The Future Pediatric Subspecialty Physician Workforce Meeting the Needs of Infants, Children, and Adolescents (2023) / Chapter Skim
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5 Influences on the Career Path of a Pediatric Subspecialty Physician
5 Influences on the Career Path of a Pediatric Subspecialty Physician
Pages 151-202
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. See Figure 5-1 for other factors identified as important in the decision to pursue fellowship training in a pediatric subspecialty. 1 One notable exception is that fellowship training for pediatric hospital medicine is 2 years (ABP, 2020)
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152 FIGURE 5-1 Factors identified as important in decision to pursue pediatric subspecialty fellowship training. SOURCE: Frintner et al., 2021a.
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Given limited evidence on some of these factors specific to pediatric subspecialists, drivers of career choices in medicine in general are also discussed, but the primary focus of this chapter is on the influences for a career as a pediatric subspecialty physician. EXPOSURE TO PEDIATRICS Early exposure to the medical specialty of pediatrics at various critical touch points, including high school and college, medical school, and early residency training, has been hypothesized to be critical in the decision to pursue a career in pediatrics and the pediatric subspecialties (Donnelly et al., 2007; Lindgren and Shah, 2023; Nelson et al., 2020; Vinci et al., 2021)
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(2018) found that 68 percent of individuals who entered pediatric subspecialty fellowship training first reported plans to do so at the start of their internship, and few changed plans to pursue such training.
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Interest in the Specific Area of Specialization One influence that may be intangible in influencing an individual's choice of specialty or subspecialty is an academic or personal interest -- something that potentially may be influenced by early exposure to that specialty or subspecialty. As noted earlier, simply being interested in the specific topic has been shown to be influential on medical students' choice of specialty in general (Levaillant et al., 2020; Rao et al., 2017; Yang et al., 2019)
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EDUCATION AND TRAINING MODEL While Chapter 1 presented a history of the development of subspecialty training and Chapter 4 provided the landscape of the current pediatric workforce, including an overview of the basic requirements of pediatric residency and fellowship training, the following sections emphasize some specific aspects of formal medical education and training that may directly influence an individual's decision to pursue subspecialty training. BOX 5-3 Trainee and Clinician Perspectives -- Personal Interest "I chose pediatric nephrology because of my interest and awe of the kidneys and their varied functions…I also just loved the mix of conditions seen by nephrologists." – Pediatric Nephrologist, Seattle, WA "I chose pediatric infectious diseases because I had an interest in vac cine research and I enjoy the broad differential diagnoses encountered in my specialty." – Pediatric Infectious Disease Attending, Baltimore, MD "I went into pediatric endocrinology because hormones are a fascinating puzzle and I can generally provide interventions that improve quality of life for patients." – Second Year Pediatric Endocrinologist, Denver, CO These quotes were collected from the committee's online call for trainee, clinician, and family perspectives.
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. Others have noted that this approach costs significant money and time (which may be a negative influence on the choice to pursue subspecialty training)
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Comparison with Internal Medicine Fellowships The internal medicine model of fellowship training may provide insights on how to address issues of low enrollment into some pediatric subspecialties. Specifically, many internal medicine fellowships with similar clinical concentrations to pediatric fellowships (e.g., adolescent medicine, critical care, endocrinology, infectious disease, nephrology, pulmonary disease, rheumatology)
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. The initial goal of these programs was to lessen the financial burden of medical education by allowing for the completion of a combined undergraduate and graduate medical education in 6 to 7 years rather than the typical 8 years; however, they soon became recognized as a viable way to quickly generate well-trained physicians (CAMPP, 2023; Drees and Omurtag, 2012; Kistemaker and Montez, 2022)
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. Length of Residency and Fellowship Training Overall length of training may influence the career path of a pediatric subspecialist; the appropriate length of training, particularly subspecialty fellowship training, is intertwined with the requirement for research during fellowship.
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. The task force concluded that the joint ABP–Accreditation Council for Graduate Medical Education (ACGME)
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I think there would be more people going into this field." – Pediatric Pulmonologist, Grand Rapids, MI "With 3 years of subspecialty training required and with only one year of that clinical (the rest of the time is research) , I think this is a barrier for clinicians who might want to go into [pediatric infectious diseases]
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supports "candidates who are committed to an academic career as physician–scientists with a strong research emphasis in a pediatric subspecialty." Candidates may begin fellowship after completion of 2 years of general pediatric residency training, then complete 4 years of fellowship training with expectations of a more robust experience in research than standard trainees. This pathway is used most commonly by those who have had prior experience in a clinical or research field and does not shorten over all training, but shifts time away from the broader experiences in general pediatric training (ABP, 2022e)
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. The 2022 AAMC Report on Residents reveals that 60 percent of the individuals who completed pediatric residency training from 2012 through 2021 and did not pursue subspecialty training are practicing in the state where they did their residency training (AAMC, 2022b)
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State (Women) Adolescent Medicine 60.2 56.1 61.4 Child Abuse Pediatrics 54.4 33.3 57.7 Developmental-Behavioral Pediatrics 60.7 43.5 64.2 Neonatal-Perinatal Medicine 59.5 52.6 62.6 Pediatric Cardiology 45.0 42.0 48.5 Pediatric Critical Care Medicine 56.0 53.2 58.0 Pediatric Emergency Medicine 61.5 56.9 64.0 Pediatric Endocrinology 60.5 57.2 61.4 Pediatric Gastroenterology 57.9 51.9 61.7 Pediatric Hematology/Oncology 60.5 59.5 61.2 Pediatric Hospital Medicinea 78.9 100.0 66.7 Pediatric Infectious Diseases 58.7 62.4 56.6 Pediatric Nephrology 57.1 61.1 55.5 Pediatric Pulmonology 63.8 60.3 65.7 Pediatric Rheumatology 59.3 48.3 63.4 NOTE: aThe percentage for pediatric hospital medicine reflects only a very small number of residents given that the first examination for certification was administered in 2020.
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. FINANCING OF GRADUATE MEDICAL EDUCATION GME, which includes initial residency and subsequent fellowship training, is a critical step in the physician pipeline.
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Role of Medicare in Graduate Medical Education Medicare GME payments make up the largest portion of public funding for residency training programs. Medicare GME is mandatory funding with payments, based on the statutory formulas, guaranteed annually.
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Role of the Children's Hospital Graduate Medical Education Program The CHGME program was established in the Healthcare Research and Quality Act of 1999 to provide GME payments to freestanding children's hospitals. Prior to the CHGME program, the Medicare program provided payments based on the Medicare share of total inpatient days for direct GME payments and as an add-on to the Medicare inpatient prospective payment system for indirect GME payments.
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FIGURE 5-2 CHGME annual appropriations and residents supported.
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.9 Although CHGME payments are similar to Medicare GME in structure, there are key differences. Similar to Medicare, direct and indirect payments are calculated based on formulas, and a cap on the number of residents is applied to each hospital.
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, emergency medicine, some of the big fellowships are really getting the preponderance of the funding from the hospitals…there is no financial support through CHGME for the research training that's necessary to facilitate the career development of physician scientists and to meet the ABP [American Board of Pediatrics] requirement for scholarly activity.11 The CHGME program is unique in that the 2013 reauthorization of the program established a Quality Bonus System (QBS)
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However, educational debt may more strongly influence the choice of a career in primary care for medical students from economically disadvantaged backgrounds (Phillips et al., 2014)
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Furthermore, there are disparities in the level of debt burden. For example, medical students from URiM backgrounds have more educational debt, which may further complicate recruitment of URiM candidates to subspecialty careers (Dugger et al., 2013; Orr et al., 2023; Toretsky et al., 2018, 2019; Youngclaus and Fresne, 2020)
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A more recent survey (in 2022) on payment for physician specialties revealed that pediatrics overall and pediatric subspecialties tended to have the lowest compensation, and surgical specialties received the highest compensation; in fact, ABP-certified pediatric subspecialties represented 8 of the 20 lowest paying specialties, and the 5 specialties with the lowest compensation were all ABP-certified subspecialties (i.e., pediatric endocrinology, pediatric infectious disease, pediatric rheumatology, pediatric hematology and oncology,
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. oi:10.1542/peds.2020-027771 Only subspecialty training in cardiology, critical care, and neonatology resulted in a positive lifetime financial return (Figure 5-3)
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Scholarship and Loan Repayment Programs Scholarship and loan repayment programs aim to reduce financial barriers to entry for health professions careers and/or provide a financial incentive, leveraging student debt, for a desired health workforce outcome such as specialty choice or practice in an underserved setting. In 2019, among all medical students with the highest levels of debt, nearly half reported plans to seek loan forgiveness through a public service program (Youngclaus and Fresne, 2020)
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. Pediatric Specialty Loan Repayment Program The Pediatric Specialty Loan Repayment Program, administered by HRSA, was established in the Patient Protection and Affordable Care Act, offering up to a $35,000 loan repayment a year for each year of full-time services providing pediatric medical subspecialty, pediatric surgical specialty, or child and adolescent mental and behavioral health care, including substance abuse prevention and treatment services for up to 3 years.
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. INFLUENCES ON LIFESTYLE 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 (Levaillant et al., 2020; Newton et al., 2005; Rao et al., 2017; Yang et al., 2019)
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WORKFORCE PLANNING AND RECRUITMENT EFFORTS Federal and state governments along with the private sector invest in a number of programs designed to support and develop the health care workforce, either overall or specifically for pediatric subspecialties. Aside from its role in loan repayment, NHSC, discussed earlier, is one program that seeks to get more clinicians into geographic areas that have shortages of health professionals.
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The third domain, "Economic Strategy," focuses on ways to minimize educational debt and strategies to achieve parity with other providers. The final domain, "Recruitment/Outreach and Early Integration," primarily examines other avenues to attract medical students to pediatrics, including early
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evenings, overnights, weekends, and holidays." – Pediatric Emergency Medicine Faculty, Houston, TX These quotes were collected from the committee's online call for trainee, clinician, and family perspectives. exposure at high school and college levels, marketing strategies, increased shadowing opportunities for preclinical medical students, and incorporating pediatrics into preclinical curricula.
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focus on enhancing opportunities for medical students from racial/ethnic minority and disadvantaged backgrounds. The goal of HCOP is to identify, recruit, and support students from disadvantaged backgrounds for education and training for a career in health care professions.
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. As one of the newest subspecialties, pediatric hospital medicine has made concerted efforts to increase representation in their applicants by instituting a diversity and inclusion task force to review past recruitment practices for implicit bias or racism, conducting pre-interview events, highlighting opportunities for mentorship during the recruitment process, developing evidence-based best practice recommendations, and surveying matched and unmatched fellowship applicants to analyze effective URiM
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An important factor to recognize is that the pipeline for recruitment into pediatric subspecialties is the cohort of existing pediatrics residents who, in turn, draw from the existing cohort of medical students (Weyand et al., 2020)
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. It is critical to support the current pediatric subspecialty workforce, while also considering ways to expand the pipeline and encourage future medical students to consider a pediatric subspecialty career.
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. Although there are few studies of burnout specific to pediatric subspecialists, burnout has been documented in pediatric emergency medicine physicians (Gorelick et al., 2016; Gribben et al., 2019)
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: Concerted efforts toward increasing physician workforce diversity require an understanding of the workplace conditions that racially minoritized physicians face…[h] owever, little research exists documenting the experi ence of minoritized and marginalized physicians and how their experiences of racism may drive burnout, reduce well-being, and impact the practice of medicine.
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; • The length of fellowship training; • The requirement for scholarly activity during fellowship; • The debt burden of education and training; • Relatively lower salaries, particularly for some pediatric medical subspecialties compared with general pediatricians in outpatient practice and adult medical subspecialists; and • Lifestyle factors (e.g., work–life balance, job satisfaction, burnout)
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Finding #5-9: Medical students from URiM backgrounds have higher levels of educational debt on average than other students. Finding #5-10: Pediatricians are among the lowest paid specialists, even among primary care specialties.
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Conclusion #5-5: While pediatric subspecialty training is largely sup ported by the discretionary CHGME program, the lower level of fund ing places a disproportionate financial burden on freestanding children's hospitals compared with Medicare GME hospitals. This may limit the expansion and training of pediatric subspecialties.
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Residency and fellowship training needs to reflect this reality and abandon the inflexible approach of applying a single training model for the vast majority of graduates. Finally, as is discussed further in Chapter 5, the financial realities of educational debt coupled with the relatively low salaries for many specialists and the time demands for subspecialty training require consideration for ways to remove financial disincentives to entering pediatric subspecialty careers.
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RECOMMENDATION 5-4 Congress should increase funding for the Pediatric Specialty Loan Repayment Program to $30 million as origi nally authorized. HRSA should focus on loan repayment for high-prior ity pediatric medical subspecialties as well as subspecialists from URiM and/or economically disadvantaged backgrounds.
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2023. Medicaid graduate medical education payments: Results from the 2022 50-state survey.
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2021. Children's hospitals graduate medical education (CHGME)
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2017. State-based approaches to reforming Medic aid-funded graduate medical education.
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2021b. Physician workforce: Caps on Medicare-funded graduate medical education at teaching hospitals.
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2022c. Teaching health center graduate medical education (THCGME)
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2023. Functions and structure of a medical school: Standards for accreditation of medical education programs leading to the M.D.
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2023. Interventions associated with racial and ethnic diversity in US graduate medical education.
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BMC Medical Education 15(6)
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1995. Graduate medical education and physician practice location: Implications for physician workforce policy.
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2019. Factors influencing subspecialty choice among medical students: A systematic review and meta-analysis.
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