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

The prevalence of congenital heart disease (CHD) is estimated to be 0.8% to 1% of live births, making it the most common class of birth defects.^6,7  Forty thousand children are born each year in the United States with some form of CHD. As most children born with CHD now survive into adulthood,⁸  a threshold was crossed in 2005 when, for the first time, more adults are living with CHD than children. Today, an estimated 2 to 3 million people are alive with CHD, creating a growing population of both pediatric and ACHD patients needing care for complications such as rhythm disorders, heart failure, and pulmonary hypertension.⁹  Although collaboration with primary care providers is essential for high-quality care, the PC care team often fills the role of the medical home for these patients and their families.^10,11  As overall survival from CHD has increased, more cardiologists are needed to care for these patients throughout childhood and adolescence and into adulthood.

In addition to caring for children with CHD, pediatric cardiologists frequently evaluate children referred for heart murmurs, chest pain, and syncope. In-hospital consultations include preterm infants with persistent pulmonary hypertension of the newborn and patent ductus arteriosus, children with systemic or genetic conditions with possible cardiac involvement, and acquired heart diseases (eg, Kawasaki disease, myocarditis, pericarditis, acute rheumatic fever), and the recently described coronavirus disease 19-related condition of multisystem inflammatory syndrome.¹²  There is also a growing need for preventive cardiology care to address long-term cardiovascular health related to the obesity epidemic, hypertension, and lipid disorders.^13,14 

Complicating the workforce assessment are significant disparities in access to advanced care and clinical outcomes. Tertiary centers for complex pediatric heart disease are not uniformly accessible, and families may need to travel significant distances for specialists and procedures with attendant out-of-pocket costs.^15–19  PC has one of the lowest rates of rural practice among all the pediatric subspecialties,²⁰  and outcomes are worse in economically depressed communities and areas remote from top-performing pediatric cardiac centers.²¹  Forty-five percent of the continental US population lives more than a 1-hour drive to an ACHD center,¹⁶  and 11 states lack either a dedicated pediatric cardiac ICU or a mixed pediatric and cardiac ICU.²² 

Socioeconomic and systemic barriers may prevent at-risk populations from receiving optimal health care.^15,23,24  Outcomes are also affected by insurance status: an uninsured child has 2 to 3 times the mortality risk after surgical repair than their insured peers.^25,26  Social drivers of health are associated with adverse outcomes, including less frequent prenatal diagnosis, increased CHD incidence, higher infant mortality, worse surgical outcomes, greater inpatient resource utilization, more missed clinic appointments, increased loss to follow-up, lower academic achievement, reduced family quality of life, and increased complications and hospitalizations as an adult.^27–30  The goals for the future workforce should include mitigating these disparities.

PC has roots in the 17^th century with the first description of rheumatic fever. Historical landmarks that followed include Matthew Baillie’s description of transposition of the great arteries in 1797, Louis-Etienne Arthur Fallot’s description of the tetrad of lesions that bears his name in 1888, Maude Abbott’s Atlas of Congenital Heart Disease in 1936, and the development of the Blalock-Taussig-Thomas shunt by Alfred Blalock, Helen Taussig, and Vivien Thomas in 1945.³¹  More recently, the field has benefited from William Rashkind performing the first balloon atrial septostomy, the discovery that prostaglandin infusion could maintain patency of the ductus arteriosus after birth, the field of interventional catheterization heralded by Jean Kan’s first pulmonary balloon valvuloplasty, the development of cardiopulmonary bypass that began the era of open heart surgery,³²  and the organization of dedicated intensive care units for pre and postoperative care of children requiring heart surgery. The PC subboard was established in 1960,³³  with the first certification exam in 1961. Through 2023, the American Board of Pediatrics (ABP) has certified 4117 pediatric cardiologists,³⁴  6.0% having also been certified in another, most in pediatric critical care (4.9%) and neonatal-perinatal medicine (1.0%).³⁵  The number of pediatric cardiologists with additional certification in pediatric critical care medicine has increased in recent years. Another area of sub-specialization is ACHD, which became a board-certified field under the aegis of the American Board of Internal Medicine in 2015. To date, 484 ACHD certifications have been awarded,³⁶  of which 333 trained as pediatric cardiologists³⁷  before fellowship in ACHD, with the remaining 151 initially training in adult cardiology.

Based on ABP data through June 2023, 4117 pediatric cardiologists have ever been board-certified, of which 3096 (75%) were actively enrolled in Maintenance of Certification (MOC). The ABP data on currently certified subspecialists include individuals who may not be in the workforce because of recent retirement, death, or other factors. Consequently, descriptions of the current workforce limit the sample to the 3045 currently certified pediatricians ≤70 years. Of these, 40.6% identified as female, with that proportion increasing over time.³⁸  In 2014, the percentage of female fellows exceeded 50% for the first time, reaching a high of 53.4% in 2022.³⁹  However, the representation of women in leadership roles, including clinical subspecialty directors, endowed chairs, and division directors, continues to lag well behind that of male pediatric cardiologists.⁴⁰ 

The median age of pediatric cardiologists was 46 years with 16.0% being 61 to 70 years. Almost three-quarters (73.2%) were American medical graduates (AMG) with a Doctor of Medicine (MD) degree, 3.3% were AMGs with a Doctor of Osteopathy (DO) degree, 10.3% were international medical graduates (IMG) with an MD degree, and 13.1% were IMGs with an international degree.³⁴  Like some other pediatric subspecialties, the proportion of IMGs has substantially decreased since 2014. Race and ethnicity estimates based on surveys from 2018 to 2022³⁹  suggest that the majority (60.2%) characterized themselves as white, 23.9% as Asian, and 9.2% as underrepresented in medicine (URiM), comprised primarily of those self-identifying as Black or African American (2.4%) or Hispanic, Latino, or Spanish (4.8%) origin.

MOC enrollment surveys of current ABP-certified pediatric cardiologists from 2018 to 2022 had a 55.2% response rate for PC, reflecting responses from 1361 eligible pediatricians ≤70 years. Because of nonuniformity in the number of questions answered in the survey, the percentages reported are for individual questions. The majority reported being employed full-time (92.7%) and 66.2% reported working ≥50 hours per week on average over the last 6 months, exclusive of time on-call at home. Women were more likely to indicate part-time employment status compared with men (11.3% vs 2.5%). Most (89.4%) spent ≥50% of their time in clinical care, though considerable variation exists in the distribution of efforts among clinical, research, educational, and administrative activities. Only 3.2% reported spending ≥50% of their time on research. Most (84.2%) reported having a faculty appointment. Over three-quarters (77.7%) reported a primary work setting within an urban environment and close to half (47.3%) reported ≥50% of their patients received public insurance.⁴¹ 

When the workforce is limited to the United States, there was an average of 57.3 board-certified pediatric cardiologists per US state (range 0–329) in 2023, which translates to 4.0 per 100 000 children 0 to 17 years (range 0.0–25.4) across the United States (Fig 1).⁴²  There was wide variability in the distribution of pediatric cardiologists within states, with most concentrated in urban settings and few in rural areas. Analyses from 2019 showed the average driving distance to a certified pediatric cardiologist was 17.4 miles; distances ranged from a low of 5 miles in Rhode Island to a high of 138.0 miles in North Dakota (excluding Alaska, Hawaii, Puerto Rico, and the District of Columbia).

PC training is unique in that additional training beyond the 3-year fellowship is common. Nearly 60% of graduates pursue additional training,⁴³  with 1 to 2 more years being essential for sub-subspecialty careers.^43–47  From 2012 to 2022, there has been a steady increase in fellowship programs (16.4% from 2012–2022)⁴⁸  and positions (25.4%).³⁹  However, the number of applicants has remained stable,⁴⁹  resulting in a fall in the ratio of applicants to positions from 1.6 (2007) to 1.1 (2023).⁴⁸  This contrasts with other large fellowship programs, like neonatology, pediatric critical care medicine, and pediatric emergency medicine, which have seen a 27%, 33%, and 43% growth in applications since 2017, respectively.⁴⁹  This may be problematic for the PC workforce should the trend continue.

With respect to diversity, among 489 PC fellows training during academic year 2022 to 2023, 53.4% identified as female. Two-thirds (66.7%) were AMGs with an MD degree; 10.2% were AMGs with a DO degree; 0.41% were AMGs with an unknown degree; 12.7% were IMGs with an MD degree; and 9.4% were IMGs with an international degree.⁵⁰  In 2022, over half (57.7%) self-identified as white, 23.2% as Asian, and 11.0% as URiM (ie, Black or African American, Hispanic, Latino, or Spanish origin, American Indian or Native Alaskan, or Native Hawaiian or Pacific Islander origin).³⁹  These numbers, when compared with certified pediatric cardiologists, confirm that more women, DOs, and URiM are entering training.

An assessment of the PC workforce is critical as there has been recent concern about a tightening job market for new fellowship graduates.⁵¹  Leslie et al reported that pediatric cardiology fellows’ confidence in finding a job in their chosen subspecialty trended downward from 2019 to 2021.⁵²  A comprehensive survey by Ross et al in 2015 found considerable variation in job availability across subdisciplines within PC.⁴³  Although every graduate found work in their subspecialty, the majority rated obtaining a job as “somewhat difficult.” Advanced imaging jobs were rated as “neutral” to obtain, whereas ACHD, heart failure and transplantation, and cardiac critical care jobs were perceived as relatively easy to obtain. More recent assessments suggest that the number of trainees entering cardiac critical care has caught up with the demand and that this market may be tightening as well.⁴⁷  On the other hand, Ezzedine and colleagues estimate a current shortage of 170 physicians trained in ACHD,⁵³  and there may be a shortfall of electrophysiology physicians by 2032, with an inadequate number of available training positions.⁴⁵ 

Recent publications have highlighted differences in financial remuneration across pediatric subspecialties.⁵⁴  Although older reports suggest compensation may be less important in choosing a pediatric subspecialty career,⁵⁵  increasingly high rates of debt may impact current career decision-making. Approximately 36.8% of current PC fellows owe $200 000 or more compared with 39.5% for all pediatric subspecialty fellows, based on results from the ABP’s Subspecialty In-training Exam Survey in 2022 (personal communication, ABP, February 20, 2023). However, PC is 1 of only 3 ABP subspecialties reported to have a favorable financial return on time invested in additional training when average compensation is compared with that of general pediatrics.⁵⁴ 

The ABP Foundation contracted with the Sheps Center for Health Services Research at the University of North Carolina and Strategic Modeling and Analysis Ltd. to construct a workforce model estimating the pediatric subspecialty workforce supply 70 years and younger from 2020 to 2040.⁵⁶  The model uses a microsimulation approach, which applies probabilities to individual-level behaviors related to the inflow of fellows, geographic diffusion, out-of-country returners, attrition, and retirement. It provides baseline estimates at the national and subnational levels for both headcount (HC, absolute number) of pediatric cardiologists and the estimated clinical workforce equivalent (CWE), HC adjusted for self-reported time spent in clinical and consultative care, per 100 000 children 0 to 18 years. Alternative scenarios explore how the workforce might change in response to important factors in this field. The model also accounts for changes in the child population at the national and subnational level based on the US Census Bureau⁵⁷ ; differences by subspecialty for census regions are discussed in the summary article in this supplement.⁵⁸ 

A detailed description of the methods for the workforce model’s development is provided in this supplement.⁵ 

The model’s baseline projection HC estimates will increase by 83% from 2431 (2020) to 4488 (2040). Adjusting for time spent in clinical care and population, the model estimates CWE per 100 000 children will increase by 63% from 2.16 (2020) to 3.51 (2040). Regionally, the Northeast and the Midwest have the highest CWE per 100 000 children. The model estimates they will experience the largest growth in supply at 70% and 88%, respectively (Fig 2). Historically, half to two-thirds of graduates choose to remain in the region where they did their fellowship training,⁵⁹  which may explain why these 2 regions have a higher density of providers as there are many training programs in these areas.

When examining supply at the census division level, there is a large discrepancy between the divisions with the largest projected supply of cardiologists and fellows and the areas of projected child population growth (Tables 1 and 2). The Mountain, West South Central, Pacific, and South Atlantic divisions are projected to have 3 to 5 times the relative child population increase, though they have the lowest increases in CWE per 100 000 children. Despite overall PC growth nationally, specific areas of the country may face shortages, given projected increases in the child population.⁵⁸ 

The model also provides alternative scenarios to assess how supply will change if various factors shift at the census division level (Tables 1 and 2). In this paper, we focus on the following scenarios: (1) a 12.5% increase in the number of fellows trained between 2026 and 2040, (2) a 12.5% decrease in the number of fellows over that same period, and (3) a 12.5% decrease in the number of fellows, a 7% decrease in the CWE, and increased exit from the field. These scenarios were chosen to predict PC workforce needs based on (1) a range of possible increases in workforce demand, (2) a decreasing or stable fellowship applicant pool, (3) increasing numbers of clinicians working part-time reflecting gender shifts and historical data, and (4) increasing potential for burnout.

When the model accounts for a 12.5% increase in fellows over 10 years (2026–2036), CWE per 100 000 children increases by 69% from baseline to 3.65. With a 12.5% decrease in fellows, CWE per 100 000 children increases by only 56% to 3.37. In the worst-case scenario, with a decrease in fellows and clinical time coupled with early exits, CWE per 100 000 children increases by only 45% to 3.13. Early exit alone only has a minimal effect, suggesting that, although the workforce’s average age is 49.1 years, retirement from the field will be outweighed by the larger number of trainees entering.

In all projections in the model, there is an increase in the number of pediatric cardiologists and CWE per 100 000 children. However, the significant geographic disparities in the current supply become even more pronounced by 2040. The alternative scenarios discussed above affect the 2040 projections in subtle but predictable ways without significantly altering the differential growth across regions. In all scenarios considered, the West North Central and East South Central Census Divisions have the most significant increase in pediatric cardiologists but are not the home to the largest training sites. Furthermore, they are the only ones to routinely surpass other divisions from 2020 to 2040, suggesting a subtle but significant shift in the location of practicing pediatric cardiologists. It is beyond this project’s scope to predict the future workforce in the pediatric cardiac sub-subspecialties, but understanding the supply and demand for these subdisciplines is critical to assessing the PC workforce and aligning training positions with patient needs. Furthermore, higher survival rates, longevity, greater acuity, and technological advances will likely further increase the clinical need for pediatric cardiologists.

Although the magnitude of the CWE increase varies, the projected workforce increase is in stark contrast to the unchanged number of PC applicants. Because the model considers historical growth in fellow positions, whereas the number of trainees applying has not similarly increased, an inflection point could occur in the near future when available spots exceed applicants and programs go unfilled. This should encourage early engagement and mentoring of trainees to consider PC as a career choice.

As is the case with other subspecialties, pediatric cardiologists may continue to care for those with congenital or early-acquired heart disease throughout their lives. ACHD is likely to be the subspecialty of greatest growth and has an intrinsic connection to the pediatric workforce because of the patient population and the training pathways. Physicians may come from pediatrics, internal medicine, or combined internal medicine and pediatrics residencies followed by either pediatrics or adult cardiology fellowships and subsequently 2 years of ACHD fellowship. Adults requiring congenital heart surgery have lower mortality rates when a pediatric cardiac surgeon performs these compared with adult cardiac surgeons,⁶⁰  further adding to the demand at pediatric centers and by pediatric providers. Consideration should be given to targeting aspiring ACHD applicants early in their careers and working with governing boards to shorten training to encourage the growth of this sub-subspecialty.

Lastly, the impact of population changes may also be that trainees will need to look at jobs farther from where they trained to meet child health needs. Concurrently, the areas of greatest population growth may need to increase their training positions and promote their graduates to stay in those areas and care for the increased numbers of children residing there.

The scenarios modeled highlight the increasing supply and uneven distribution of pediatric cardiac care throughout the United States. The projected increases will help address the greater demands from population growth, increased survival and complexity, and technological advances in diagnostics and therapies. However, the misalignment in population growth, projected workforce supply, and driving distance to cardiac centers may require further expansion of outreach clinics to decrease barriers to care. As these satellite clinics expand farther from major centers, this may result in further subspecialization of the general PC workforce, necessitating a choice between a hospital-based career versus one focused more remotely from tertiary care centers. Telemedicine is another area that may increase access, though invasive procedures and advanced cross-sectional imaging will still necessitate travel for many patients.

The future workforce will continue to rely on more than board-certified pediatric cardiologists. Advanced practice providers (APP) are key team members, particularly in heart failure and cardiac critical care.^61,62  However, they may not significantly reduce the workforce demands in all areas as they often require supervision, particularly for outpatient referrals.⁶³  Recruiting more APPs into pediatric fields and developing specialized continuing professional education for cardiac APPs may help address these concerns and facilitate successful integration into other areas of cardiac practice.⁶⁴ 

Notably, frequent comorbidities require care from many other subspecialists. Developmental outcomes are critically important clinical endpoints for patients with CHD,^65,66  though the availability of developmental-behavioral pediatricians is limited, with only modest projected growth and decreases in some populous areas of the country. The health and well-being of CHD patients similarly rely on the availability of other pediatric subspecialists, highlighting the interdependence of the entire pediatric subspecialty workforce.

Given the growing geographic disparity between the supply of cardiologists and projected population growth, future graduates will likely have to expand their job search more widely than in the past. More general cardiology graduates practicing in rural or other underserved areas could reduce barriers to care. Incentives to expand training programs and/or clinical services in areas of greater need may help reduce disparities in access.

Historically, pediatricians and pediatric subspecialties are paid substantially less than similar positions in adult medicine.⁶⁷  This relates, in part, to the differential higher payments for Medicare compared with Medicaid. A concerted effort to lobby for equalization of Medicaid to Medicare payments, increased funding for subspecialty training, loan forgiveness from educational debt for working in underserved areas as defined by the subspecialty, and other financial incentives to offset the long training pathway may help enhance the PC workforce.

Although the modeling described in this paper provides the most in-depth analysis of the projected workforce supply to date, several issues require further investigation. One critical issue is why the number of fellowship applicants has not increased relative to some other pediatric subspecialties and in concert with the increase in available training positions. Given that PC remains in the top 3 pediatric subspecialties in lifetime earnings, this is likely not financially driven. It may reflect perceptions of fewer options for part-time work, greater work intensity and lack of shift work, or job availability. Additionally, although the percentage of women entering the field is increasing, it lags behind the percentage of women entering training in general pediatrics and other pediatric subspecialties as PC has the lowest percentage of women ever certified³⁴  and the lowest proportion of women among 3-year fellowships in 2022.³⁹  Disparities in career advancement for women⁴⁰  should be addressed to maximize the talent pool in the field.

Another crucial issue requiring more investigation is the relationships between subspecialist supply, market demand for sub-subspecialists, and true patient-driven need for those services. Institutions currently offer fellowships based on their history of training, clinical volumes, funding, and other local factors. Some centers offer several advanced training positions and others none, with the number of positions and areas of sub-subspecialization changing from year to year, driven mostly by available funding and the interests of internal applicants with occasional insight from the perceived job market. Because of the uneven distribution of pediatric cardiac centers throughout the United States, the availability of subspecialist jobs is a poor surrogate for true patient-driven clinical need. The distance patients travel to access cardiac centers for those services varies greatly, potentially exacerbated by restrictions requiring in-state care.⁶⁸ 

Understanding the true need and demand for such services will allow centers that can provide such training to better manage the supply; this could be achieved through collaboration with the ABP, the Society of Pediatric Cardiology Training Program Directors, and other sub-subspecialty organizations. Workforce surveys should be repeated more frequently to provide up-to-date information to allow for informed decision-making on training positions, subspecialty job availability, and geographic trends in job availability. Fellowship applicants may then be able to use these data to make informed career decisions based on the confluence of their interests and the current job market. The large number of new cardiologists projected by the modeled scenarios requires a concerted effort to recruit trainees to apply for PC fellowships and target adult cardiology fellows interested in ACHD to enter the field.

There is considerable projected growth in the supply of pediatric cardiologists by 2040 in all scenarios considered. The projected increase of CWE per 100 000 children is greatest in the areas with the lowest projected child population growth and lowest in the areas with the greatest projected child population growth, exacerbating the current imbalance in supply and access to care. Although there are no data that tie the location and size of training programs with patient need, the historical observation of limited diffusion of trainees from their fellowship site suggests that future graduates will likely have to expand their job search more widely than in the past and that incentivizing fellowship and employment growth and creating novel models of care in areas of increasing child population must be considered to address the cardiac needs of children.

The authors thank Emily McCartha, Andrew Knapton, and Adriana R. Gaona for their review of the modeling data presented. We also thank Virginia A. Moyer and Patience Leino for their editorial support. Last, we thank the pediatricians who shared their information with the American Board of Pediatrics Foundation and made this supplement possible.

ABP

American Board of Pediatrics

ACHD

adult congenital heart disease

AMG

American medical graduate

APP

advanced practice provider

CHD

congenital heart disease

CWE

Clinical Workforce Equivalent

DO

Doctor of Osteopathy

HC

headcount

IMG

international medical graduate

MD

Doctor of Medicine

PC

pediatric cardiology

URiM

underrepresented in medicine