Child Health Needs and the Pediatric Hematology-Oncology Workforce: 2020–2040

In contemporary practice, PHO subspecialists care for infants, children, adolescents, and young adults (hereafter, “children”) with all types of cancer and nonmalignant blood conditions. PHO subspecialists may act as short-term consultants for some disorders (eg, anemias resulting from nutritional deficiencies). However, the majority of the subspecialty’s practice focuses on chronic care for children with long-term illnesses (eg, leukemia) or lifelong conditions (eg, hemoglobinopathies, congenital coagulopathies). For many children with cancer, the PHO physician temporarily assumes the role of the primary care physician because of the length, intensity, and complexity of treatment. Care is often provided in concert with a larger team that may include surgeons, radiation oncologists, other pediatric subspecialty physicians, advanced practice providers, psychologists, nutritionists, social workers, and others, creating a de facto medical home for the chronic care needs of these children.

Although cancer is much more uncommon in children than adults, at least 15 000 children and young adults (0–19 years) in the United States were diagnosed with cancer in 2022.¹  Of these children, >85% will be alive 5 years after diagnosis¹³  and require PHO follow-up care to mitigate late effects of treatment.¹⁴  With the exception of a few genetic cancer predisposition syndromes, childhood cancer is a random event increasing in incidence by approximately 0.5% to 0.7% annually.^13,15  Regarding other hematologic diseases, the Centers for Disease Control and Prevention estimates that ∼30 000 children in the United States have SCD.¹⁶  Accurate estimates of the number of children with other disorders are more difficult because of the lack of registries. Increasing incidence of disease, improvements in survival from novel treatments, and the need for long-term follow-up because of chronic disease and treatment sequelae suggest that the number of patients requiring care by PHO subspecialists will increase over time.

Hematology emerged as a pediatric subspeciality in the 1920s and 1930s as a result of seminal studies in thalassemia and other inherited anemias by medical pioneers, including Thomas Denton Cooley and Louis Diamond.¹⁷  Natural extension into oncology occurred through childhood leukemia, the most common childhood cancer, which, at that time, was uniformly fatal if untreated resulting from bleeding and infection. PHO divisions in hospitals were established throughout the United States starting in the late 1940s after training and research support became available through the National Institutes of Health. The American Board of Medical Specialties formally approved the subspecialty in 1973. The American Board of Pediatrics (ABP) offered its first PHO certifying examination in 1974, and the Accreditation Council for Graduate Medical Education (ACGME) approved PHO fellowship training in 1983.

Based on ABP data through June 2023, 4231 pediatricians have ever been board-certified in PHO. Of these, 2929 (69.2%) were actively enrolled in Maintenance of Certification.¹⁸  ABP data on currently certified subspecialists include individuals who may not be in the workforce because of recent retirement, death, or other factors. To correct this, further descriptions of the current workforce that follow limit the sample to the 2898 actively board-certified PHO pediatricians aged ≤70 years.

Most (60.3%) identified as female, 39.7% as male, and none identified as gender nonbinary or declined to answer (the ABP began data on gender nonbinary in 2021).¹⁸  The median age was 45 years and 12.2% were aged 61 to 70 years, reflecting a relative youthfulness compared with other pediatric subspecialties. Regarding medical training, 71.3% were American medical graduates (AMGs) with a Doctor of Medicine (MD) degree, 5.5% were AMGs with a Doctor of Osteopathy (DO) degree, 11.7% were international medical graduates (IMGs) with an MD degree, and 11.5% were IMGs with an international degree. Self-identification of race and ethnicity estimates from 2018 through 2023 suggest that the majority (64.1%) of PHO physicians are White and 20.9% are Asian. Approximately 10.0% self-identify as underrepresented in medicine (URiM), which includes Black or African American, Hispanic, Latino, or Spanish origin, American Indian or Native Alaskan, or Native Hawaiian or Pacific Islander descent.¹⁹ 

The ABP’s Maintenance of Certification enrollment surveys collected data on the current work characteristics of ABP-certified PHO physicians.²⁰  Surveys from 2018 through 2022 averaged a 57.2% response rate for PHO, reflecting responses from 1349 eligible PHO physicians aged ≤70 years old. Because of response skip patterns in the surveys, the percentages reported are for individual questions. The majority reported being employed full-time (92.3%); 65.4% reported working ≥50 hours per week on average over the past 6 months, exclusive of time on-call but not working. Women were more likely to indicate part-time employment status (10.1%) compared with men (2.2%). Most (61.2%) spent ≥50% of their time in clinical care, whereas 21.6% reported spending ≥50% of their time in research, one of the highest proportions among the pediatric subspecialties.²⁰  The largest proportion of respondents (83.9%) endorsed having a faculty appointment and 40.8% reported that their primary work setting was within a medical school or parent university. The majority (82.2%) reported a primarily urban work setting. About 48.6% reported that ≥50% of their patients received public insurance. These data are similar to a workforce scoping effort performed by the American Society of Pediatric Hematology-Oncology, which collected data from members and PHO departments from 2010 through 2021. In that study, approximately 70% of PHO physicians reported working in hospital-based urban academic settings⁹  and spending, on average, only 60% of their time on clinical care activities.²¹  Most PHO physicians pursued academic career trajectories balancing clinical care, education, and research. Participation in clinical research is intertwined with the practice of PHO,²²  and systematic clinical research requires significant institutional support, most often found in an academic setting.^23,24 

The high rates of work within academic facilities in urban areas mentioned previously are reflected in the disparities in geographic distribution of PHO subspecialists when the workforce is limited to subspecialists in the United States (Fig 1). In June 2023, there were an average of 54.5 current board-certified PHO subspecialists per US state (range, 0–327), which translates to 3.8 PHO subspecialists per 100 000 children aged 0 to 17 years (range, 0.0–34.2) across the United States.²⁵  Analyses from 2019 showed the average driving distance to a certified PHO subspecialist was 19.0 miles; distances ranged from a low of 5.8 miles in Rhode Island to a high of 125.3 miles in Wyoming (excluding Alaska, Hawaii, Puerto Rico, and the District of Columbia).²⁶ 

Recent publications have highlighted differences in financial remuneration across pediatric subspecialties and in comparison with adult subspecialties.²⁷  The increasingly high rates of education-related debt may impact an individual’s choice to pursue a subspecialty and, if so, which one.²⁸  Approximately 38.6% of current PHO fellows owe $200 000 or more compared with 39.5% for all pediatric subspecialty fellows, based on results from the ABP’s Subspecialty In-training Exam Survey in 2022 (personal communication, ABP, February 20, 2023). Recent studies highlight the negative financial return of pediatric subspecialty fellowship training in general²⁹  and the lower compensation in PHO relative to 7 other pediatric subspecialites.³⁰ 

PHO experienced a steady increase in the number of fellowship programs, available positions, and applicants from 2008 to 2018.¹⁰  Recent data suggest that growth has peaked and may be declining. The annual snapshot data from the ACGME demonstrates growth of 13.2% in US-accredited programs from 68 (2012–2013) to 77 (2021–2022).¹⁰  Over the same time, the total number of first-year fellows, including individuals who accepted positions before or after the match, remained the same (160 in 2012 to 161 in 2022). This suggests a stable entering workforce. However, looking at those fellowship positions filled during the match, there has been a decrease from 90% of positions filled in 2017 to only 75.6% of positions filled in 2021.¹⁰  A significant factor contributing to this decline was a decrease in the proportion of IMGs from 31.6% of all PHO fellows in 2017 to only 23% in 2020 because of federal immigration policy and COVID-19 pandemic limitations on the health care workforce.³¹  This may also be affected by several additional factors, including future compensation and perceptions about job availability.³² 

Among the 466 postgraduate year level 1–3 PHO fellows in standard, noncombined US fellowship training programs during academic year 2022–2023, 68.7% identified as female and 31.3% as male, reflecting the trend toward a majority female workforce. Of fellows in training programs, 57.7% were AMGs with an MD degree, 13.5% were AMGs with a DO degree, 15.2% were IMGs with an MD degree, and 8.6% were IMGs with an international degree, with a substantial shift toward AMG with a DO degree. Self-identification of race and ethnicity indicates that 56.3% of PHO fellows identify as White and 22.0% as Asian. Approximately 13% identified themselves as from a URiM background, an increase compared with the 10% of currently board-certified PHO physicians. Fellowship program size and location are distributed similarly to the PHO currently board-certified physicians (Fig 1).

The details of the model development are presented in the accompanying article by Fraher et al.³³  In brief, the ABP Foundation, in collaboration with 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 Modeling and Analysis Ltd., used a microsimulation approach incorporating data from multiple sources to account for individual provider, current subspecialty workforce, and geographic characteristics to predict the PHO physician workforce aged ≤70 years from 2020 through 2040. Workforce projections presented in the model and below are expressed in headcount (HC) (absolute numbers) and clinical workforce equivalent (CWE), which is HC adjusted by the reported proportion of time spent in direct clinical or consultative care (eg, patient billing and charting with or without trainees) per 100 000 children aged 0 to 18 years. Ten alternative scenarios were created to explore the potential impacts of changes in factors, including workforce entry through fellowship training, workforce exit and reentry, and time spent on clinical activities. The model also takes into account changes in the child population at the national and subnational level based on the US Census Bureau³⁴ ; differences by subspecialty for Census regions are discussed in the summary article of this supplement.³⁵ 

The model is publicly available online as an interactive data visualization tool.³⁶  Details of scenarios and 95% confidence intervals for all estimates are provided in Tables 1–2 and in the interactive online tool. Next, we discuss the scenarios most relevant for PHO. 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.

The model predicts growth in the PHO physician workforce at baseline through 2040 and in several alternative scenarios. The baseline scenario predicts an 89% growth in the HC of PHO physicians from 2460 in 2020 to 4641 by 2040 (Table 1). When the model is adjusted for CWE per 100 000 children, the predicted workforce growth is 66% by 2040 (Table 2).

Alternative scenarios, including varied clinical time or extreme changes to fellowship training size, had appreciable impacts on workforce growth in both the short and long term. Increasing or decreasing clinical time by 7% resulted in projections that are +12% and –11% different from the baseline, respectively, by 2040 for CWE per 100 000 children. Similarly, increasing or decreasing the size of the fellowship pathway by 12.5% resulted in a difference in growth of +7% and –6% from baseline to 2040 for CWE per 100 000 children. The combination of best- and worst-case scenarios resulted in a difference in growth of ±18% from baseline by 2040. Alternative scenarios depicting changes in workforce exit or smaller impacts on the fellowship pathway size did not result in appreciable differences in the PHO physician workforce in 2040. However, they indicated short-term shortages would be present. The scenario with a 12.5% decrease in fellows seems most likely to occur in PHO based on the current perceptions of limited jobs, the financial outlook of the field, and increasing training requirements. If incoming fellows decreased by 12.5%, the projected supply of PHO physicians would decrease from +66% to +59%.

Similar to the overall national projections, the PHO model projects an increase in the workforce in each of the 4 US Census regions. However, even in 2020, the distribution of PHO physicians by census region or division was unbalanced. Figure 2 depicts the difference in the current and projected workforce in the Northeast region compared with the 3 other regions, forecasting a difference of 1.4 to 1.6 times greater in 2020 and 1.5 to 1.8 times greater in 2040.

A closer examination of the census divisions and inclusion of the alternative scenarios by HC and CWE per 100 000 children (Tables 1–2) suggests that by 2040, the New England Census division could have a concentration of CWE per 100 000 children 2.9 times higher than the Mountain division. This discrepancy may be problematic as the Mountain region’s child population growth is expected to increase 20% by 2040, whereas the child population in New England is projected to increase only 5% from 2020 to 2040.

The pediatric subspecialist workforce model provides a description of the current workforce and several potential future states. Overall, the model predicts that the US PHO physician workforce will grow between 2020 and 2040 and is most affected by scenarios that modify the amount of time physicians spend in clinical care. Geographic maldistribution is also a critical finding; the current PHO physician workforce is unequally distributed geographically with the heaviest concentrations in the Northeast and the model predicts that this disparity will grow. This finding is not unexpected because PHO care requires a multidisciplinary approach, often delivered in specialized children’s facilities commonly located in high-population urban areas. However, this approach results in differences in access to care nationwide. The geographic dispersion of PHO physicians within this model reflects the geographic location of dominant pediatric cancer treatment and research centers in the field. However, not all PHO physicians work specifically at these large institutions; 60.5% of graduating PHO fellows practice in the same state as their fellowship program,³⁷  suggesting that many graduates remain within the geographic reach of their training institution.

These and other observations from the data highlight opportunities for deliberate discussion and research focused on medical delivery systems to ensure a future workforce that is best able to care for our pediatric population.

Pediatric residency training is increasingly focused on ambulatory and inpatient general pediatric care settings, decreasing trainee exposure to the PHO subspecialty. This shift may directly affect future residents’ interest in the subspeciality as a career but may also decrease the general pediatrician’s comfort level with PHO-related care in their own practices. A lack of familiarity with PHO presentations, diagnoses, and treatments may increase subspecialist referrals, increasing subspecialist workload and disparities for patients with access barriers. Although this area needs further study, future residency curriculum designs may consider ways to include more outpatient PHO exposure to help prepare general pediatricians.

The employment perspectives of graduating fellows are of concern, both real and perceived.³²  Over the past 15 years, PHO fellows have extended their training into additional years focused on research or in a noncertified specialized clinical fellowship (eg, neuro-oncology, bone marrow transplantation, coagulation).¹¹  From 2015 through 2020, nearly 30% of PHO graduates remained in a training role for at least one year after graduation.^9,11  Other recent graduates fill hospitalist roles while searching for more permanent positions.⁹  These two options prolong the time fully trained PHO physicians are relatively undercompensated and decrease their total lifetime earning potential.²⁹  In a survey of graduating pediatric fellows in 2019 and 2021, <52% of graduating PHO fellows expected to get a job in their field, <38% expected jobs to be available in an academic center; only 26% thought they would be able to find a job where they wanted to live.³²  These responses were dramatically lower than other pediatric subspecialties and perceptions or realities regarding job availability may be a barrier to developing a future workforce. More recently, fellows and faculty have recognized that fellows are struggling to find jobs, leading to high levels of stress and anxiety experienced by fellows.³⁸  Providing additional tools and resources to fellows to guide them through the job search process is an area of current focus.

Only 10% of the PHO physician workforce identifies as URiM, lower than the 14.6% in general pediatrics. This does not reflect the diversity of the PHO patient population: the racial and ethnic diversity of the national childhood cancer population is similar to the overall population, which is ∼63% White, 11% Black or African American, and 20% to 22% Hispanic, Latino, or Spanish origin²² ; the population of the children with SCD is predominantly Black or African American.¹⁶  The increase in trainees from URiM backgrounds in the current fellowship cohort is a hopeful step forward, but the PHO subspecialty, as a whole, must continue purposeful actions to recruit and maintain a diverse workforce. Workforce diversity begins long before decisions are made around a specific pediatric subspecialty; therefore, support of the undergraduate, medical, and pediatrics training programs and models for equitable faculty advancement is needed.

In the model development, the modeling team used a measure of provider CWE per 100 000 children to account for (1) the pediatric population distribution and (2) nonclinical responsibilities that go unrecognized in a straightforward HC assessment. The importance of such adjustment is seen in the substantially reduced predicted growth of the PHO physician workforce from 89% (HC per 100 000 children) to 66% (CWE per 100 000 children) between 2020 and 2040. The model’s alternative scenarios that adjusted physician clinical time showed an even greater impact on the future workforce. Formal administrative (eg, committees, leadership) and quasi-administrative (eg, electronic health record, insurance prior authorization, care coordination) duties are a growing national concern across all physician specialties because they are associated with dissatisfaction and burnout.^39,40  This model provides quantitative evidence that time spent on other duties directly translates into a smaller workforce dedicated to direct patient care.

As noted previously, this subspecialty includes care of children with cancer or nonmalignant blood disorders because of historical events. Over time, the needs of children with nonmalignant blood disorders, such as SCD, thalassemia, or coagulation disorders, have diverged from those of children with cancer, whereas assessment of the workforce does not distinguish between these cohorts. Children with SCD face multiple barriers to equitable care and frequently experience tremendous morbidity and mortality related to their disease process and the social drivers of health, including bias and racism.^41–43  A strong PHO workforce committed to hematology care is essential to providing equitable, high-quality care, evidenced-based care to children with SCD and other nonmalignant blood disorders.

Meanwhile, several factors are increasing clinical demand. Recent technological advances for diagnosis and treatment, such as immunotherapies and molecular targeting, require dedicated training and infrastructure development.^44–46  Even with technological advances, cancer remains a leading cause of childhood death. All PHO clinicians are familiar with end-of-life care and some focus their clinical time in this field, although the actual impact of this focus on time for other clinical care is unknown. Despite the multidisciplinary nature of PHO clinical management, care coordination falls heavily on the PHO team because of the frequent involvement of clinical trials and specialized therapies. Furthermore, the PHO patient population generally extends to young adults with cancer and hematologic disorders during active treatment,⁴⁷  involves transition to adult subspecialists,⁴⁸  and supports life-long cancer survivor follow-up.⁴⁹  These findings are compelling given an increasing patient population, yet PHO physicians’ perception of the job market is not optimistic.³² 

As noted, the PHO subspeciality has placed significant value on research during fellowship training and in academic employment metrics. This emphasis favors the recruitment of trainees to highly research-focused academic institutions, potentially contributing to the observed geographic disparities, delayed career starts, and waning interest in the subspecialty. Of additional concern is the mismatched expectations that training at such facilities will be followed by employment in those or similar facilities.⁵⁰  However, employment options may include smaller community settings, leading to poor job satisfaction⁵¹  and overall exit from the workforce. This situation presents an opportunity for the ACGME and other accreditation bodies to influence training programs. There is potential for creating clinically focused training programs that eliminate or significantly reduce the focus on research and potentially decrease training time. Such programs could be located at smaller institutions and in geographic areas with lower PHO physician concentration to provide an opportunity for these institutions to recruit and retain physicians and increase access for their local patients.

This model’s use of the CWE per 100 000 children does not imply that this is the best measure of workforce-to-population ratio for optimal patient outcomes and workforce retention or even that there is a singular “best” number. A Canadian study explored the ratio of one full-time clinical equivalent physician for every 15 patients with a new cancer diagnosis⁵² ; however, this ratio has not been assessed in the US health care system. The impact of other factors, including the role of advanced practice providers, patient population needs, or significant clinical research efforts, are poorly understood as well. How clinical need is measured is an area of vital importance for future investigation if we wish to create a workforce that meets the needs of our patients. Future research also should focus on better understanding the evolving job market facing PHO fellows and the burden administrative tasks place on CWE, provider satisfaction, and burnout given the emotionally rewarding but challenging work with children and their families facing significant morbidity and mortality risks. Data on how these factors influence the PHO workforce are important to support the PHO workforce as it cares for its growing patient population.

The paucity of data regarding workforce efforts directed toward cancers vs nonmalignant blood disorders is a limitation of the current modeling project and the data used to inform it, which can be addressed in future workforce research. A survey of adult hematology and oncology fellows found that exposure to the field of hematology and strong mentorship were positively associated with pursuing a hematology-focused career.⁵³  Given the financial considerations for aspiring pediatric hematologists and oncologists, future PHO workforce surveys⁹  should attempt to collect data in such a way as to further our understanding of the current state and barriers for careers in pediatric hematology and/or oncology. More nuanced data will inform training, education, practice, and policy needs for the PHO workforce and all the children it serves.

PHO is constantly evolving and changing the lives of the patients and families it affects. This article, one in a series exploring the current and potential future pediatric subspecialty workforce, provides new data in the hopes that we can drive education, policy, and research toward even better care of our pediatric population while supporting the members of the workforce. The model presented here depicts a PHO workforce with increasing geographic maldistribution. Nonclinical activities such as research and administrative responsibilities limit the physician workforce available to provide clinical care. These tangible challenges can be overcome through dedicated efforts by the subspeciality and supporting regulatory agencies.

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

ABP

American Board of Pediatrics

ACGME

Accreditation Council for Graduate Medical Education

AMG

American Medical Graduate

CWE

Clinical workforce equivalent

DO

Doctor of Osteopathy

HC

Headcount

IMG

International Medical Graduate

MD

Doctor of Medicine

PHO

Pediatric hematology-oncology

SCD

Sickle cell disease

URiM

Underrepresented in medicine