The Future Pediatric Subspecialty Physician Workforce Meeting the Needs of Infants, Children, and Adolescents (2023) / Chapter Skim
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4 The Pediatric Health Care Workforce Landscape
4 The Pediatric Health Care Workforce Landscape
Pages 101-150
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From page 101... ...
In addition, many other health and social care practitioners provide high-quality care and services for children and youth and are critical to the pediatric health care workforce, especially for team-based care. This chapter focuses primarily on ABP-certified pediatric subspecialty physicians, including their demographics and work profiles.
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The typical pediatric subspecialty workforce pathway, and key decision points, are exemplified in Figure 4-1. (For more on the specific factors along this pathway that influence an individual's choice to pursue pediatric subspecialty training throughout this pathway, see Chapter 5.)
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Overview of Education and Training Requirements As of May 2023,1 in addition to a number of basic requirements regarding the structure and content of residency programs, ABP-certified pediatric residency programs are required to have faculty members with subspecialty board certification in adolescent medicine, developmentalbehavioral pediatrics, neonatal-perinatal medicine, pediatric critical care medicine, pediatric emergency medicine, and subspecialists from at least five other distinct pediatric medical disciplines (ACGME, 2022a)
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For more on the research requirements of fellowship and alternate training pathways, see Chapter 5. Preparation of Pediatric Subspecialists to Care for Today's Children Entrustable professional activities (EPAs)
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. GENERAL PEDIATRICIANS The following section gives a brief overview of actively practicing general pediatricians, residents in general pediatrics, and pediatric residency programs.
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Reprinted with permission from the American Board of Pediatrics.
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. PEDIATRIC SUBSPECIALTY FELLOWS As noted earlier, some pediatrics residents pursue fellowship training in more specialized areas of pediatric care beyond the required training for general pediatrics.
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SOURCES: NRMP, 2022, 2023a. Demographics In 2023, NRMP reported that there were 860 accredited programs in the 15 ABP-certified pediatric medical specialties participating in the match, offering 1,786 positions, ranging from 23 positions in child abuse pediatrics to 288 positions in neonatal-perinatal medicine (NRMP, 2023b)
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Data retrieved by ABP based on academic year snapshot data from the ACGME. Reprinted with permission from the American Board of Pediatrics.
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. (See later in this chapter for the percentage of women and 5 Calculated on the ABP dashboard by choosing to analyze by medical degree and choosing "all" under the "training program location" filter (ABP, 2023k)
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Developmental-Behavioral Adolescent Medicine Child Abuse Pediatrics Neonatal-Perinatal Medicine Pediatric Cardiology Pediatrics 300 200 Trainee Count 100 0 Pediatric Critical Care Pediatric Pediatric Emergency Medicine Pediatric Endocrinology Pediatric Gastroenterology Medicine Hematology-Oncology 300 200 Trainee Count 100 0 Pediatric Hospital Medicine* Pediatric Infectious Disease Pediatric Nephrology Pediatric Pulmonology Pediatric Rheumatology 300 200 Trainee Count 100 0 2009 2011 2013 2015 2017 2019 2021 2009 2011 2013 2015 2017 2019 2021 2009 2011 2013 2015 2017 2019 2021 2009 2011 2013 2015 2017 2019 2021 2009 2011 2013 2015 2017 2019 2021 111 (continued)
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SOURCE: ABP, 2023j. Reprinted with permission from the American Board of Pediatrics.
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For example, the American Board of Thoracic and Cardiac Surgery certifies congenital heart surgeons to care for infants, children, and adolescents with congenital, acquired, or end-stage heart disease (Surgical Advisory Panel et al., 2014)
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. TABLE 4-3 Numbers of Pediatric Subspecialists Ever Certified by ABP and Numbers Maintaining Certification by Subspecialty Maintaining Subspecialty Ever Certified Certification Adolescent Medicine 836 580 Child Abuse Pediatrics 425 363 Developmental-Behavioral Pediatrics 1,043 803 Neonatal-Perinatal Medicine 7,871 5,319 Pediatric Cardiology 4,117 3,096 Pediatric Critical Care Medicine 3,689 3,128 Pediatric Emergency Medicine 3,493 3,017 Pediatric Endocrinology 2,218 1,508 Pediatric Gastroenterology 2,232 1,882 Pediatric Hematology/Oncology 4,231 2,929 Pediatric Hospital Medicine 2,542 2,537 Pediatric Infectious Diseases 1,876 1,368 Pediatric Nephrology 1,199 729 Pediatric Pulmonology 1,585 1,254 Pediatric Rheumatology 626 508 Total 37,983 29,021 NOTES: Data are as of June 14, 2023.
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As seen in Figure 4-5, ABP-certified pediatric subspecialists report spending the bulk of their professional time on direct or consultative patient care. Less than 8 percent of subspecialists reported spending more than 50 percent of their time doing research, and nearly half (48.3 percent)
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SOURCE: ABP, 2023n. Reprinted with permission from the American Board of Pediatrics.
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. Geographic Distribution Most ABP-certified pediatric subspecialists report working primarily in an urban setting (76 percent)
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The pediatric subspecialty workforce has as few as 2.3 percent of pediatric pulmonologists and 2.4 percent of pediatric cardiologists and pediatric rheumatologists identifying as Black or African American and 4.0 percent of child abuse specialists identifying as Hispanic, Latino, or of Spanish descent (ABP, 2023q) .11 Overall, pediatric medical subspecialists are becoming increasingly female and from URiM backgrounds.
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SOURCE: ABP, 2023q. MODELING THE FUTURE SUBSPECIALTY WORKFORCE In a committee webinar on November 2, 2022,12 Laurel Leslie, vice president of research for ABP, and Colin Orr, assistant professor in the Division of General Pediatrics and Adolescent Medicine at The University of North Carolina at Chapel Hill, gave a presentation on a workforce model under development to estimate the future supply of the pediatric subspecialty physician workforce.
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PRIMARY CARE CLINICIANS Apart from pediatricians, a variety of primary care clinicians provide care for children, particularly in team-based models of care. These clinicians include nurses, physician assistants, and physicians (e.g., adult subspecialty physicians who care for children, family medicine physicians)
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Fellows Certified Fellows Certified Adolescent Medicine 79.6 76.8 27.9 26.8 Child Abuse Pediatrics 77.6 83.0 18.2 15.9 Developmental-Behavioral Pediatrics 89.7 76.6 20.8 14.0 Neonatal-Perinatal Medicine 72.4 58.3 20.1 14.8 Pediatric Cardiology 53.5 40.6 11.0 9.2 Pediatric Critical Care Medicine 65.2 48.6 13.0 12.0 Pediatric Emergency Medicine 67.2 60.8 18.0 12.5 Pediatric Endocrinology 80.3 73.6 19.4 14.2 Pediatric Gastroenterology 69.4 52.3 20.5 14.7 Pediatric Hematology/Oncology 68.5 60.3 13.0 10.0 Pediatric Hospital Medicine 73.1 72.8 16.5 11.0 Pediatric Infectious Diseases 68.9 58.8 17.4 17.8 Pediatric Nephrology 70.1 62.5 14.6 12.9 Pediatric Pulmonology 65.5 49.2 17.7 13.1 Pediatric Rheumatology 76.9 70.7 18.7 12.2 Overall 68.8 58.8 16.8 13.0 NOTES: Data for specialists maintaining certification reflect those who answered the survey as a part of maintenance of certification from 2018 to 2022, and are estimates given the response rate of 60.5 percent. The data overall do not include information regarding the small group of subspecialists who have completed fellowship training but are not yet certified.
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In the primary care and advanced practice provider workforce that cares for children insured by Medicaid/CHIP, use of nurse practitioners and physician assistants increased significantly from 2016 to 2019 (see Table 4-7) and the number of advanced practice providers providing care to the pediatric Medicaid population also increased (see Figure 4-7)
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beneficiaries with one or more evaluation and management visits to a pediatric subspecialist per 1,000 Medicaid beneficiaries less than 19 years old. Clinician specialty was determined using the primary specialty in the National Plan and Provider Enumeration System dataset and may overrepresent the number of clinicians in primary care, such as for internal medicine physicians.
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Clinician specialty was determined using the primary specialty in the NPPES dataset and may overrepresent the number of clinicians in primary care. Advanced practice provider numbers likely represent practice in both primary and subspecialty care.
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. Pediatric acute and primary care NPs report working in multiple subspecialties with pediatric patients, including adolescent care, cardiology, critical care, emergency care, gastroenterology, hematology/oncology, neonatology, and pulmonology (PNCB, 2022)
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* - Related APRN ROLES Nurse Nurse- Clinical Nurse Nurse Role & Population Foci Anesthetist Midwife Specialist ++ Practitioner + Licensure occurs at Levels of FIGURE 4-8 APRN Consensus Model.
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There is no current mechanism or standardized process to evaluate or recognize an NP's specialty practice expertise. The Consensus Model outlines expectations that an NP's practice aligns with their role in providing care (i.e., an NP working in a pediatric intensive care unit would be an acute care pediatric NP)
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. 18 A National Provider Identifier (NPI)
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. Adult-Trained Subspecialty Physicians Who Care for Children Some children receive subspecialty care from adult-trained medical subspecialists (primarily internal medicine subspecialists)
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This board offers specialty certificates in psychiatry, neurology, and neurology with special qualification in child neurology. ABMS = American Board of Medical Specialties.
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. However, as noted in Table 4-8, the American Board of Family Medicine (ABFM)
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and is administered by the American Board of Internal Medicine; certification requires one year of fellowship training in an ACGME-accredited hospice and palliative medicine program (AAHPM, 2023)
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. After completion of the CAP residency, CAPs are certified in general psychiatry by the American Board on Psychiatry and Neurology and may pursue subspecialty certification in child and adolescent psychiatry.
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Some pediatric health care subspecialty clinics have psychologists that are trained to care for children with comorbid medical and psychological conditions embedded in the practice, so that they can work collaboratively with the pediatric subspecialists (Apple and Clemente, 2022)
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Using data from the 2015 American Psychological Association Survey of Psychology Health Service Providers, the National Plan and Provider Enumeration System/National Provider Identifier Registry, and the American Board of Professional Psychology Board Certifications, Lin and Stamm (2020) found that nearly 6 percent of licensed doctoral-level psychologists self-reported a clinical child and adolescent specialty (4,012 out of 69,655)
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. Community Health Workers Community health workers (CHWs)
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. Finding #4-5: Fellowship position fill rates and numbers of first year fellows show significant variation across the pediatric medical subspecialties.
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Conclusion #4-2: Pediatric education and training needs to be more responsive to the changing needs of infants, children, and adolescents. Conclusion #4-3: Advanced practice providers, adult-trained subspe cialists, family medicine physicians, CAPs, child psychologists, social workers and many other health professionals are important parts of the workforce that provide overall care for the pediatric population, but there are variable levels of evidence for their numbers, patterns of care, and impact on child health and well-being.
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Therefore, to achieve a goal of enhancing education, training, recruitment, and retention, the committee provides the following recommendation: RECOMMENDATION 4-1 The Association of Medical School Pediat ric Department Chairs should periodically convene representatives from ABP and ACGME, all pediatric professional societies, and major pedi atric education and training organizations (including, but not limited to, child and adolescent psychiatry, family medicine, and advanced prac tice providers) to review and adjust educational and training curricula (e.g., continuing education, standardized pediatric subspecialty training, and specialty recognition and certification)
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ABFM. (American Board of Family Medicine)
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2022b. ACGME program requirements for graduate medical education in family medicine.
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Journal of the American Board of Family Medicine 25(2)
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Journal of the American Board of Family Medicine 33(6)
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2021. Advanced practice provider inclusive staffing models and patient outcomes in pediatric critical care.
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Journal of the American Board of Family Medicine 34(1)
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2010. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases.
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2006. Family physicians in the child health care workforce: Opportunities for collaboration in improv ing the health of children.
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2018. Care coordination in pediatric health care settings: The critical role of social work.
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Annals of Family Medicine 17(5)
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