The pediatric endocrinology (PE) workforce in the United States is struggling to sustain an adequate, let alone optimal, workforce capacity. This article, one of a series of articles in a supplement to Pediatrics, focuses on the pediatric subspecialty workforce and furthers previous evaluations of the US PE workforce to model the current and future clinical PE workforce and its geographic distribution. The article first discusses the children presenting to PE care teams, reviews the current state of the PE subspecialty workforce, and presents projected headcount and clinical workforce equivalents at the national, census region, and census division level on the basis of a subspecialty workforce supply model through 2040. It concludes by discussing the educational and training, clinical practice, policy, and future workforce research implications of the data presented. Data presented in this article are available from the American Board of Pediatrics, the National Resident Matching Program, and the subspecialty workforce supply model. Aging, part-time appointments, and unbalanced geographic distribution of providers diminish the PE workforce capacity. In addition, limited exposure, financial concerns, and lifestyle perceptions may impact trainees. Additional workforce challenges are the subspecialty’s increasingly complex cases and breadth of conditions treated, reliance on international medical graduates to fill fellowship slots, and high relative proportion of research careers. The recent limitations on pediatric endocrinologists providing gender-affirming care may also impact the geographic distribution of the subspecialty’s workforce. Deliberate actions need to be taken now to continue serving the needs of children.

The pediatric endocrinology (PE) workforce in the United States, predicted in 2014 to be in surplus after 2016,1  is now facing a deficit to meet projected clinical needs. The presumed 6% annual increase in PE fellowship training positions was replaced by stagnation, with a decline in total fellows from 254 (2012) to 225 (2020), followed by a modest increase to 243 (2022).2  Growing clinical demands, aging of the PE workforce, varying time spent in clinical practice, limited exposure of trainees to the subspecialty, and increasing financial constraints are hypothesized to contribute to the diminishing workforce. Careful review of the available data, examination of current trends, and correction of factors leading to this concerning workforce trajectory are needed to remedy the situation.

This article is part of a supplement that anticipates the future pediatric subspecialty supply from 2020 to 2040.3  It provides a novel analysis to inform discussions focused on sustaining the PE workforce by identifying the infants, children, adolescents, and young adults (hereafter, children) cared for by pediatric endocrinologists, reviews data on the status of the current PE workforce, summarizes new data on the projected PE workforce, and proposes training, practice, policy, and workforce initiatives to address the PE workforce concerns.

Changes in childhood epidemiology and health suggest that growth in the number and diversity of pediatric endocrinologists may be needed to match the increased patient volume and diagnostic and ethnic diversity of the patient population. The incidence of some “traditional” disorders seen by pediatric endocrinologists, such as diabetes and obesity, continues to rise. Between 2001 and 2009, the prevalence of type 1 diabetes and type 2 diabetes (T2D) among children <20 years of age increased by 21.1% and 30.5%, respectively.4  Currently, the United States has an estimated 210 000 children with diabetes. The unremitting obesity epidemic (18.5% of children aged 2–19 years)5  is accompanied by a rising prevalence of T2D and increases in dyslipidemia, hypertension, and related disorders.4,6 

Further, the spectrum of conditions with increasing prevalence among youth referred to PE subspecialists continues to expand. Pediatric endocrinologists now care for an increasing number of children with endocrine consequences from treatment of childhood cancer and organ transplantation. Survival rates at 5 years for childhood cancer have substantially improved to >80%, with 40% to 50% of the survivors developing an endocrinopathy.7  With improved survival rates for cystic fibrosis, cystic fibrosis-related diabetes now has a prevalence of 2% in young children, 19% in adolescents, and 40% to 50% in adults with cystic fibrosis.8  Impaired bone health associated with genetic bone diseases, chronic inflammatory disorders, neuromuscular diseases, eating disorders, and other chronic conditions requires long-term endocrine surveillance and treatment. The use of second-generation antipsychotics for managing disruptive behaviors among children has also increased and, with it, the complications of metabolic syndrome.6  In addition, with 1.8% of children identifying as transgender, gender diverse, or nonbinary,9,10  the demand for pediatric endocrinologists in gender clinics continues to increase. Pediatric endocrinologists are the most experienced with the use of “puberty-blocking” gonadotropin-releasing hormone agonists; their knowledge of both puberty suppression and exogenous pubertal induction and side effects encompasses the expertise needed to provide quality care for gender-expansive youth.

Most adult endocrinologists, primary care providers, and advanced practice providers do not have the knowledge, capacity, comfort level, and available resources to treat these expanded PE needs. Few primary care practices have the time to provide standard-of-care attention to these diagnoses, which require frequent monitoring, input from allied health specialists (eg, dieticians, nurse specialists, certified educators), and prolonged patient visits with limited reimbursement. Further, deficiencies in structures for transition of care and reluctance among adult providers to assume care often require pediatric endocrinologists to provide ongoing care for young adults with chronic endocrine conditions.11 

PE was established by Lawson Wilkins in 1935 at Johns Hopkins University.12  During the 1950s and 1960s, second-generation pediatric endocrinologists established endocrine subspecialty programs throughout North America, with the management of diabetes evolving in parallel as a clinical pediatric discipline. The Lawson Wilkins Pediatric Endocrine Society (now known as the Pediatric Endocrine Society [PES]) was founded in 1971, and the Council on Diabetes and Youth was established within the American Diabetes Association in 1980.12  Medical and economic factors led to the integration of pediatric diabetes and general endocrine care and training. The PE subboard of the American Board of Pediatrics (ABP) was established in 1978. The growth of PE has paralleled the growth of academic medicine, and as of 2022, there were 67 Accreditation Council for Graduate Medical Education-approved training programs in North America.

On the basis of ABP data through June 2023, a total of 2218 pediatricians have ever been board-certified in PE, 68.0% of whom were actively enrolled in Maintenance of Certification.13  The ABP data on currently certified subspecialists include individuals who may not be in the current workforce because of recent retirement, death, or other factors. To correct this, descriptions of the current workforce provided below are limited to the 1494 currently certified pediatricians ≤70 years of age. Geographic and fellowship data are limited to the United States.

Of these 1494 currently certified pediatric endocrinologists (2023), 73.6% identified as female, 26.3% as male, and 0.1% as gender nonbinary (the ABP has only offered options of decline to answer and nonbinary since 2021).14  In 2023, the median age of board-certified pediatric endocrinologists was 47 years, with 13.6% being age 61 to 70 years. The median age of female pediatric endocrinologists was 45 years compared with 51 years for their male counterparts, paralleling increasing numbers of women in pediatric subspecialties. Regarding medical training, 63.0% were American medical school graduates (AMGs) with a Doctor of Medicine (MD) degree, 3.8% were AMGs with a Doctor of Osteopathy (DO) degree, 18.2% were international medical graduates (IMGs) with an MD degree, and 15.0% were IMGs with an international degree. Notably, PE relies on a high number of IMGs, for whom visa requirements and changing immigration policies may limit availability for the future US workforce. The proportion of pediatric endocrinologists with DO degrees also increased over the past decade, paralleling general pediatrics and other pediatric subspecialties. Race and ethnicity estimates from 2018 to 2022 suggest that ∼14.2% of pediatric endocrinologists self-identified as underrepresented in medicine, which include Black or African American; Hispanic, Latino, or Spanish origin; American Indian or Native Alaskan; or Native Hawaiian or Pacific Islander origin.15 

Data on the work characteristics of current ABP-certified pediatric endocrinologists are collected through the ABP’s Maintenance of Certification enrollment surveys. Surveys from 2018 to 2022 had a 59.2% response rate for PE, reflecting responses from 811 eligible subspecialists aged ≤70 years.16  The majority report being employed full time (84.3%); 52.1% report working ≥50 hours per week on average over the last 6 months, exclusive of time on call but not working (compared with 29.1% among general pediatricians). Women (17.6%) were substantially more likely to indicate part-time employment status than men (5.4%), a higher proportion than many other subspecialties; the proportion of the part-time PE workforce is projected to increase.16  Approximately 44.4% reported that ≥50% of their patients received public insurance.16 

Most pediatric endocrinologists (80.1%) spent ≥50% of their time in clinical care and 10.1% reported spending ≥50% of their time in research, a higher percentage than many other pediatric subspecialties. Approximately three-quarters (72.2%) reported a primary work setting within an urban environment. Only 3.8% of pediatric endocrinologists currently describe their work setting as “rural.” Over one-third (37.1%) endorsed that their primary work setting was within a medical school or parent university, with most (79.8%) having a faculty appointment. These academic medicine appointments typically involve duties in research, education, administration, and other activities that limit the time available for clinical practice. In fact, among pediatric endocrinologists, >20% devote <50% time to patient care. In summary, current workforce numbers may overestimate the current clinical work capacity and underestimate the availability of pediatric endocrinologists to meet clinical care needs.

When the workforce is limited to the United States, PE geographic distribution in the United States is markedly uneven, ranging from 0.6 per 100 000 children aged 0 to 17 years in Idaho to 7.2 per 100 000 children in the District of Columbia, based on June 2023 data. In 2023, there was an average of 28.1 currently certified PE subspecialists per US state (range 1–165), which translates to 2.0 PE subspecialists per 100 000 children aged 0 to 18 years (range 0.6–7.2) across the United States. Only 21 states have >2 pediatric endocrinologists per 100 000 children; 8 states have <1 per 100 000 children. There is wide variability in the distribution of pediatric endocrinologists within states, with most being concentrated in urban settings. Analyses from 2019 showed the average driving distance to a certified pediatric endocrinologist was 20.4 miles; distances ranged from a low of 5.3 miles in Rhode Island to a high of 132.4 miles in North Dakota (excluding Alaska, Hawaii, Puerto Rico, and the District of Columbia).17  Between 2003 and 2019, the percentage of children within 20 miles of a pediatric endocrinologist increased from 42% to 51%, but 12% of children still must travel >40 miles to access PE specialty care after waiting as long as 6 months in many regions of the country.17  The skewed distribution toward urban/suburban work settings may reflect the desire among graduating trainees to pursue academic medicine careers rather than full-time clinical practice and the location of many jobs in academic medical centers.18  The PES job board has witnessed an increase in the number of positions available, particularly over the past few years.19 

Regarding the pathway to PE, yearly snapshot data from the Accreditation Council for Graduate Medical Education show there was a 7.5% increase in United States-accredited programs (67 to 72) between academic years 2012 to 2013 and 2021 to 2022. An ABP analysis of the National Resident Matching Program (NRMP) data suggests that 15 to 26 positions have been filled outside of the Match each year over the last decade. The ABP total count of first-year fellows in the United States, incorporating individuals who take positions before or after the Match, demonstrates that the number of first-year PE fellows over the last decade decreased by 3.4% from 88 (2012) to 85 (2022).18  Thus, unlike most pediatric subspecialties, both the number of training programs and fellows has remained relatively unchanged.16 

Among the 243 PE fellows in training during the 2022–2023 academic year in standard, noncombined, United States-accredited fellowship programs, 80.2% identified as female and 19.8% as male. Regarding medical training, 59.3% of fellows were AMGs (45.7% MD degree, 12.8% DO degree, and 0.8% unknown degree) and 40.7% of fellows were IMGs (19.8% MD degree, 11.1% international degree, 9.9% unknown degree). This represents an increase in IMGs over those currently in practice. A slightly higher proportion (19.4%) self-identified as underrepresented in medicine compared with practicing PE subspecialists.2  Fellows that remain in the United States commonly take a first position posttraining near their training location.20 Figure 1 shows the variability in PE fellowship locations in academic year 2021 to 2022, and highlights the relationship between training location on workforce distribution.20 

FIGURE 1

US distribution of PE subspecialists (aged ≤70 years) per 100 000 children (aged 0–17 Years) in 2023 and fellowship program size and locations for academic year 2021 to 2022. Source: ABP Certification Management System and Accreditation Council for Graduate Medical Education program data based on the 2021–2022 academic year snapshot. Sample: Limited to pediatricians aged ≤70 years and maintaining their certification as of June 2023.

FIGURE 1

US distribution of PE subspecialists (aged ≤70 years) per 100 000 children (aged 0–17 Years) in 2023 and fellowship program size and locations for academic year 2021 to 2022. Source: ABP Certification Management System and Accreditation Council for Graduate Medical Education program data based on the 2021–2022 academic year snapshot. Sample: Limited to pediatricians aged ≤70 years and maintaining their certification as of June 2023.

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Given the general increase in pediatric subspecialists overall, it is particularly striking that the slope of incoming PE fellows is flat or decreasing.14  Factors hypothesized to contribute to the pathway shortage include lack of early exposure to the subspecialty, financial concerns, insufficient mentorship, and potentially negative trainee perceptions regarding the quality of life of pediatric endocrinologists.18  Personal characteristics, intellectual interests, curriculum, clinical experiences, and debt can influence a medical student’s career choice.21,22  Because pediatric subspecialties do not require medical school rotations, exposure of learners during a critical period of career planning is random.23  Most first- and second-year pediatric residents experience endocrinology only on inpatient services managing patients with diabetes mellitus or diabetes insipidus. This creates the impression that the subspecialty is one-dimensional and rife with psychosocial challenges. By the time third-year residents have an outpatient PE rotation, most have typically already committed to a different path. Thus, insufficient exposure to PE’s extensive variety and complexity during critical career choice periods presumably contributes to the declining number of applicants for PE fellowship training.24 

Recent publications have highlighted differences in financial remuneration across pediatric subspecialties as compared with adult subspecialties.25  Although older reports suggest compensation may be less important for residents in choosing a pediatric subspecialty career,26  the increasingly high rates of debt may impact decision-making. Medical student debt, now averaging $232 000, dissuades trainees from undertaking additional years of training and postponing compensation as independent practicing attending physicians and choosing pediatrics as a career.27  Of note, approximately 30.5% of current PE fellows owe $200 000 or more compared with 39.5% for all pediatric subspecialty fellows, on the basis of results from the ABP’s Subspecialty In-training Exam Survey in 2022 (personal communication, ABP February 2023). Pediatric endocrinologists’ relatively low average salary further discourages those for whom debt-repayment potential is a key consideration.28,29  Quality of life, including a distinct separation between personal and professional time, is a top priority for today’s medical trainees.30  The unique need for coverage of diabetes-related calls overnight from parents and patients may dissuade trainees from PE. Given the profound impact of experiences with mentors in driving career choices,29  exposure to faculty struggling with multiple stressors may further reduce attraction to the subspecialty.

In 2019, the ABP Foundation initiated a pediatric subspecialty modeling project to characterize the future supply of US pediatric subspecialists aged ≤70 years at the national and subnational levels for 2020 to 2040.3  The resulting model incorporates data from the ABP and other national resources. Baseline workforce estimates are provided by headcount (HC; absolute numbers) and clinical workforce equivalent (CWE; HC adjusted for the self-reported percentage of time spent in direct clinical or consultative care). Both also can be viewed per 100 000 children aged 0 to 18 years. The model includes alternative scenarios altering the training pool, clinical time, and early exits.31  The model results can be reviewed through an interactive, online data visualization tool.32  The model accounts for changes in the child population at the national and subnational level on the basis of the US Census Bureau33 ; differences by subspecialty for census regions and divisions are discussed in the summary article in this supplement.32 

The numbers reported below may differ from those in the previous section because of differences in years (2020 vs 2023), sample selection criteria, and inclusion of self-reported clinical time.

Details of the baseline estimates and scenarios relevant to PE are presented; estimates of 95% confidence intervals (CIs) are available in Tables 1 and 2 and the online data visualization.

TABLE 1

Estimated Headcount for Pediatric Endocrinology Subspecialists (Aged ≤70 Years) Per 100 000 Children (Aged 0 to 18 Years) by US Census Division for Different Model Scenarios, 2020 to 2040

Census RegionCensus DivisionYear 2020Year 2040
Baseline ModelBaseline Model12.5% Decrease in Fellows12.5% Increase in Fellows7% Reduction in Clinical Time7% Increase in Clinical TimeIncreased Level of Exit at All AgesIncreased Level of Exit in MidcareerDecrease in Fellows, Reduction in Clinical Time and Increased Early Exit by 5 y From the WorkforceIncrease in Fellows and an Increase in Clinical Time
Midwest East North Central 1.59 [1.57–1.60] 2.33 [2.11–2.56] 2.29 [2.07–2.50] 2.45 [2.20–2.69] 2.33 [2.11–2.56] 2.33 [2.12–2.54] 2.36 [2.14–2.58] 2.34 [2.08–2.60] 2.26 [2.03–2.49] 2.45 [2.20–2.69] 
(+47%) (+44%) (+54%) (+47%) (+47%) (+49%) (+48%) (+42%) (+54%) 
West North Central 1.93 [1.92–1.95] 3.28 [2.96–3.61] 3.14 [2.77–3.51] 3.32 [2.89–3.76] 3.28 [2.96–3.61] 3.29 [2.98–3.59] 3.26 [2.89–3.62] 3.25 [2.85–3.65] 3.16 [2.75–3.57] 3.32 [2.89–3.76] 
(+70%) (+63%) (+72%) (+70%) (+70%) (+69%) (+68%) (+64%) (+72%) 
South East South Central 1.56 [1.56–1.56] 2.64 [2.25–3.03] 2.53 [2.14–2.93] 2.71 [2.29–3.14] 2.64 [2.25–3.03] 2.65 [2.30–2.99] 2.61 [2.17–3.05] 2.57 [2.20–2.94] 2.47 [2.10–2.84] 2.71 [2.29–3.14] 
(+69%) (+63%) (+74%) (+69%) (+70%) (+67%) (+65%) (+58%) (+74%) 
South Atlantic 1.81 [1.80–1.82] 2.25 [2.09–2.41] 2.18 [1.99–2.37] 2.31 [2.12–2.49] 2.25 [2.09–2.41] 2.25 [2.09–2.40] 2.25 [2.06–2.44] 2.24 [2.07–2.42] 2.20 [2.01–2.38] 2.31 [2.12–2.49] 
(+24%) (+20%) (+27%) (+24%) (+24%) (+24%) (+24%) (+21%) (+27%) 
West South Central 1.31 [1.30–1.33] 2.13 [1.93–2.32] 2.05 [1.88–2.22] 2.21 [2.01–2.40] 2.13 [1.93–2.32] 2.14 [1.96–2.32] 2.13 [1.92–2.33] 2.13 [1.93–2.32] 2.04 [1.83–2.24] 2.21 [2.01–2.40] 
(+62%) (+56%) (+68%) (+62%) (+63%) (+62%) (+62%) (+55%) (+68%) 
Northeast Middle Atlantic 2.54 [2.52–2.56] 3.51 [3.24–3.78] 3.36 [3.03–3.69] 3.64 [3.33–3.96] 3.51 [3.24–3.78] 3.52 [3.28–3.76] 3.50 [3.22–3.79] 3.50 [3.19–3.81] 3.36 [3.06–3.65] 3.64 [3.33–3.96] 
(+38%) (+32%) (+43%) (+38%) (+39%) (+38%) (+38%) (+32%) (+43%) 
New England 3.87 [3.82–3.93] 6.43 [5.80–7.06] 6.24 [5.48–7.00] 6.74 [6.02–7.47] 6.43 [5.80–7.06] 6.41 [5.80–7.02] 6.47 [5.73–7.21] 6.43 [5.80–7.07] 6.19 [5.45–6.94] 6.74 [6.02–7.47] 
(+66%) (+61%) (+74%) (+66%) (+65%) (+67%) (+66%) (+60%) (+74%) 
West Mountain 1.24 [1.22–1.26] 1.79 [1.52–2.06] 1.71 [1.43–1.98] 1.86 [1.58–2.14] 1.79 [1.52–2.06] 1.79 [1.48–2.11] 1.79 [1.55–2.02] 1.81 [1.57–2.05] 1.76 [1.49–2.03] 1.86 [1.58–2.14] 
(+44%) (+38%) (+50%) (+44%) (+45%) (+44%) (+46%) (+42%) (+50%) 
Pacific 1.64 [1.63–1.65] 2.05 [1.87–2.23] 1.99 [1.80–2.19] 2.10 [1.92–2.28] 2.05 [1.87–2.23] 2.05 [1.85–2.24] 2.04 [1.88–2.19] 2.03 [1.87–2.19] 1.99 [1.83–2.16] 2.10 [1.92–2.28] 
(+25%) (+21%) (+28%) (+25%) (+25%) (+24%) (+24%) (+21%) (+28%) 
Census RegionCensus DivisionYear 2020Year 2040
Baseline ModelBaseline Model12.5% Decrease in Fellows12.5% Increase in Fellows7% Reduction in Clinical Time7% Increase in Clinical TimeIncreased Level of Exit at All AgesIncreased Level of Exit in MidcareerDecrease in Fellows, Reduction in Clinical Time and Increased Early Exit by 5 y From the WorkforceIncrease in Fellows and an Increase in Clinical Time
Midwest East North Central 1.59 [1.57–1.60] 2.33 [2.11–2.56] 2.29 [2.07–2.50] 2.45 [2.20–2.69] 2.33 [2.11–2.56] 2.33 [2.12–2.54] 2.36 [2.14–2.58] 2.34 [2.08–2.60] 2.26 [2.03–2.49] 2.45 [2.20–2.69] 
(+47%) (+44%) (+54%) (+47%) (+47%) (+49%) (+48%) (+42%) (+54%) 
West North Central 1.93 [1.92–1.95] 3.28 [2.96–3.61] 3.14 [2.77–3.51] 3.32 [2.89–3.76] 3.28 [2.96–3.61] 3.29 [2.98–3.59] 3.26 [2.89–3.62] 3.25 [2.85–3.65] 3.16 [2.75–3.57] 3.32 [2.89–3.76] 
(+70%) (+63%) (+72%) (+70%) (+70%) (+69%) (+68%) (+64%) (+72%) 
South East South Central 1.56 [1.56–1.56] 2.64 [2.25–3.03] 2.53 [2.14–2.93] 2.71 [2.29–3.14] 2.64 [2.25–3.03] 2.65 [2.30–2.99] 2.61 [2.17–3.05] 2.57 [2.20–2.94] 2.47 [2.10–2.84] 2.71 [2.29–3.14] 
(+69%) (+63%) (+74%) (+69%) (+70%) (+67%) (+65%) (+58%) (+74%) 
South Atlantic 1.81 [1.80–1.82] 2.25 [2.09–2.41] 2.18 [1.99–2.37] 2.31 [2.12–2.49] 2.25 [2.09–2.41] 2.25 [2.09–2.40] 2.25 [2.06–2.44] 2.24 [2.07–2.42] 2.20 [2.01–2.38] 2.31 [2.12–2.49] 
(+24%) (+20%) (+27%) (+24%) (+24%) (+24%) (+24%) (+21%) (+27%) 
West South Central 1.31 [1.30–1.33] 2.13 [1.93–2.32] 2.05 [1.88–2.22] 2.21 [2.01–2.40] 2.13 [1.93–2.32] 2.14 [1.96–2.32] 2.13 [1.92–2.33] 2.13 [1.93–2.32] 2.04 [1.83–2.24] 2.21 [2.01–2.40] 
(+62%) (+56%) (+68%) (+62%) (+63%) (+62%) (+62%) (+55%) (+68%) 
Northeast Middle Atlantic 2.54 [2.52–2.56] 3.51 [3.24–3.78] 3.36 [3.03–3.69] 3.64 [3.33–3.96] 3.51 [3.24–3.78] 3.52 [3.28–3.76] 3.50 [3.22–3.79] 3.50 [3.19–3.81] 3.36 [3.06–3.65] 3.64 [3.33–3.96] 
(+38%) (+32%) (+43%) (+38%) (+39%) (+38%) (+38%) (+32%) (+43%) 
New England 3.87 [3.82–3.93] 6.43 [5.80–7.06] 6.24 [5.48–7.00] 6.74 [6.02–7.47] 6.43 [5.80–7.06] 6.41 [5.80–7.02] 6.47 [5.73–7.21] 6.43 [5.80–7.07] 6.19 [5.45–6.94] 6.74 [6.02–7.47] 
(+66%) (+61%) (+74%) (+66%) (+65%) (+67%) (+66%) (+60%) (+74%) 
West Mountain 1.24 [1.22–1.26] 1.79 [1.52–2.06] 1.71 [1.43–1.98] 1.86 [1.58–2.14] 1.79 [1.52–2.06] 1.79 [1.48–2.11] 1.79 [1.55–2.02] 1.81 [1.57–2.05] 1.76 [1.49–2.03] 1.86 [1.58–2.14] 
(+44%) (+38%) (+50%) (+44%) (+45%) (+44%) (+46%) (+42%) (+50%) 
Pacific 1.64 [1.63–1.65] 2.05 [1.87–2.23] 1.99 [1.80–2.19] 2.10 [1.92–2.28] 2.05 [1.87–2.23] 2.05 [1.85–2.24] 2.04 [1.88–2.19] 2.03 [1.87–2.19] 1.99 [1.83–2.16] 2.10 [1.92–2.28] 
(+25%) (+21%) (+28%) (+25%) (+25%) (+24%) (+24%) (+21%) (+28%) 

Numbers denote HC per 100 000 children [95% CI]. Percentages indicate change from baseline year 2020.

TABLE 2

Estimated Clinical Workforce Equivalent for Pediatric Endocrinology Subspecialists (Aged ≤70 Years) Per 100 000 Children (Aged 0–18 Years) by US Census Division for Different Model Scenarios, 2020 to 2040

Census RegionCensus DivisionYear 2020Year 2040
Baseline ModelBaseline Model12.5% Decrease in Fellows12.5% Increase in Fellows7% Reduction in Clinical Time7% Increase in Clinical TimeIncreased Level of Exit at All AgesIncreased Level of Exit in MidcareerDecrease in Fellows, Reduction in Clinical Time and Increased Early Exit by 5 y From the WorkforceIncrease in Fellows and an Increase in Clinical Time
Midwest East North Central 0.98 [0.97–0.99] 1.43 [1.30–1.57] 1.40 [1.27–1.54] 1.50 [1.35–1.66] 1.33 [1.21–1.46] 1.53 [1.40–1.67] 1.45 [1.31–1.59] 1.44 [1.28–1.60] 1.29 [1.16–1.42] 1.61 [1.45–1.77] 
(+47%) (+44%) (+54%) (+37%) (+57%) (+49%) (+47%) (+32%) (+65%) 
West North Central 1.19 [1.18–1.20] 2.02 [1.82–2.22] 1.93 [1.71–2.16] 2.05 [1.78–2.31] 1.88 [1.69–2.07] 2.16 [1.96–2.37] 2.00 [1.78–2.23] 2.00 [1.75–2.25] 1.81 [1.57–2.05] 2.19 [1.90–2.48] 
(+70%) (+63%) (+72%) (+58%) (+82%) (+69%) (+68%) (+53%) (+84%) 
South East South Central 0.95 [0.95–0.95] 1.62 [1.38–1.86] 1.56 [1.31–1.80] 1.67 [1.41–1.93] 1.51 [1.29–1.73] 1.74 [1.52–1.97] 1.60 [1.33–1.87] 1.58 [1.35–1.81] 1.41 [1.20–1.62] 1.79 [1.51–2.06] 
(+71%) (+64%) (+75%) (+59%) (+83%) (+69%) (+66%) (+48%) (+88%) 
South Atlantic 1.11 [1.10–1.12] 1.38 [1.28–1.48] 1.34 [1.22–1.45] 1.41 [1.30–1.53] 1.28 [1.19–1.38] 1.48 [1.37–1.58] 1.38 [1.27–1.49] 1.37 [1.27–1.48] 1.25 [1.15–1.36] 1.51 [1.39–1.64] 
(+25%) (+21%) (+28%) (+16%) (+33%) (+25%) (+24%) (+13%) (+37%) 
West South Central 0.82 [0.80–0.83] 1.31 [1.19–1.43] 1.26 [1.16–1.36] 1.36 [1.24–1.48] 1.22 [1.10–1.33] 1.40 [1.28–1.53] 1.30 [1.18–1.43] 1.31 [1.19–1.42] 1.16 [1.05–1.28] 1.45 [1.32–1.58] 
(+60%) (+54%) (+66%) (+49%) (+72%) (+60%) (+60%) (+42%) (+78%) 
Northeast Middle Atlantic 1.56 [1.54–1.57] 2.15 [1.99–2.32] 2.06 [1.85–2.26] 2.23 [2.04–2.43] 2.00 [1.85–2.16] 2.31 [2.15–2.47] 2.15 [1.97–2.32] 2.14 [1.96–2.33] 1.91 [1.75–2.08] 2.39 [2.18–2.60] 
(+38%) (+32%) (+44%) (+29%) (+48%) (+38%) (+38%) (+23%) (+54%) 
New England 2.39 [2.35–2.42] 3.94 [3.55–4.33] 3.82 [3.36–4.28] 4.13 [3.68–4.58] 3.66 [3.30–4.03] 4.20 [3.79–4.61] 3.96 [3.51–4.41] 3.94 [3.56–4.33] 3.52 [3.10–3.95] 4.42 [3.94–4.91] 
(+65%) (+60%) (+73%) (+54%) (+76%) (+66%) (+65%) (+48%) (+85%) 
West Mountain 0.76 [0.75–0.77] 1.10 [0.94–1.27] 1.05 [0.88–1.22] 1.15 [0.98–1.32] 1.03 [0.87–1.18] 1.18 [0.98–1.39] 1.10 [0.96–1.25] 1.12 [0.97–1.26] 1.01 [0.86–1.16] 1.23 [1.05–1.41] 
(+46%) (+39%) (+52%) (+36%) (+56%) (+46%) (+48%) (+33%) (+62%) 
Pacific 1.01 [1.00–1.01] 1.26 [1.15–1.37] 1.22 [1.11–1.34] 1.29 [1.18–1.40] 1.17 [1.07–1.27] 1.35 [1.22–1.47] 1.25 [1.16–1.35] 1.25 [1.15–1.35] 1.14 [1.04–1.23] 1.38 [1.26–1.50] 
(+25%) (+21%) (+28%) (+16%) (+34%) (+24%) (+24%) (+13%) (+37%) 
Census RegionCensus DivisionYear 2020Year 2040
Baseline ModelBaseline Model12.5% Decrease in Fellows12.5% Increase in Fellows7% Reduction in Clinical Time7% Increase in Clinical TimeIncreased Level of Exit at All AgesIncreased Level of Exit in MidcareerDecrease in Fellows, Reduction in Clinical Time and Increased Early Exit by 5 y From the WorkforceIncrease in Fellows and an Increase in Clinical Time
Midwest East North Central 0.98 [0.97–0.99] 1.43 [1.30–1.57] 1.40 [1.27–1.54] 1.50 [1.35–1.66] 1.33 [1.21–1.46] 1.53 [1.40–1.67] 1.45 [1.31–1.59] 1.44 [1.28–1.60] 1.29 [1.16–1.42] 1.61 [1.45–1.77] 
(+47%) (+44%) (+54%) (+37%) (+57%) (+49%) (+47%) (+32%) (+65%) 
West North Central 1.19 [1.18–1.20] 2.02 [1.82–2.22] 1.93 [1.71–2.16] 2.05 [1.78–2.31] 1.88 [1.69–2.07] 2.16 [1.96–2.37] 2.00 [1.78–2.23] 2.00 [1.75–2.25] 1.81 [1.57–2.05] 2.19 [1.90–2.48] 
(+70%) (+63%) (+72%) (+58%) (+82%) (+69%) (+68%) (+53%) (+84%) 
South East South Central 0.95 [0.95–0.95] 1.62 [1.38–1.86] 1.56 [1.31–1.80] 1.67 [1.41–1.93] 1.51 [1.29–1.73] 1.74 [1.52–1.97] 1.60 [1.33–1.87] 1.58 [1.35–1.81] 1.41 [1.20–1.62] 1.79 [1.51–2.06] 
(+71%) (+64%) (+75%) (+59%) (+83%) (+69%) (+66%) (+48%) (+88%) 
South Atlantic 1.11 [1.10–1.12] 1.38 [1.28–1.48] 1.34 [1.22–1.45] 1.41 [1.30–1.53] 1.28 [1.19–1.38] 1.48 [1.37–1.58] 1.38 [1.27–1.49] 1.37 [1.27–1.48] 1.25 [1.15–1.36] 1.51 [1.39–1.64] 
(+25%) (+21%) (+28%) (+16%) (+33%) (+25%) (+24%) (+13%) (+37%) 
West South Central 0.82 [0.80–0.83] 1.31 [1.19–1.43] 1.26 [1.16–1.36] 1.36 [1.24–1.48] 1.22 [1.10–1.33] 1.40 [1.28–1.53] 1.30 [1.18–1.43] 1.31 [1.19–1.42] 1.16 [1.05–1.28] 1.45 [1.32–1.58] 
(+60%) (+54%) (+66%) (+49%) (+72%) (+60%) (+60%) (+42%) (+78%) 
Northeast Middle Atlantic 1.56 [1.54–1.57] 2.15 [1.99–2.32] 2.06 [1.85–2.26] 2.23 [2.04–2.43] 2.00 [1.85–2.16] 2.31 [2.15–2.47] 2.15 [1.97–2.32] 2.14 [1.96–2.33] 1.91 [1.75–2.08] 2.39 [2.18–2.60] 
(+38%) (+32%) (+44%) (+29%) (+48%) (+38%) (+38%) (+23%) (+54%) 
New England 2.39 [2.35–2.42] 3.94 [3.55–4.33] 3.82 [3.36–4.28] 4.13 [3.68–4.58] 3.66 [3.30–4.03] 4.20 [3.79–4.61] 3.96 [3.51–4.41] 3.94 [3.56–4.33] 3.52 [3.10–3.95] 4.42 [3.94–4.91] 
(+65%) (+60%) (+73%) (+54%) (+76%) (+66%) (+65%) (+48%) (+85%) 
West Mountain 0.76 [0.75–0.77] 1.10 [0.94–1.27] 1.05 [0.88–1.22] 1.15 [0.98–1.32] 1.03 [0.87–1.18] 1.18 [0.98–1.39] 1.10 [0.96–1.25] 1.12 [0.97–1.26] 1.01 [0.86–1.16] 1.23 [1.05–1.41] 
(+46%) (+39%) (+52%) (+36%) (+56%) (+46%) (+48%) (+33%) (+62%) 
Pacific 1.01 [1.00–1.01] 1.26 [1.15–1.37] 1.22 [1.11–1.34] 1.29 [1.18–1.40] 1.17 [1.07–1.27] 1.35 [1.22–1.47] 1.25 [1.16–1.35] 1.25 [1.15–1.35] 1.14 [1.04–1.23] 1.38 [1.26–1.50] 
(+25%) (+21%) (+28%) (+16%) (+34%) (+24%) (+24%) (+13%) (+37%) 

Numbers denote CWE per 100 000 children [95% CI]. Percentages indicate change from baseline year 2020.

The baseline model predicted there would be 1465 certified pediatric endocrinologists in the United States in 2020. This corresponds to 1.8 HC per 100 000 children in 2020, with a predicted growth to 2.54 HC per 100 000 children (+41%) by 2040. When adjusting for clinical time, these 1465 pediatric endocrinologists correspond to 900 CWE nationally, or 1.1 CWE per 100 000 children, with a projected growth to 1.6 CWE per 100 000 children (+41%) by 2040. Modeling interpretations henceforward are displayed in CWE per 100 000 children.

The projected increase in supply indicates that, if the inflow of fellows remains constant at 2019 levels, which the model assumes for all subspecialties, then exits from the workforce will not exceed inflow, retention, and attrition. The model allows users to observe how the supply projection would change if incoming fellows decreased by 12.5% by 2030. This decrease adjusts the supply projection to 1.5 CWE per 100 000 children by 2040 and equates to an increase from 48% to 54% of fellowship positions remaining unfilled in the NRMP Match. However, this prediction may already be a reality for PE, because the 95% CI for this scenario (1.11–1.51) overlaps with 95% CI for the baseline model (1.11–1.56).

The model also predicts worsening geographic maldistribution. Analyses of US Census Bureau data at the regional level projected 23% growth in the child population aged 0 to 18 years in the West compared with growth of 4% in the Northeast, 19% in the South, and 2% in the Midwest. When adjusted for the predicted growth in the pediatric population in the model, the Midwest is projected to have the highest growth (55%), followed by the Northeast (48%), the South (41%), and the West (30%). Figure 2 displays these national data for the 4 census regions. Tables 1 and 2 further explore geographic maldistribution by HC and CWE at the census division level for all scenarios.

FIGURE 2

Estimated CWE for PE subspecialists (aged ≤70 years) 100 000 children (aged 0–18 years) by US Census region, 2020 to 2040. CWE indicates HC adjusted by the reported proportion of time spent in direct clinical or consultative care.

FIGURE 2

Estimated CWE for PE subspecialists (aged ≤70 years) 100 000 children (aged 0–18 years) by US Census region, 2020 to 2040. CWE indicates HC adjusted by the reported proportion of time spent in direct clinical or consultative care.

Close modal

When the model combines a 12.5% decrease in fellows, 7% decrease in clinical time, and earlier exit at all career stages, the projected supply shifts from a 41% increase (1.6 CWE per 100 000 children) to a 27% increase (1.4 CWE per 100 000 children). As shown in Table 2, when factors cause decreases in supply, geographic disparities become more acute. For example, the South Atlantic and Pacific divisions would only see a 13% increase in supply under this scenario.

The model may not take into account 3 unique factors about the field: (1) the high proportion of IMGs in fellowship and practice, (2) the high proportion of endocrinologists aged >60 years and possible early exit, and (3) the increasing clinical needs by region. Given that approximately one-third of ABP-certified pediatric endocrinologists have been internationally trained, this proportion of the workforce is subject to US policies concerning IMGs and immigrants in general. IMGs who train in the United States may not meet legal requirements to stay and practice in the United States or may have their training paid for by their foreign governments and be required to return to their native country to deliver PE care. Increased attrition presents an additional challenge because >20% of those actively board-certified in PE are aged >70 years and another 13.6% are aged 61 to 70 years. These individuals may choose to retire or have shifts in their clinical time because of the transition to more research, teaching, or administrative roles outside of clinical care. PE already demonstrates higher self-reported rates of careers in research than 10 of the other 14 pediatric subspecialties. Some pediatric endocrinologists are also leaving clinical medicine to pursue careers in drug, therapeutic, and device development. Last, the model lacks a robust measure of clinical need or market demand at the national or subnational level. One study reported that children in the South may have higher rates of obesity,34  whereas another reports that any region of the United States is at risk for elevated BMI,35  which may lead to metabolic consequences from obesity. We anticipate that the limited number of CWE per 100 000 children predicted in this model will not be able to meet the needs of the numbers of US children with endocrinological needs, which have been steadily increasing over the last several decades.

Although PE as a subspecialty will be over a century old by 2040, future workforce growth is small, at best, and may be inadequate to meet the growing demands for care at both the regional and national levels without a greater understanding of how need is best addressed.

Therefore, immediate comprehensive actions are necessary to increase the PE workforce by 2040 to meet demand.36 

In an effort to address limited early exposure and negative perceptions, PE subspecialists have worked to enhance the pathway to the subspecialty with programs such as the Endocrine Discovery Program scholarships for medical students and residents to attend the PES annual meeting and a Student Endocrinology Exposure Development Program, presenting monthly case studies to early-in-career trainees contemplating a PE career. However, partnerships with medical schools and residencies are needed to increase early exposure by including pediatric subspecialty exposure in core rotations for medical students and during the 18 months of residency. This exposure should emphasize outpatient activities to better capture the subspecialty’s multidimensional scope and continuity-of-care aspect and not simply focus on inpatient consultations. PE divisions should create and sustain rotations for medical students distinguished by exposure to interesting, challenging patients and enthusiastic endocrinology mentors, both fellows and faculty, to positively influence career path selection. Key organizations (eg, Council of Pediatric Specialties, Association of Pediatric Program Directors) should urge early residency exposure to nonprocedural subspecialties, including PE, during the critical career planning period. Changes in the length of training requirements or other educational innovations could be considered to provide a more cost-efficient pathway to a clinical career to those not destined for an academic research career.

Further, PE does not have diversity in race and ethnicity or gender identities that reflect its patient population. For example, metabolic syndrome and T2D disproportionately impact children from Black, Hispanic, and underserved groups.37  Racial and ethnic distribution has improved among our trainees, with individuals from underrepresented communities currently comprising 23% of pediatric endocrine trainees versus 12% in 2006 and fellows identified as Black increasing from 5.5% of 236 fellows in 2018 to 13.5% in 2020. However, greater diversification continues to be a priority. The emergence of transgender care has dramatically altered the dimensions and communities served by pediatric endocrinologists. Recognizing that the effectiveness of chronic medical care is enhanced when delivered by providers and teams who can authentically identify with their patients, the need for a more diverse PE workforce and training in cultural sensitivity is clear.

Another approach to extending access to PE care is to pursue innovative provider training of primary care physicians and advanced practice providers, such as physician assistants and nurse practitioners, to collaborate with centrally located, board-certified pediatric endocrinologists through telehealth. In reality, however, only the most routine endocrine disorders are amenable to such extensions, with the management of nuanced, complex, and acutely ill children with endocrine disorders still requiring the depth of knowledge in pathophysiology and evidence-based treatments obtained through fellowship training. In addition, the pediatric nurse practitioner workforce is not expected to grow substantially.38  Meeting the endocrinological needs of US children will require substantive changes in the scope of work for primary care physicians and the creative development of PE care delivery models, both of which will require incentivization.

Financial barriers to choosing PE must be addressed. Medical student loan forgiveness measures for applicants committed to working in underserved regions must expand beyond current options and target subspecialties with lower future financial rewards. Such initiatives would improve recruitment and reduce the effect of debt on the risk of burnout.30  Improvement in reimbursement through shared care models that recognize and appropriately reward the essential expertise of the endocrinologist could be implemented to enable changes in compensation necessary to sustain nonprocedural pediatric subspecialties in general.

More recently, the demand for gender-affirming care continues to grow parallel with the increase observed with each successive generation in the subpopulation self-identifying as sex and gender diverse.39  Unfortunately, professional, legal, and personal threats to pediatric endocrinologists providing this care are resulting in some providers leaving the state where they practice, further reducing the number of pediatric endocrinologists in areas such as the South. At the same time, sanctuary states for these youth seeking care, such as California,40  may attract providers of gender care and contribute to change in the distribution of pediatric endocrinologists. It is unclear how these political challenges may impact interest in PE for medical students.

Both the impact of possible trends in child health needs and in the workforce described above or any interventions to address these trends should be carefully monitored. Also, although the model provides better information than the pediatric endocrinology field has had up to this point, we still lack strong measures of child health needs and how they interact with the available workforce and market demands. Future workforce research will continue to be a priority.

PE is a rewarding career enhanced by continuity of patient care, availability of effective and innovative therapeutics, and intellectual stimulation.29  It provides the opportunity through clinical care and research to substantially impact critical current pediatric health challenges, including obesity, diabetes, and transgender care. However, several factors detailed above impede a positive trajectory of the PE workforce, thus limiting access to care for increasing numbers of children with diverse, complex, and critical health care needs. Actions to enhance the career pathway and sustain satisfaction in PE are urgently needed to deliver evidence-based and equitable care to children in the near future.

We thank Emily McCartha, Andrew Knapton, and Adriana Gaona for their review of the modeling data presented. We also thank Virginia A. Moyer and Patience Leino for their editorial support. We also thank the leadership of the Pediatric Endocrine Society subspecialty society for comments on the manuscript. Last, we thank the pediatricians who shared their information with the ABP Foundation and made this supplement possible.

Dr Aye drafted the initial manuscript and critically reviewed and revised the manuscript; Drs Boney, Orr, Leonard, Leslie, and Allen 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: Funded by the American Board of Pediatrics (ABP) Foundation. The ABP Foundation, the Carolina Health Workforce Research Center at the University of North Carolina at Chapel Hill’s Sheps Center for Health Services Research, and the 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 ABP or the ABP Foundation.

CONFLICT OF INTEREST DISCLOSURES: Dr Orr receives grant funding from the ABP Foundation. Dr Leslie is an employee of the ABP. The other authors have indicated they have no potential conflicts of interest to disclose.

ABP

American Board of Pediatrics

AMG

American medical school graduate

CI

confidence interval

CWE

Clinical Workforce Equivalent

DO

Doctor of Osteopathy

HC

headcount

IMG

international medical graduate

MD

Doctor of Medicine

NRMP

National Resident Matching Program

PE

pediatric endocrinology

PES

Pediatric Endocrine Society

T2D

type 2 diabetes

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