The Future Pediatric
Subspecialty Physician
Workforce
Meeting the Needs of Infants,
Children, and Adolescents
__________
Committee on the Pediatric Subspecialty Workforce and
Its Impact on Child Health and Well-Being
Board on Health Care Services
Health and Medicine Division
Board on Children, Youth, and Families
Division of Behavioral and Social Sciences and Education
Consensus Study Report
NATIONAL ACADEMIES PRESS 500 Fifth Street, NW, Washington, DC 20001
This activity was supported by contracts between the National Academy of Sciences and the American Academy of Pediatrics, the American Board of Pediatrics, the Association of Medical School Pediatric Department Chairs, The Annie E. Casey Foundation, the Children’s Hospital Association, the Council of Pediatric Subspecialties, the National Institute of Child Health and Human Development, and the Robert Wood Johnson Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
International Standard Book Number-13: 978-0-309-70840-1
International Standard Book Number-10: 0-309-70840-0
Digital Object Identifier: https://doi.org/10.17226/27207
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2023. The future pediatric subspecialty physician workforce: Meeting the needs of infants, children, and adolescents. Washington, DC: The National Academies Press. https://doi.org/10.17226/27207.
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COMMITTEE ON THE PEDIATRIC SUBSPECIALTY WORKFORCE AND ITS IMPACT IN CHILD HEALTH AND WELL-BEING
FREDERICK P. RIVARA (Chair), Seattle Children’s Guild Association Endowed Chair in Pediatric Outcomes Research; Vice Chair and Professor, Department of Pediatrics; Adjunct Professor, Department of Epidemiology, University of Washington
KELLY J. BETTS, Assistant Dean/Assistant Professor, University of Nebraska Medical Center, College of Nursing West Nebraska Division; Primary Care Pediatric Nurse Practitioner, Community Action Health Clinic, Gering, Nebraska
KENDALL M. CAMPBELL, Professor and Chair, Department of Family Medicine, University of Texas Medical Branch
KECIA N. CARROLL, Chief, Division of General Pediatrics, Professor of Pediatrics, Environmental Medicine and Public Health, The Icahn School of Medicine at Mount Sinai
CANDICE CHEN, Associate Professor, Fitzhugh Mullan Institute for Health Workforce Equity, Milken Institute School of Public Health, The George Washington University
CHRISTOPHER B. FORREST, Professor of Pediatrics, Applied Clinical Research Center, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
ELENA FUENTES-AFFLICK, Professor of Pediatrics and Vice Dean, Zuckerburg San Francisco General Hospital, University of California, San Francisco
RACHEL L. GARFIELD, Executive Director, Vermont Child Health Improvement Program; Associate Professor, Department of Pediatrics, Larner College of Medicine at the University of Vermont
KRISTIN HITTLE GIGLI, Assistant Professor, Graduate Nursing University of Texas at Arlington; Pediatric Nurse Practitioner, Pediatric Intensive Care Unit, University of Texas Southwestern Medical Center, Children’s Health
JAVIER A. GONZALEZ DEL REY, Professor of Clinical Pediatrics, Division of Pediatric Emergency Medicine, Cincinnati Children’s Hospital Medical Center; Associate Chair for Education and Director, Cincinnati Children’s Pediatric Education Center; Designated Institutional Official, University of Cincinnati College of Medicine
SHAFALI SPURLING JESTE, Las Madrinas Chair and Chief, Division of Neurology, Children’s Hospital Los Angeles, Professor of Pediatrics and Neurology, USC Keck School of Medicine
OPHIR D. KLEIN, Executive Director, Cedars-Sinai Guerin Children’s; Vice Dean for Children’s Services, David and Meredith Kaplan Distinguished Chair in Children’s Health, Professor of Pediatrics, Cedars-Sinai Medical Center; Adjunct Professor of Orofacial Sciences and Pediatrics, University of California San Francisco
VICTORIA FAY NORWOOD, Robert J. Roberts Professor of Pediatrics, Division of Pediatric Nephrology, University of Virginia School of Medicine, and Children’s Hospital
ELIANA M. PERRIN, Bloomberg Distinguished Professor of Primary Care, Department of Pediatrics—School of Medicine, School of Nursing, Johns Hopkins University
SAMIR S. SHAH, Vice Chair, Clinical Affairs and Education, Cincinnati Children’s Hospital Medical Center; James M. Ewell Professor, Department of Pediatrics, University of Cincinnati College of Medicine
CHRISTOPHER J. STILLE, Professor and Section Head, General Academic Pediatrics, and Stephen Berman, M.D. Endowed Chair in General Pediatrics, University of Colorado School of Medicine
BONNIE T. ZIMA, Professor-in-Residence, Child and Adolescent Psychiatry, Vice Chair for Faculty Development, Associate Chair for Academic Affairs, UCLA-Semel Institute for Neurosciences and Human Behaviors; UCLA Center for Health Services and Society
National Academy of Medicine (NAM) Fellow
JULIEANNE P. SEES, Associate Professor of Pediatrics and Orthopaedic Surgery, Midwestern University; Chair, Department of Affiliates, American Osteopathic Association; Director, American Osteopathic Academy of Orthopaedics
Study Staff
TRACY A. LUSTIG, Study Director
RUTH COOPER, Associate Program Officer
ISAAC SUH, Research Associate (starting August 2022)
NIKITA VARMAN, Research Associate (through June 2022)
ADAEZE OKOROAJUZIE, Senior Program Assistant (starting January 2023)
TOCHI OGBU-MBADIUGHA, Senior Program Assistant (through November 2022)
ARZOO TAYYEB, Finance Business Partner (through April 2023)
JULIE WILTSHIRE, Senior Finance Business Partner (starting April 2023)
JULIE SCHUCK, Senior Program Officer, Board on Children, Youth, and Families
NATACHA BLAIN, Senior Board Director, Board on Children, Youth, and Families
SHARYL J. NASS, Senior Director, Board on Health Care Services
Reviewers
This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.
We thank the following individuals for their review of this report:
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by PATRICK H. DELEON, Uniformed Services University, and SHARI BARKIN, Virginia Commonwealth University. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.
Acknowledgments
The study committee and the Health and Medicine Division (HMD) project staff take this opportunity to recognize and thank the many individuals who shared their time and expertise to support the committee’s work and to inform deliberations.
This committee appreciates the sponsors of this study for their generous financial support: the American Academy of Pediatrics, the American Board of Pediatrics, The Annie E. Casey Foundation, the Association of Medical School Pediatric Department Chairs, the Children’s Hospital Association, the Council of Pediatric Subspecialties, the National Institute of Child Health and Human Development, and the Robert Wood Johnson Foundation. The contents provided do not necessarily represent the official views of the sponsors.
The committee benefitted greatly from discussions with individuals who made presentations during the committee’s open sessions:
The committee is thankful for the team at Carelon Research, including Lauren Parlett, Katherine Harris, Claire Bocage, Roopalini Bakthavachalam, and Madhavi Sunkara, who produced a commissioned analysis of pediatric subspecialty use among a commercial health plan population.
The committee also thanks researchers who contributed to two other analyses submitted to this committee. They include Mitchell Maltenfort and Andrea Allen at the Children’s Hospital of Philadelphia who contributed to an analysis of PEDSnet data of children at academic pediatric medical centers, and Qian Luo at The George Washington University who contributed to an analysis of data from the Transformed Medicaid Statistical Information System.
Deep appreciation goes to staff at the National Academies of Sciences, Engineering, and Medicine for their efforts and support in the report process, especially to Elizabeth Ferre, Erin Fox, Joe Goodman, Anne Marie Houppert, Christopher Lao-Scott, Megan Lowry, Amber McLaughlin, Rachael Nance, Shaakira Parker, Marguerite Romatelli, Leslie Sim, Roberta Wedge, Anesia Wilks, and Taryn Young. The committee also gives special thanks to Tasha Bigelow, Mark Goodin, and Laura Penny, copyeditors.
Finally, the committee thanks the many patients, families, residents, fellows, and practicing clinicians who shared their perspectives and experiences.
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3 PEDIATRIC SUBSPECIALTY USE DATA ANALYSES
4 THE PEDIATRIC HEALTH CARE WORKFORCE LANDSCAPE
The Pathway to Becoming a Pediatric Subspecialty Physician
Pediatric Subspecialty Fellows
Actively Practicing Pediatric Subspecialty Physicians
Modeling the Future Subspecialty Workforce
Mental Health, Behavioral Health, and Social Care Professionals
Other Related Health Professionals
5 INFLUENCES ON THE CAREER PATH OF A PEDIATRIC SUBSPECIALTY PHYSICIAN
Coaching, Mentorship, and Role-Modeling
Financing of Graduate Medical Education
Educational Debt and Earning Potential
Workforce Planning and Recruitment Efforts
6 TRENDS IN THE PEDIATRIC–SCIENTIST WORKFORCE
The Importance of Pediatric Research
Unique Challenges of Pediatric Research
The Pediatric Physician–Scientist Workforce
Challenges to the Physician–Scientist Workforce and Interventions to Support Pediatric Researchers
The Pediatric Research Funding Landscape: Adequacy and Distribution
7 INNOVATIONS AT THE PRIMARY-SPECIALTY CARE INTERFACE
Collaboration and Coordination Between Pediatric Primary and Specialty Care
Challenges of Consultation, Referral, and Co-management
Promising Primary–Specialty Care Models
Investing in Pediatric Primary Care to Improve the Primary-Specialty Care Interface
8 FINANCING CHILDREN’S HEALTH CARE
Financing and Coverage of Children’s Subspecialty Care
Payment Rates for Children’s Subspecialty Care
Compensation for Pediatric Medical Subspecialty Physicians
How Financing and Payment Tie to Provider Salaries, Practice Decisions, and Access to Care
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Preface
The health of children has dramatically changed in the last 2–3 decades. Mortality rates for children have decreased, although children still die at much higher rates in the United States compared to those in other high-income countries. While the number of children in the United States has not appreciably increased over the last 20 years, the sociodemographic composition and the physical, mental, and behavioral health of the pediatric population has shifted. The miracle of immunizations has virtually eradicated infections such as measles, bacterial meningitis, varicella, pertussis, and many other diseases that once filled hospitals, but their places are now taken by children with a large variety of chronic, and often lifelong, illnesses. The rate of teen suicide has increased, reflecting the large burden of pediatric mental health problems that have been highlighted by the COVID-19 pandemic. Many children live in families that are stressed by poverty, language barriers, and interpersonal and structural racism, creating challenges for parents and health care providers to meet their needs.
The United States does not have a pediatric health care “system.” We have health care organizations that have grown organically to meet the needs of our patients. They have attempted to use the continuing, tremendous advances in science to improve the health outcomes of children they serve. One of the main ways this has occurred has been in focusing on pediatric subspecialists to deliver the majority of care to the ever increasingly complicated acutely and chronically ill children in the population. This has often resulted in relegating primary care practitioners to providing preventive and acute illness care, and being referrers to subspecialists, with a lack of partnership between the two groups in caring for these children.
The effect of this evolution has been to create enormous strains in health care organizations. The demand for pediatric services has led to large growth in pediatric departments in U.S. medical schools and other multispecialty groups to meet the demand. But this has often been unsuccessful, resulting in barriers to care that do not meet the Institute of Medicine criteria for high-quality care as being safe, timely, efficient, equitable, effective, and patient centered. Since children constitute the largest group in America living in poverty, they are the largest group in which their health care is insured by Medicaid. Following the development of the Children’s Health Insurance Program (CHIP) in the 1990s, the Affordable Care Act and Medicaid expansion, and other changes, uninsured rates dropped overall so that very few children in the United States are uninsured (recognizing some geographic variation). While Medicaid provides good coverage for children, reimbursement to hospitals and clinicians is inadequate to cover the costs of care, resulting in further strains on pediatric health care organizations. Access to pediatric subspecialty care is threatened, in part, by relatively low salaries, which in turn reflect low Medicaid/CHIP reimbursement rates for all types of care and reimbursement methodologies, and a limited supply of new entrants into the workforce, particularly in the non-procedurally based pediatric subspecialties. The financial realities of college and medical school debt coupled with the high cost of living in many of the cities in which academic medical centers are located, and the relatively low salaries for many specialists, necessitate a variety of mechanisms to overcome financial disincentives.
The academic “triple threat” (clinician, researcher, teacher) is dead—if it ever truly existed. Academic medical centers cannot fulfill their missions of clinical care, education, and research without a workforce that is composed of faculty who are individually differentiated in the skills and effort in each of these three areas. Access to subspecialty care is further threatened by the complexification of subspecialty medicine, which like much of health care, has become more time intensive. In addition, most pediatric subspecialists work for large health systems, decreasing physicians’ sense of control and contributing to burnout and a desire to cut back on clinical time to reduce attendant stress. The burnout of many pediatricians combined with the dissatisfaction of families with long wait times for specialist appointments beg for new models of care that reset the relationship between pediatric specialists and primary care providers, making them more partners in care of children with chronic diseases. The pandemic has shown us how rapidly new technology such as telehealth can be implemented and widely adopted. Indeed, many organizations did in 2 weeks what they had previously spent 2 years discussing. Finally, continued advances in child and adult health require continued scientific discovery, but the system for producing and
nurturing pediatric physician–scientists has been inadequate, particularly at the beginning of their careers. Overall, increasing the number of pediatric subspecialists alone is not the answer. The situation requires a more comprehensive approach that addresses all of these factors.
The committee is grateful to our sponsors for, first of all, appreciating the current crisis and then coming together to support this work. We hope that the information gathered in this report and the recommendations of the committee will be used to bring about substantial change to the systems that determine the health care of the most vulnerable children who are entrusted to us for their care. The needs of children today are not the same as the needs of children 50 or 75 years ago. The systems that provide them care need to evolve to meet these demands.
Frederick P. Rivara, M.D., M.P.H., Chair
Committee on the Pediatric Subspecialty Workforce and Its Impact on Child Health and Well-Being
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Acronyms and Abbreviations
| AAFP | American Academy of Family Practitioners |
| AAMC | Association of American Medical Colleges |
| AANP | American Association of Nurse Practitioners |
| AAP | American Academy of Pediatrics |
| ABP | American Board of Pediatrics |
| ABPN | American Board of Psychiatry and Neurology |
| ACA | Affordable Care Act |
| ACCR | American Chiropractic College of Radiology |
| ACGME | Accreditation Council for Graduate Medical Education |
| ACO | accountable care organization |
| ADHD | attention deficit hyperactivity disorder |
| AHEC | area health education center |
| AHRQ | Agency for Healthcare Research and Quality |
| AMA | American Medical Association |
| AMBS | American Board of Medical Specialties |
| AMG | American medical graduate |
| AML | acute myeloid leukemia |
| AOA | American Osteopathic Association |
| AOBP | American Osteopathic Board of Pediatricians |
| APRN | advanced practice registered nurse |
| ASO | administrative services only |
| BOS | Bureau of Osteopathic Specialties |
| BPCA | Best Pharmaceuticals for Children Act |
| CAMPP | Consortium of Accelerated Medical Pathway Programs |
| CAP | child and adolescent psychiatry |
| CBO | Congressional Budget Office |
| CDC | Centers for Disease Control and Prevention |
| CHA | Children’s Hospital Association |
| CHC | community health center |
| CHGME | Children’s Hospital Graduate Medical Education program |
| CHIP | Children’s Health Insurance Program |
| CKD | chronic kidney disease |
| CMMI | Capability Maturity Model Integration |
| CMS | Centers for Medicare and Medicaid Services |
| COE | centers of excellence |
| CORE | Coordinating Optimal Referral Experiences |
| CRS | Congressional Research Service |
| CSHCN | children with special health care needs |
| CYSHCN | children and youth with special health care needs |
| DEIA | diversity, equity, inclusion, accessibility |
| DO | doctor of osteopathic medicine |
| DSRIP | Delivery System Reform Incentive Payment Program |
| E/M | evaluation and management |
| EPA | entrustable professional activity |
| EPSDT | early and periodic screening, diagnosis, and treatment |
| FDA | Federal Drug Administration |
| FFS | fee-for-service |
| FMAP | Federal Medical Assistance Percentage |
| FOPE | Future of Pediatric Education |
| FOPE II | Future of Pediatric Education II |
| FSMB | Federation of State Medical Boards |
| GAO | Government Accountability Office |
| GME | graduate medical education |
| HCOP | Health Careers Opportunity Program |
| HCUP | Healthcare Cost and Utilization Project |
| HHS | Department of Health and Human Services |
| HiSTEP | High School Scientific Training and Enrichment Program |
| HRSA | Health Resources and Services Administration |
| IAP | Innovation Acceleration Program |
| IHI | Institute for Healthcare Improvement |
| IMG | international medical graduates |
| InCK | Integrated Care for Kids |
| INMED | Indians into Medicine Program |
| IOM | Institute of Medicine |
| IPPS | Inpatient Prospective Payment System |
| IVIG | intravenous immunoglobin |
| IWPR | Institute of Women’s Policy Research |
| LCME | Liaison Committee on Medical Education |
| MACPAC | Medicaid and CHIP Payment and Access Commission |
| MCHB | Maternal and Child Health Bureau |
| MCO | managed care organization |
| MCPAP | Massachusetts Child Psychiatry Access Project |
| MedPAC | Medicare Payment Advisory Commission |
| MEPPS | Medical Expenditure Panel Survey |
| MOC | maintenance of certification |
| MS1 | first-year medical student |
| MSQ | Matriculating Student Questionnaire |
| NAM | National Academy of Medicine |
| NASEM | National Academies of Sciences, Engineering, and Medicine |
| NCBDDD | National Center on Birth Defects and Developmental Disabilities |
| NCIPC | National Center for Injury Prevention and Control |
| NCIRD | National Center for Immunization and Respiratory Diseases |
| NCQA | National Committee for Quality Assurance |
| NEHRS | National Electronic Health Records Survey |
| NES | non-English speaking |
| NHSC | National Health Service Corps |
| NICHD | National Institute of Child Health and Development |
| NICU | neonatal intensive care unit |
| NIH | National Institutes of Health |
| NP | nurse practitioner |
| NRC | National Research Council |
| NRMP | National Resident Matching Program |
| PA | physician assistant |
| PACT | Pediatricians Accelerate Childhood Therapies |
| PCCM | primary care case management |
| PCMH | patient-centered medical homes |
| PCORI | Patient Centered Outcomes Research Institute |
| PCP | primary care providers |
| PGY | postgraduate year |
| PICU | pediatric intensive care unit |
| PREA | Pediatric Research Equity Act |
| OASH | Office of the Assistant Secretary for Health |
| OECD | Organization for Economic Co-operation and Development |
| OHDSI | Observational Health Data Sciences and Informatics |
| ONC | Office of the National Coordinator for Health Information Technology |
| QBS | quality bonus system |
| R01 | research project grants |
| RACE | Research to Accelerate Cures and Equity for Children |
| RBRVS | resource-based relative value scale |
| RCT | randomized controlled trials |
| RVU | relative value units |
| SAMHSA | Substance Abuse and Mental Health Services Administration |
| SCHIP | State Children’s Health Insurance Program |
| SCTC | Subspeciality Clinical Training and Certification |
| SEPA | Science Education Partnership Award |
| SHCN | special heath care needs |
| SIM | State Innovation Model |
| STEM | science, technology, engineering, and math |
| TAGGS | Tracking Accountability in Government Grants System |
| THCGME | Teaching Health Center Graduate Medical Education program |
| T-MSIS | Transformed Medicaid Statistical Information System |
| URiM | underrepresented in medicine |
| VBP | value-based purchasing |
| WHO | World Health Organization |
