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Video Abstract

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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.

On January 4, 2023, the New York Times published an article, “Why Saving Kids is Bad Business in America,”1  describing the negative impact of market forces and low Medicaid reimbursement rates on pediatric hospital bed capacity and rural hospital closures. This news article echoed concerns raised in the peer-reviewed medical literature about the limitations of the US health care system’s capacity to address the health care needs of infants, children, adolescents, and young adults (hereafter, “children”) with acute and chronic conditions requiring specialized care.2  Both suggest a mismatch of child health needs and market demand.

Previous conceptual frameworks regarding the medical workforce have highlighted the impact of 3 domains on health care: (1) child health needs (services necessary to achieve a desired health standard), (2) market demand (patients’ or payors’ willingness to purchase services), and (3) supply.3,4  Ideally, child health needs, market demand, and the supply of pediatric subspecialty providers are balanced to provide skilled, high-quality, equitable pediatric subspecialty care for all children. Recent events (eg, the coronavirus disease 2019 [COVID-19] pandemic, unsteady financial markets, changing government policies) reveal the sensitivity of each of these domains to the environment, as depicted in Fig 1.

FIGURE 1

Conceptual framework of 4 workforce domains.

FIGURE 1

Conceptual framework of 4 workforce domains.

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This supplement focuses on 1 domain: the supply of the US pediatric subspecialty physician workforce. Pediatric subspecialists play an essential role in providing expert consultation and care in collaboration with primary care pediatricians, advanced practice providers; home and school health nurses; mental health clinicians; respiratory, speech, physical, and occupational therapists; registered dieticians; community health workers; parent and patient navigators; and children and their families. Research indicates that pediatric subspecialty care results in decreased costs and improved clinical and survival outcomes for children compared with care by adult subspecialists.5,6  Previous studies have yielded conflicting results about supply, with reports of pediatric subspecialty oversupply, undersupply, and geographic maldistribution.711  Factors that may negatively impact future supply include higher educational debt, lower lifetime earning potential for most pediatric subspecialties compared with general pediatricians and adult subspecialists, changing perceptions of job availability postfellowship, variable funding for pediatric fellowships, reliance on internationally trained physicians in the pediatric subspecialty workforce, and experiences of discrimination, moral injury, and burnout, particularly in the wake of COVID-19 coupled with rising racism and discrimination.1219  These barriers and 13 overarching recommendations were summarized in the National Academies of Sciences, Engineering, and Medicine (NASEM) consensus study report, “The Pediatric Subspecialty Workforce and Its Impact on Child Health and Well-being,”20  published in September 2023.

This supplement further informs this debate by examining 15 pediatric subspecialties certified by the American Board of Pediatrics (ABP). Since 1992, the ABP has collected and published workforce data, which currently consist of (1) demographic and training data for all pediatric residents and fellows in ABP-certified subspecialties, (2) demographic and certification data on all ABP-certified general pediatricians and pediatric subspecialists, and (3) practice and career data from 7 voluntary surveys collected throughout a certified pediatrician’s career, from residency through each 5-year maintenance of certification (MOC) cycle.

In 2017, pediatric thought leaders challenged the ABP to proactively enhance the accessibility and use of its data through (1) the transformation of its annual data report from a static, paper-based report to a publicly available, interactive online platform (implemented in 2018),21  (2) the collection and dissemination of race and ethnicity data from trainees and certified pediatricians (implemented in 2018),21,22  (3) the broadening of options for gender identity (implemented in 2021), and (4) the pursuit of more rigorous and sophisticated analyses of ABP data. In 2019, the ABP Foundation partnered with the Carolina Health Workforce Research Center at the University of North Carolina at Chapel Hill’s Cecil G. Sheps Center for Health Services Research and the Strategic Modeling and Analysis Ltd to model the pediatric subspecialty workforce supply through 2040 using ABP data, US Census Bureau data, and other available information, as indicated.

The supplement consolidates data regarding the 15 individual subspecialties certified by the ABP into 1 digital product. The findings reveal heterogeneity across these subspecialties regarding patients served, current demographics, geographic distribution, workforce characteristics, and growth and geographic trends through 2040 (excluding pediatric hospital medicine which, as a new subspecialty, has limited historical data for modeling).

In this opening article, we review the health care needs of children over the next 2 decades. We next describe the current pediatric subspecialist workforce and preview the goals of the workforce model. We close with a description of the overall organization of this supplement.

All workforce discussions must start with the needs of the patients served. The last 3 decades have witnessed substantive improvements in child health resulting from advances in technology, diagnostic testing, precision medicine, and therapeutic interventions. Advances for rare monogenic disorders, polygenic diseases, and common conditions, such as asthma, are dramatically changing the lives of children with these conditions.19  Learning collaboratives have vastly improved the dissemination and implementation of evidence-based care for disorders like prematurity, inflammatory bowel disease, cystic fibrosis, and congenital heart disease.23  These improvements continue to require expertise and collaboration among all members of a patient’s health care team, with a clearly defined structure that incorporates consultation from pediatric subspecialists.

However, changes in the epidemiology of childhood diseases highlight the ongoing need to evaluate the workforce’s capacity to meet children’s health care needs. It is estimated that 2 in 5 children 5 to 17 years of age have at least 1 chronic medical condition.24  Although asthma rates have remained stable, the rates of obesity, hypertension, and type 2 diabetes continue to climb.2527  Approximately 1 in 6 US children are now estimated to have a developmental disorder.28  Among adolescents, teen vaping and firearm morbidity and mortality have increased significantly.29,30  Mental health conditions for children were rising before the COVID-19 pandemic31  and have increased alarmingly over the last 3 years, resulting in what the US Surgeon General has called a “mental health pandemic for youth.”32  With more adolescents and adults self-identifying as sexual- and gender-diverse, the associated rates of attempted suicide were recently reported at 23%, compared with 6% of their heterosexual peers.33  Children cared for by pediatric subspecialists for acute physical trauma or chronic medical conditions are at a uniquely high risk of coexisting mental health conditions related to factors including their diagnoses, treatment effects, socioeconomic and familial consequences, and reduction in wellbeing and quality of life.3437 

Not surprisingly, children’s overall health and the trajectory of any medical condition they acquire may be negatively affected by their exposure to adverse childhood experiences, racism, poverty, environmental pollutants and complications of climate change, and the presence of coexisting medical or developmental disabilities.19,3841  The national poverty rate for children 0 to 17 years of age in 2021 was 16.9% (range by state: 8.1% to 27.7%), 4.2 percentage points higher than the national average and almost 7 percentage points higher than for adults >65 years of age (10.3%).42  Sociodemographic data indicate that >50% of US children are from a racial or ethnic minority, and >1 in 4 children are growing up in immigrant families.43  Children from minoritized populations are more likely to live in poverty and have parents who are not securely employed, exacerbating health disparities.41  In addition, many new therapies, such as the cystic fibrosis transmembrane regulator modulators, have been predominantly tested in non-Hispanic white populations and may be less effective in children from racial or ethnic minorities without additional research, increasing disparities in health outcomes.44 

Geography also impacts child health. The US child population increased from 64.2 million (1990) to 73.6 million (2021) and is anticipated to grow to 78.2 million by 2050. The South and West are responsible for much of that growth, with 3 states (Texas, Florida, California) accounting for one-half of it.45  Rural areas, common in those regions, reveal higher rates of children living in families with incomes less than half of the federal poverty level (12.2%) compared with urban areas (9.2%)46  and reveal increasing gaps in access to both physical and mental health care.47  A significant and increasing percentage of children (>50% of children as of November 2022) are insured through Medicaid or the Children’s Health Insurance Program.48  Medicaid coverage varies substantially by state,49  and reimbursement rates fall well below those of Medicare and commercial insurance,50,51  further exacerbating access to care. It is not known how the end of the COVID-19 public health emergency will impact Medicaid coverage rates for children and families; however, some states are revealing a decline, particularly in those that do not prioritize renewals or the continuous enrollment provision added during the COVID-19 pandemic.52 

Pediatric subspecialists are specifically trained to care for children with acute and chronic specialized health needs. Most pediatric subspecialists in the United States first complete a 3-year general pediatrics residency before completing a 3-year subspecialty fellowship. Exceptions are adolescent medicine and pediatric emergency medicine, in which some physicians enter fellowship after a non-pediatric residency, and pediatric hospital medicine, which currently requires a 2-year fellowship. Training program requirements for pediatric subspecialty fellowships are set by the Accreditation Council of Graduate Medical Education (ACGME), which allows for increases in the number of training positions by institutional graduate medical education (GME) leadership with approval by the ACGME Review Committee for Pediatrics. The ABP sets the criteria to determine which individual subspecialty fellowship graduates are eligible to sit for the ABP’s board examinations.

As of June 2023, the total number of pediatric subspecialists ever certified by the ABP was 38 126, of whom 29 359 were actively enrolled in MOC.53  Previous workforce reports have largely focused on pediatric subspecialists as a single entity; however, fundamental differences exist. Pediatric subspecialties may be defined by their patients’ age (eg, neonatal–perinatal medicine), the setting in which they practice (eg, pediatric emergency medicine), or in-depth knowledge of a specific body system (eg, pediatric endocrinology). They may be primarily hospital-based in inpatient units (eg, pediatric critical care medicine), primarily outpatient-based (eg, developmental–behavioral pediatrics), or some combination (eg, pediatric cardiology).

Publications using ABP data have highlighted the variability by subspecialty regarding total numbers, demographics (ie, age, sex, race, and ethnicity), training history (ie, Doctor of Medicine (MD), Doctor of Osteopathy, international degree, American or international medical school location, educational debt), and work characteristics (hours worked, full-time or part-time status, primary work setting, and effort allocation across clinical care, education, research, and administration).8,11,54,55  Differences across board-certified subspecialists were recently reaffirmed by using available ABP data through June 2023 for subspecialists ≤70 years of age (Tables 1 and 2). Particularly striking are differences across subspecialties in total number; the proportion of women, individuals from underrepresented minority groups, international medical graduates, and full-time or part-time staff; and reported clinical and research effort allocation.

TABLE 1

Characteristics of Pediatric Subspecialists (≤70 Years) Certified by the ABP

Pediatric Subspecialty (First-Year Examination Offered by the ABP)Overall Certifications by the ABPCurrently Certified by the ABP (≤70 Years)
Ever Certified, nCurrently Maintaining Certification,an (%)Age 61–70,an (%)Female,an (%)MD,a,bn (%)American Medical Graduate,an (%)Underrepresented in Medicine (Estimated)cn (%)Number per 100 000 Children (0–17 y) in the United Statesd,e, 2023, n
Adolescent Medicine (1994)e 836 580 (69.4) 132 (23.8) 426 (76.8) 505 (91.0) 487 (87.7) 152 (26.8) 1.01 
Cardiology (1961) 4117 3096 (75.2) 487 (16.0) 1237 (40.6) 2545 (83.6) 2333 (76.6) 262 (9.2) 4.02 
Child Abuse Pediatrics (2009) 425 363 (85.4) 72 (21.1) 284 (83.0) 320 (93.6) 320 (93.6) 51 (15.9) 0.45 
Critical Care Medicine (1987) 3689 3128 (84.8) 395 (12.8) 1494 (48.6) 2553 (83.0) 2287 (74.3) 333 (12.0) 4.06 
Developmental-Behavioral Pediatrics (2002) 1043 803 (77.0) 175 (23.2) 578 (76.6) 656 (86.9) 615 (81.5) 86 (14.0) 0.99 
Emergency Medicine (1992)e 3493 3017 (86.4) 442 (14.9) 1806 (60.8) 2583 (86.9) 2468 (83.0) 327 (12.5) 4.39 
Endocrinology (1978) 2218 1508 (68.0) 203 (13.6) 1100 (73.6) 1213 (81.2) 998 (66.8) 212 (14.2) 1.97 
Gastroenterology (1990) 2232 1882 (84.3) 279 (15.5) 940 (52.3) 1418 (79.0) 1188 (66.1) 241 (14.7) 2.40 
Hematology-Oncology (1974) 4231 2929 (69.2) 354 (12.2) 1747 (60.3) 2407 (83.1) 2225 (76.8) 254 (10.0) 3.82 
Hospital Medicine (2019) 2542 2537 (99.8) 71 (2.8) 1858 (73.4) 2206 (87.1) 2218 (87.6) 269 (11.0) 3.40 
Infectious Diseases (1994) 1876 1368 (72.9) 255 (19.8) 759 (58.8) 1110 (86.0) 936 (72.6) 226 (17.8) 1.68 
Neonatal-Perinatal Medicine (1975) 7871 5319 (67.6) 1041 (20.2) 3003 (58.3) 3823 (74.2) 3247 (63.0) 755 (14.8) 6.85 
Nephrology (1974) 1199 729 (60.8) 118 (16.6) 443 (62.5) 545 (76.9) 446 (62.9) 93 (12.9) 0.94 
Pulmonary (1986) 1585 1254 (79.3) 246 (21.0) 577 (49.2) 973 (83.0) 789 (67.3) 119 (13.1) 1.55 
Rheumatology (1992) 626 508 (81.2) 66 (13.4) 347 (70.7) 436 (88.8) 388 (79.0) 52 (12.2) 0.65 
Unweighted Average N/A 77.4% 16.5% 63.0% 84.3% 75.9% 14.1% 2.55 
Weighted Average N/A 76.4% 15.3% 58.7% 82.4% 74.1% 12.3% N/A 
Pediatric Subspecialty (First-Year Examination Offered by the ABP)Overall Certifications by the ABPCurrently Certified by the ABP (≤70 Years)
Ever Certified, nCurrently Maintaining Certification,an (%)Age 61–70,an (%)Female,an (%)MD,a,bn (%)American Medical Graduate,an (%)Underrepresented in Medicine (Estimated)cn (%)Number per 100 000 Children (0–17 y) in the United Statesd,e, 2023, n
Adolescent Medicine (1994)e 836 580 (69.4) 132 (23.8) 426 (76.8) 505 (91.0) 487 (87.7) 152 (26.8) 1.01 
Cardiology (1961) 4117 3096 (75.2) 487 (16.0) 1237 (40.6) 2545 (83.6) 2333 (76.6) 262 (9.2) 4.02 
Child Abuse Pediatrics (2009) 425 363 (85.4) 72 (21.1) 284 (83.0) 320 (93.6) 320 (93.6) 51 (15.9) 0.45 
Critical Care Medicine (1987) 3689 3128 (84.8) 395 (12.8) 1494 (48.6) 2553 (83.0) 2287 (74.3) 333 (12.0) 4.06 
Developmental-Behavioral Pediatrics (2002) 1043 803 (77.0) 175 (23.2) 578 (76.6) 656 (86.9) 615 (81.5) 86 (14.0) 0.99 
Emergency Medicine (1992)e 3493 3017 (86.4) 442 (14.9) 1806 (60.8) 2583 (86.9) 2468 (83.0) 327 (12.5) 4.39 
Endocrinology (1978) 2218 1508 (68.0) 203 (13.6) 1100 (73.6) 1213 (81.2) 998 (66.8) 212 (14.2) 1.97 
Gastroenterology (1990) 2232 1882 (84.3) 279 (15.5) 940 (52.3) 1418 (79.0) 1188 (66.1) 241 (14.7) 2.40 
Hematology-Oncology (1974) 4231 2929 (69.2) 354 (12.2) 1747 (60.3) 2407 (83.1) 2225 (76.8) 254 (10.0) 3.82 
Hospital Medicine (2019) 2542 2537 (99.8) 71 (2.8) 1858 (73.4) 2206 (87.1) 2218 (87.6) 269 (11.0) 3.40 
Infectious Diseases (1994) 1876 1368 (72.9) 255 (19.8) 759 (58.8) 1110 (86.0) 936 (72.6) 226 (17.8) 1.68 
Neonatal-Perinatal Medicine (1975) 7871 5319 (67.6) 1041 (20.2) 3003 (58.3) 3823 (74.2) 3247 (63.0) 755 (14.8) 6.85 
Nephrology (1974) 1199 729 (60.8) 118 (16.6) 443 (62.5) 545 (76.9) 446 (62.9) 93 (12.9) 0.94 
Pulmonary (1986) 1585 1254 (79.3) 246 (21.0) 577 (49.2) 973 (83.0) 789 (67.3) 119 (13.1) 1.55 
Rheumatology (1992) 626 508 (81.2) 66 (13.4) 347 (70.7) 436 (88.8) 388 (79.0) 52 (12.2) 0.65 
Unweighted Average N/A 77.4% 16.5% 63.0% 84.3% 75.9% 14.1% 2.55 
Weighted Average N/A 76.4% 15.3% 58.7% 82.4% 74.1% 12.3% N/A 
a

Source: ABP Certification Management System through June 2023.

b

The MD degree is offered in the United States and internationally.

c

Source: Estimated from the ABP Maintenance of Certification Enrollment Survey. Underrepresented in medicine includes anyone who has selected “American Indian or Alaska Native,” “Black or African American,” “Hispanic, Latino, or Spanish Origin,” and “Native Hawaiian or Other Pacific Islander.”

d

Source: ABP Certification Management System in 2019.

e

Certifications also granted by American Boards of Internal Medicine, Family Medicine, and Emergency Medicine. Their data are not included in this table except for the number per 100 000 children.

TABLE 2

Work Characteristics of Pediatric Subspecialists (≤70 Years) as Reported on the ABP’s MOC Enrollment Surveys From 2018 to 2022a,b,c

Pediatric SubspecialtyFull-time, %≥50 Hr/Wk, %Primary Work Setting in Medical School or Parent University (%)Proportion of Time Spent in Clinical Care, Average, SD, Median (%)Proportion of Time Spent in Research, Average, SD, Median (%)Proportion of Patients on Medicaid or Other Public Insurance ≥50% (%)
Adolescent medicine 84.2 47.0 32.3 58, 27.8, 60 7.7, 16.2, 0 49.3 
Cardiology 92.7 66.2 38.1 72.1, 20.6, 80 7.1, 13.2, 4 47.3 
Child abuse pediatrics 81.5 48.9 31.8 60.2, 24.8, 64 4.5, 10.3, 0 71.0 
Critical care medicine 92.9 61.9 31.2 63.8, 25.6, 70 8.8, 17.2, 1 40.2 
Developmental–behavioral pediatrics 74.9 41.5 26.8 67.8, 25.6, 75 5.7, 14.2, 0 53.7 
Emergency medicine 84.3 24.0 24.6 66.6, 26.7, 75 5.4, 11.7, 0 41.9 
Endocrinology 84.3 52.1 37.1 67.2, 26.8, 75 12.2, 21.2, 4 44.4 
Gastroenterology 90.4 52.7 29.8 70.3, 25.2, 80 9.1, 18.2, 1 39.0 
Hematology-oncology 92.3 65.4 40.8 52.3, 29.3, 60 24.1, 28.2, 10 48.6 
Hospital medicine 88.6 43.9 26.3 66.9, 23, 70 3.5, 9.5, 0 51.2 
Infectious diseases 91.8 57.5 38.1 45.3, 31.3, 45 19.4, 27.5, 5 49.5 
Neonatal–perinatal medicine 91.0 59.4 22.0 68.7, 24.7, 75 6.8, 14.8, 0 47.6 
Nephrology 90.5 62.6 43.8 61.8, 25.5, 70 11.4, 19.4, 5 51.1 
Pulmonary 89.5 59.4 39.7 63.7, 26.7, 70 13, 21.3, 5 58.4 
Rheumatology 83.4 56.6 49.3 59.3, 28.3, 68 16.3, 24.6, 5 31.0 
Unweighted average 87.5% 53.3% 34.1% 62.9% 10.3% 48.3% 
Weighted averaged 89.4% 54.4% 31.5% 64.7% 9.8% 46.8% 
Pediatric SubspecialtyFull-time, %≥50 Hr/Wk, %Primary Work Setting in Medical School or Parent University (%)Proportion of Time Spent in Clinical Care, Average, SD, Median (%)Proportion of Time Spent in Research, Average, SD, Median (%)Proportion of Patients on Medicaid or Other Public Insurance ≥50% (%)
Adolescent medicine 84.2 47.0 32.3 58, 27.8, 60 7.7, 16.2, 0 49.3 
Cardiology 92.7 66.2 38.1 72.1, 20.6, 80 7.1, 13.2, 4 47.3 
Child abuse pediatrics 81.5 48.9 31.8 60.2, 24.8, 64 4.5, 10.3, 0 71.0 
Critical care medicine 92.9 61.9 31.2 63.8, 25.6, 70 8.8, 17.2, 1 40.2 
Developmental–behavioral pediatrics 74.9 41.5 26.8 67.8, 25.6, 75 5.7, 14.2, 0 53.7 
Emergency medicine 84.3 24.0 24.6 66.6, 26.7, 75 5.4, 11.7, 0 41.9 
Endocrinology 84.3 52.1 37.1 67.2, 26.8, 75 12.2, 21.2, 4 44.4 
Gastroenterology 90.4 52.7 29.8 70.3, 25.2, 80 9.1, 18.2, 1 39.0 
Hematology-oncology 92.3 65.4 40.8 52.3, 29.3, 60 24.1, 28.2, 10 48.6 
Hospital medicine 88.6 43.9 26.3 66.9, 23, 70 3.5, 9.5, 0 51.2 
Infectious diseases 91.8 57.5 38.1 45.3, 31.3, 45 19.4, 27.5, 5 49.5 
Neonatal–perinatal medicine 91.0 59.4 22.0 68.7, 24.7, 75 6.8, 14.8, 0 47.6 
Nephrology 90.5 62.6 43.8 61.8, 25.5, 70 11.4, 19.4, 5 51.1 
Pulmonary 89.5 59.4 39.7 63.7, 26.7, 70 13, 21.3, 5 58.4 
Rheumatology 83.4 56.6 49.3 59.3, 28.3, 68 16.3, 24.6, 5 31.0 
Unweighted average 87.5% 53.3% 34.1% 62.9% 10.3% 48.3% 
Weighted averaged 89.4% 54.4% 31.5% 64.7% 9.8% 46.8% 
a

The MOC Enrollment Survey is offered after completing the ABP’s MOC Enrollment on a 5-year rolling basis. The survey averaged a 57.6% response rate (range 55.2% to 66.7%) across the pediatric subspecialties listed except for hospital medicine. Hospital medicine had a lower representation rate (39.4%) because it was first certified in 2019.

b

Only percentages are given because the sample size for a given question is dependent on branching logic throughout the survey (eg, those self-reporting as clinically inactive would not receive questions about the proportion of patients on Medicaid or other public insurance).

c

All questions here were asked to those actively working (∼97% to 99% of respondents).

d

Weights were applied by using the estimated number of pediatricians currently board-certified.

When the workforce is limited to the United States, geographic maldistribution is frequent. Unlike adult subspecialists, most pediatric subspecialists are concentrated in academic medical centers in urban settings, except for neonatologists and emergency medicine subspecialists providing care in hospital-based community programs. Publicly available ABP data dashboards21  and Table 1 indicate a marked variation in the ratio of subspecialists to children 0 to 17 years of age and in the average driving distance to a subspecialist, by both state and subspecialty.

Most US pediatric fellowship training programs are in urban areas, closely mirroring the geographic distribution of pediatric subspecialists (Fig 1). The overall number of first-year pediatric subspecialty fellows in fellowship programs has increased from 1145 (2008) to 1692 (2022). However, increases have been limited to selected subspecialties (eg, pediatric critical care medicine) with negligible increases, if any, among some of the smaller subspecialties (eg, pediatric infectious diseases).56  Differences in US fellowship programs and the demographic, financial, and training characteristics of US fellows in academic year 2021 to 2022 are summarized in Table 3.

TABLE 3

Characteristics of Pediatric Subspecialty ACGME-Accredited Fellowship Programs and Fellows in the United States

Pediatric SubspecialtyUS-Based, ACGME-Approved Program DataFellow Counts, Levels 1–3Fellow Characteristics, 2022–2023
Fellowship Programs in 2021–2022,an10-y Change in Program Number, 2012–2013 to 2021–2022,a %Total Fellows, 2022–2023,bn10-y Change in Fellows, 2012–2013 to 2022–2023,b %Female,bn (%)MD,bn (%)American Medical Graduates, n (%)Under- represented in Medicine (Estimated),cn (%)Average Educational Debt ≥$200 000,d %
Adolescent medicine 32 14.3 93 17.7 74 (79.6) 75 (80.6) 85 (91.4) 24 (27.9) 45.0 
Cardiology 64 16.4 489 22.3 261 (53.4) 388 (79.3) 378 (77.3) 49 (11.0) 36.8 
Child abuse pediatrics 31 40.9 58 75.8 45 (77.6) 45 (77.6) 50 (86.2) 10 (18.2) 54.0 
Critical care medicine 77 24.2 617 47.6 402 (65.2) 490 (79.4) 503 (81.5) 73 (13.0) 45.8 
Developmental–behavioral pediatrics 44 22.2 107 96 (89.7) 81 (75.7) 72 (67.3) 21 (20.8) 30.9 
Emergency medicine 85 19.7 600 45.3 404 (67.3) 447 (74.5) 506 (84.3) 97 (18.0) 47.0 
Endocrinology 72 7.5 243 −4.3 195 (80.2) 159 (65.4) 144 (59.3) 42 (19.4) 30.5 
Gastroenterology 67 17.5 341 24.9 238 (69.8) 256 (75.1) 249 (73.0) 62 (20.5) 34.3 
Hematology-oncology 77 13.2 466 5.2 320 (68.7) 340 (73.0) 348 (74.7) 54 (13.0) 38.6 
Hospital medicine 65 N/A 193 N/A 141 (73.1) 161 (83.4) 178 (92.2) 30 (16.5) 39.9 
Infectious diseases 64 4.9 183 5.8 126 (68.9) 129 (70.5) 116 (63.4) 27 (17.4) 28.8 
Neonatal–perinatal medicine 110 13.4 839 26.4 606 (72.2) 610 (72.7) 600 (71.5) 146 (20.1) 40.4 
Nephrology 47 17.5 144 20 101 (70.1) 97 (67.4) 105 (72.9) 18 (14.6) 29.2 
Pulmonary 57 14.0 197 21.6 129 (65.5) 139 (70.6) 131 (66.5) 29 (17.7) 37.7 
Rheumatology 38 15.2 104 48.6 80 (76.9) 90 (86.5) 83 (79.8) 17 (18.7) 39.6 
Unweighted average 62 17.2% 312 26.0% 71.9% 75.4% 76.1% 17.8% 38.6% 
Weighted average N/A N/A N/A N/A 68.9% 75.0% 75.9% 16.8% 39.5% 
Pediatric SubspecialtyUS-Based, ACGME-Approved Program DataFellow Counts, Levels 1–3Fellow Characteristics, 2022–2023
Fellowship Programs in 2021–2022,an10-y Change in Program Number, 2012–2013 to 2021–2022,a %Total Fellows, 2022–2023,bn10-y Change in Fellows, 2012–2013 to 2022–2023,b %Female,bn (%)MD,bn (%)American Medical Graduates, n (%)Under- represented in Medicine (Estimated),cn (%)Average Educational Debt ≥$200 000,d %
Adolescent medicine 32 14.3 93 17.7 74 (79.6) 75 (80.6) 85 (91.4) 24 (27.9) 45.0 
Cardiology 64 16.4 489 22.3 261 (53.4) 388 (79.3) 378 (77.3) 49 (11.0) 36.8 
Child abuse pediatrics 31 40.9 58 75.8 45 (77.6) 45 (77.6) 50 (86.2) 10 (18.2) 54.0 
Critical care medicine 77 24.2 617 47.6 402 (65.2) 490 (79.4) 503 (81.5) 73 (13.0) 45.8 
Developmental–behavioral pediatrics 44 22.2 107 96 (89.7) 81 (75.7) 72 (67.3) 21 (20.8) 30.9 
Emergency medicine 85 19.7 600 45.3 404 (67.3) 447 (74.5) 506 (84.3) 97 (18.0) 47.0 
Endocrinology 72 7.5 243 −4.3 195 (80.2) 159 (65.4) 144 (59.3) 42 (19.4) 30.5 
Gastroenterology 67 17.5 341 24.9 238 (69.8) 256 (75.1) 249 (73.0) 62 (20.5) 34.3 
Hematology-oncology 77 13.2 466 5.2 320 (68.7) 340 (73.0) 348 (74.7) 54 (13.0) 38.6 
Hospital medicine 65 N/A 193 N/A 141 (73.1) 161 (83.4) 178 (92.2) 30 (16.5) 39.9 
Infectious diseases 64 4.9 183 5.8 126 (68.9) 129 (70.5) 116 (63.4) 27 (17.4) 28.8 
Neonatal–perinatal medicine 110 13.4 839 26.4 606 (72.2) 610 (72.7) 600 (71.5) 146 (20.1) 40.4 
Nephrology 47 17.5 144 20 101 (70.1) 97 (67.4) 105 (72.9) 18 (14.6) 29.2 
Pulmonary 57 14.0 197 21.6 129 (65.5) 139 (70.6) 131 (66.5) 29 (17.7) 37.7 
Rheumatology 38 15.2 104 48.6 80 (76.9) 90 (86.5) 83 (79.8) 17 (18.7) 39.6 
Unweighted average 62 17.2% 312 26.0% 71.9% 75.4% 76.1% 17.8% 38.6% 
Weighted average N/A N/A N/A N/A 68.9% 75.0% 75.9% 16.8% 39.5% 
a

Source: ACGME academic year snapshot data. Latest available data were from academic year 2021 to 2022.

b

Source: ABP Certification Management System based on fellows in Levels 1 to 3 in academic year 2022 to 2023 as captured in February 2023.

c

Source: ABP in-training examination surveys. Underrepresented in medicine includes anyone who has selected “American Indian or Alaska Native,” “Black or African American,” “Hispanic, Latino, or Spanish Origin,” and “Native Hawaiian or Other Pacific Islander.” Those with unknown race and ethnicity are excluded from the percentage calculation.

d

Source: Subspecialty in-training examination survey offered after the completion of the 2022 subspecialty in-training examinations. The proportion denominator includes those answering unsure or declining to answer; therefore, this should be considered the lowest estimate.

The financing of general GME in the United States is complex. Primary funding comes from the federal government via Medicare GME payments to support direct and indirect medical expenses in large general hospital systems. Fellowship training programs in freestanding children’s hospitals that do not receive Medicare GME dollars are eligible for funding from the Children’s Hospital Graduate Medical Education (CHGME) payment program. However, although Medicare GME dollars are tied to overall Medicare spending and increase every year, CHGME dollars must be reauthorized by Congress annually, are currently capped at $375 million, and are reimbursed at ∼51% of Medicare GME support. Other smaller sources of funding for fellowships include Medicaid GME payments, primary care training programs, health systems, training grants, international stipends, moonlighting opportunities, and philanthropic contributions.57  These factors lead to financial instability for fellowship programs and a heightened preference for those programs that generate revenue for hospital systems.57,58  It is anticipated that financial demands on health systems will continue to rise as training program positions increase because of (1) newly developed subspecialties (eg, hospital medicine, now the third-largest subspecialty) and (2) the recruitment of additional trainees due to changes in work hours, increased clinical demands as more children survive and thrive with chronic medical conditions, and concerns related to burnout and stress within training programs and among practicing subspecialists.

Economic analyses have revealed that adult subspecialists earn close to 25% ($1.2 million) more over their career than pediatric subspecialists.13,59  Differences are also present among the pediatric subspecialties, although differences vary depending on the data source used.60  Two subspecialties (pediatric cardiology and neonatal–perinatal medicine) consistently reveal higher potential than the remaining pediatric subspecialties.12,15,60,61  These disparities have widened in recent years and compound the already lower lifetime earning potential among pediatric subspecialists compared with their adult counterparts.13  Higher lifetime earning potential has been associated with higher mean fellowship fill rates.62 

Medical workforce models are often employed to identify current staffing gaps and predict future staffing and training needs. Most workforce models focus on the supply of physicians per capita, given the complexities of measuring population health needs and market demand.3 

A major goal for the authors of this supplement was to address weaknesses of previous pediatric subspecialty models by (1) examining individual pediatric subspecialties at national and subnational levels, (2) accounting for historic and current demographic, work characteristics, and geographic distribution for each subspecialty, (3) incorporating the projected growth and geographic distribution of pediatric subspecialty fellows, (4) projecting absolute numbers or headcount (HC) and clinically available subspecialists, and (5) accounting for the growth and geographic distribution of US children 0 to 18 years of age, as forecasted by the US Census Bureau.63  Although pediatric subspecialists often see children through young adulthood, we elected to use 18 years of age because that is when children move toward greater legal independence. The baseline model incorporates the number of subspecialists ≤70 years of age in the current workforce, the supply of incoming fellows (held constant at 2019 levels), exits from the workforce, the addition of subspecialists who have worked outside the United States and return to the United States to provide clinical care, and worker diffusion from training to subsequent geographic locations. Projections are provided for HC and clinical workforce equivalent, defined as HC adjusted for the self-reported proportion of time spent in clinical and consultative care, not including time on call when not providing clinical care. This term was used because of ongoing debates regarding how clinical full-time equivalents are calculated.64  An online, interactive data visualization tool with analyses at the national, census region, and census division levels permits deliberations regarding potential geographic maldistribution.65 

The model also incorporates possible future scenarios based on emerging trends or potential “wild cards”66  that may impact the other 3 domains in Fig 1 (Table 4). Ten scenarios were identified through a literature review and stakeholder engagement and were operationalized for inclusion in the model. Three overarching trends were incorporated into the scenarios and are discussed below, specifically (1) an increase or decrease in the number of fellows, (2) an increase or decrease in effective clinical time, and (3) increased attrition. Limited approaches are currently available to measure child health needs and market demand regarding subspecialty care;67  several potential impacts of the environment on these 2 factors are captured in the model’s scenarios.

TABLE 4

Environmental Factors Influencing Major Themes Across “What If” Scenarios in the US Pediatric Subspecialty Workforce Model

ScenarioEnvironmental Factors by Need, Supply, and Market Demand
Increase/decrease in fellows 
  • Supply

    • No. of students entering pediatrics

    • No. of fellows choosing a specific pediatric subspecialty

    • Federal policies impacting the no. of international medical graduates in the United States

    • Presence/absence of

      • Federal and state incentives to enter pediatrics and subspecialty care (eg, tuition-free medical schools, loan repayment, Medicaid reimbursement)

      • Federal and state incentives for subspecialties caring for children with behavioral mental health needs (eg, adolescent medicine, developmental–behavioral pediatrics, pediatrics, pediatric emergency medicine)

  • Market demand

    • No. of funded fellowship training positions

    • Increase/decrease in CHGME funding and other federal funding sources

 
Increase/decrease in effective clinical time per subspecialist 
  • Child health needs

    • Factors that worsen child health status (eg, emerging disorders, increasing medical complexity of children reaching adolescence and young adulthood requiring inter-subspecialty coordination of care, poverty, decreased insurance coverage, limited access to healthy food and exercise, climate change, air contaminants, worsening racism, increased community violence, state and federal policies that negatively impact health)

    • Factors that improve child health status (eg, state and federal policies that positively impact health, lower birth rates, fewer medical complications due to better medical treatment, novel treatments)

    • Increasing demand for the extension of care into adulthood due to the lack of adult providers with necessary expertise

  • Supply

    • Team-based subspecialty care models

    • Growth in advanced practice providers in subspecialty pediatrics

    • Percentage of time spent in consultation with primary care teams

    • Percentage of time spent on quality improvement, medical education, and research

    • Geographic redistribution of pediatric subspecialty care, through telemedicine or geographically dispersed subspecialties

    • Increase in nonmedical professional opportunities (eg, consulting, research)

    • Socioemotional/physical impact of temporary national crisis or event (eg, war, climate event, pandemic) and its impact

    • Factors heightening risk for burnout (eg, financial pressures, electronic health record, lack of institutional support for career) or moral injury (eg, lack of prioritization of children’s health needs)

    • State and federal policies with respect to international medical graduates practicing in the United States

 
Attrition due to early retirement, early exit, or career shifts 
  • Supply

    • Increase in nonmedical professional opportunities (eg, consulting, research)

    • Socioemotional/physical impact of temporary national crisis or event (eg, war, climate event, pandemic) and its impact

    • Factors heightening the risk of burnout (eg, financial pressures, electronic health record, lack of institutional support for career) or moral injury (eg, lack of prioritization of children’s health needs)

 
ScenarioEnvironmental Factors by Need, Supply, and Market Demand
Increase/decrease in fellows 
  • Supply

    • No. of students entering pediatrics

    • No. of fellows choosing a specific pediatric subspecialty

    • Federal policies impacting the no. of international medical graduates in the United States

    • Presence/absence of

      • Federal and state incentives to enter pediatrics and subspecialty care (eg, tuition-free medical schools, loan repayment, Medicaid reimbursement)

      • Federal and state incentives for subspecialties caring for children with behavioral mental health needs (eg, adolescent medicine, developmental–behavioral pediatrics, pediatrics, pediatric emergency medicine)

  • Market demand

    • No. of funded fellowship training positions

    • Increase/decrease in CHGME funding and other federal funding sources

 
Increase/decrease in effective clinical time per subspecialist 
  • Child health needs

    • Factors that worsen child health status (eg, emerging disorders, increasing medical complexity of children reaching adolescence and young adulthood requiring inter-subspecialty coordination of care, poverty, decreased insurance coverage, limited access to healthy food and exercise, climate change, air contaminants, worsening racism, increased community violence, state and federal policies that negatively impact health)

    • Factors that improve child health status (eg, state and federal policies that positively impact health, lower birth rates, fewer medical complications due to better medical treatment, novel treatments)

    • Increasing demand for the extension of care into adulthood due to the lack of adult providers with necessary expertise

  • Supply

    • Team-based subspecialty care models

    • Growth in advanced practice providers in subspecialty pediatrics

    • Percentage of time spent in consultation with primary care teams

    • Percentage of time spent on quality improvement, medical education, and research

    • Geographic redistribution of pediatric subspecialty care, through telemedicine or geographically dispersed subspecialties

    • Increase in nonmedical professional opportunities (eg, consulting, research)

    • Socioemotional/physical impact of temporary national crisis or event (eg, war, climate event, pandemic) and its impact

    • Factors heightening risk for burnout (eg, financial pressures, electronic health record, lack of institutional support for career) or moral injury (eg, lack of prioritization of children’s health needs)

    • State and federal policies with respect to international medical graduates practicing in the United States

 
Attrition due to early retirement, early exit, or career shifts 
  • Supply

    • Increase in nonmedical professional opportunities (eg, consulting, research)

    • Socioemotional/physical impact of temporary national crisis or event (eg, war, climate event, pandemic) and its impact

    • Factors heightening the risk of burnout (eg, financial pressures, electronic health record, lack of institutional support for career) or moral injury (eg, lack of prioritization of children’s health needs)

 

The supply of fellows is primarily related to career decisions to enter pediatric subspecialty medical training, which are often decided during medical school or the first year of a general pediatrics residency.68  Concerns have been raised regarding the overall interest level in pediatrics, particularly considering its markedly lower salaries compared with other specialties, rising debt among medical trainees, and the overall increase in the number of unfilled pediatric residency slots over the last decade.69  The number of trainees entering residency could significantly impact supply unless attention is paid to factors affecting career choices from college through fellowship.

An important group of pediatric subspecialties, including adolescent medicine, child abuse pediatrics, developmental–behavioral pediatrics, pediatric endocrinology, pediatric nephrology, and pediatric pulmonary, have struggled to fill their training positions in the National Resident Matching Program. They have averaged 30% to 50% fewer applicants than positions, a trend that has been consistent for the past 10 years. In comparison, programs such as pediatric cardiology, pediatric critical care medicine, and pediatric emergency medicine routinely fill >95% of available positions and may have 20 to 50 more applicants than available positions. Data regarding future earning potential15  or job availability16  may alter career decisions for current and future residents. Other factors, such as debt burden, length of subspecialty training, prestige, exposure during medical school and residency, and mentorships collectively may impact the number of fellows in the pediatric subspecialties.

Several scenarios explore differences in clinical time. Available clinical time might decrease because of supply factors, including more subspecialists seeking work–life integration. Market factors (eg, closing of pediatric units and beds for financial reasons) could worsen access for children and place a greater clinical burden on individual subspecialists in tertiary centers, also decreasing available clinical time. Greater child health needs due to environmental factors (eg, increasing poverty, racism, pollution), lack of insurance, pandemics, and global conflicts could also effectively decrease available clinical time by increasing patient needs.

Alternatively, a robust commitment to insurance coverage for children and families and advances in medical technology might decrease health care needs, leading to increased available clinical time. Available clinical time also might increase because of decreased financial support for nonclinical activities (eg, quality improvement, research, medical education) that rely heavily on clinical revenue. The development of new care models (eg, greater management of common subspecialty conditions in pediatric primary care, the implementation of team-based care models with concurrent, robust advanced practice provider training pathways, telehealth) or health care applications of artificial intelligence might positively or negatively affect clinical time. Federal or state agencies might incentivize subspecialty training through loan repayment programs or health system changes to address access issues (eg, wait times) regardless of cost, increasing supply, and available clinical time.

Given the high rates of international medical graduates in some subspecialties and their role in caring for children in underserved areas,70  US immigration policies could either increase or decrease clinical care capacity.

Several of the scenarios examine early retirement, early midcareer exits, or career shifts within pediatrics or health care in general and their impact on overall supply. Attrition might be in response to environmental factors like the socioemotional or physical effects of a national crisis (eg, war, climate events, pandemics) on supply and its impacts. Indeed, physician workforce trends due to the COVID-19 pandemic are being closely tracked, given nursing staffing reductions during and after the pandemic.71  Others have questioned the impact of burnout in the current workforce and among fellows from administrative burdens, perceived lack of support, stigma related to help-seeking, and racism and discrimination in academic medicine.7275  An increase in nonclinical professional opportunities (eg, consulting, research) might also lead to attrition from clinical care.

The model addresses the limitations of many previous modeling efforts by its use of detailed data on the current and future supply, corrections for child population growth, and attention to geographic distribution and location at the subnational level. Although the model capitalizes on the ABP’s data on certified subspecialists, some decisions were made that may limit the conclusions that can be drawn. For the sake of simplicity, the model assumes the same scope and productivity within a subspecialty, albeit based on ABP data regarding the average hours worked and percentage of clinical time specific to that subspecialty. It includes only ABP-certified pediatric subspecialists; other physicians caring for children (eg, pediatric neurologists, geneticists, allergy/immunologists, child psychiatrists, adult physicians) are not included because data on hours worked and time in pediatric subspecialty clinical care were not consistently available.76  The model also excludes advanced practice providers, despite the critical role of team-based care in addressing children’s health care needs. Limited data exist specific to these providers; available data suggest relatively slow growth in the nonphysician workforce interested in pediatric care without substantive policy change.7780  The model does not provide estimates at the state or county level because of concerns regarding small numbers for many subspecialties; the reader is referred to the ABP’s state- and county-level data on the counts of subspecialists.81  The model also focuses only on clinical care and does not address the supply of pediatric subspecialists who lead medical education, quality improvement, research workforce efforts, and scientific discovery critical to improved health outcomes in children. Last, the model does not specifically account for how child health needs unique to a subspecialty may change over time because of environmental factors, such as technological and medical advances, public expectations, state or federal policy decisions, and societal changes, or how changes in market demand could affect pediatric subspecialty care.

This supplement includes an overarching methodology article followed by 15 separate articles focused on the current ABP-certified subspecialties. Each article begins with an overview of the current and anticipated child health needs specific to the subspecialty and a description of the current workforce. The results of the model projecting the US pediatric subspecialty workforce supply ≤70 years of age through 2040 for 14 of the subspecialties are then reviewed, followed by implications across education and training, clinical practice, policy, and future workforce research. Recognizing the uniqueness of the different subspecialties, the authors for each subspecialty were asked to bring their awareness of shifting trends in child health needs in their discipline and their expert perspectives on the future pediatric subspecialty workforce to their deliberations. Given the recent approval of pediatric hospital medicine as a subspecialty and the lack of sufficient historical data for inclusion in the model, this subspecialty’s article focuses solely on extant data.

The 15 subspecialties’ articles are followed by an article examining the diversity of US children in comparison with the pediatric subspecialty workforce. The supplement closes with an epilogue, summarizing core themes across the articles and offering recommendations.82  All articles in the supplement include the term “pathway” as opposed to “pipeline,” acknowledging the lack of a single pathway into pediatric subspecialty care and potential insensitivities to US indigenous peoples.83,84 

With the proportion of adults >65 years of age in the United States anticipated to surpass children in 2034,85  attention to child health will suffer without a more holistic, lifespan-focused approach. Specifically, the United States must adopt an ongoing public commitment to meeting child health needs if our shared national goal is to improve outcomes inclusive of all children, who represent our country’s future workforce.86  Efforts are needed to integrate up-to-date data on all 4 domains outlined in Fig 1: (1) child health needs, (2) market demands, (3) the supply of pediatric subspecialists, and (4) trends in environmental factors. These efforts should parallel the creation of services-based workforce models that integrate the contributions of the myriad other members of subspecialty care teams beyond pediatric subspecialists.

The supplement authors hope that this work joins other current national efforts to catalyze a renewed focus on the health of children cared for by pediatric subspecialty care teams, including the recently published NASEM Consensus Study report on the pediatric subspecialty workforce,20  the Association of Medical School Pediatrics Department Chairs Workforce 2025 initiative,87  and the current NASEM Consensus Study, “Improving the Health and Wellbeing of Children and Youth Through Health Care System Transformation.”88  Together, these efforts challenge pediatricians and the nation at large to proactively and intentionally consider how to best provide for the health care needs of all US children, now and in the future.

The authors thank Virginia A. Moyer and Patience Leino for their editorial support. In addition, we thank the pediatricians who shared their information with the American Board of Pediatrics Foundation and made this supplement possible.

Dr Leslie drafted the initial manuscript and critically reviewed and revised the manuscript; Mr Turner provided data for the manuscript and critically reviewed and revised the manuscript; Drs Orr, Mink, Leonard, and Vinci and Ms Sabadosa critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: This manuscript and the accompanying supplement were funded by the American Board of Pediatrics Foundation. The American Board of Pediatrics Foundation, the Carolina Health Workforce Research Center at the University of North Carolina at Chapel Hill’s Cecil G. Sheps Center for Health Services Research, and Strategic Modelling Analytics & Planning Ltd partnered in the design and conduct of this study. The content is solely the authors’ responsibility and does not necessarily represent the official views of the American Board of Pediatrics or the American Board of Pediatrics Foundation.

CONFLICT OF INTEREST DISCLOSURES: Dr Leslie and Mr Turner are employees of the American Board of Pediatrics. Dr Vinci is a member of the Board of Directors of the American Board of Pediatrics. Ms Sabadosa is chair of the American Board of Pediatrics’ Family Leadership Committee and a member of the Board of Directors of the American Board of Pediatrics Foundation. Dr Mink receives grant support from the American Board of Pediatrics Foundation. The other authors have indicated they have no potential conflicts of interest relevant to this article to disclose.

ABP

American Board of Pediatrics

ACGME

Accreditation Council of Graduate Medical Education

CHGME

Children’s Hospital Graduate Medical Education

COVID-19

coronavirus disease 2019

HC

headcount

GME

graduate medical education

MD

Doctor of Medicine

MOC

maintenance of certification

NASEM

National Academies of Sciences, Engineering, and Medicine

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