diverse medical learners regardless of geographic location, a particular benefit during the current COVID-19 pandemic.