Diversity, Equity, and Inclusion, Child Health, and the Pediatric Subspecialty Workforce

Regarding the race and ethnicity minority (minoritized) population, 26% of children 0 to 17 years of age in 2021 identified as of Hispanic, Latino, or Spanish origin (Latino), 14% as Black or African American (Black), 5% as Asian, 1% as American Indian or Alaska Native (AI/AN), and 5% as multiracial.¹¹  Moreover, 1 in 4 children live in an immigrant family, defined as children with at least 1 parent born outside the United States.¹²  Currently, 50% of immigrants are from Latin America and 25% are from Asia.¹³  The US Census Bureau estimates that, by 2060, 2 in 3 children in the United States will identify as Latino, Black, Asian, AI/AN, Native Hawaiian or Other Pacific Islander, or multiracial in origin and 1 in 3 will live in an immigrant family.¹⁴  These sociodemographic variations are reflected in the diversity of languages spoken by US children.¹⁵ 

Data from 2019 to 2022 suggest that ∼20% of US children have special health care needs.¹⁶  Approximately 10% of US adolescents self-identify as sexual- and gender-diverse (SGD).¹⁷  Nearly 12 million children grow up in rural areas.¹⁸  Data from 2021 indicate that 16.9% of children live in poverty.¹⁹  Children from Black, Latino, or AI/AN communities are more likely to live in poverty compared with an aggregate of all US children, revealing how different dimensions of diversity may potentiate one another.²⁰ 

Inequities in the frequency and outcomes of pediatric conditions cared for by pediatric subspecialists have been identified on the basis of race and ethnicity,²¹  socioeconomic status,^22–24  rural geography,^18,25  SGD self-identification,²⁶  community resources,²⁷  and disability.²⁸  For example, statistically, Black infants in the NICU have an increased risk of morbidity and mortality relative to all other racial or ethnic groups,²⁹  children living in poverty have increased asthma morbidity and mortality,³⁰  and children from the SGD community experience stigmatization and often face significant mental health obstacles.³¹ Table 1 provides further data regarding inequities in the occurrence and treatment of several conditions cared for by pediatric subspecialists. These health inequities may begin in early childhood, be amplified by adverse childhood experiences, including racism and discrimination, and contribute to poor health outcomes in adulthood.^32,33 

The social–ecological model of health is frequently used in health promotion to acknowledge the complexity of patients’ and their families’ lived experiences and their impact on health.³⁴  This model conceptualizes health as the complex interaction of individual characteristics, interpersonal interactions, and community and societal factors. Although medicine can influence ∼16% of overall health, drivers outside of medicine have a more significant influence on the health of the children it serves.³⁵  Recent focus on health over the lifespan highlights how health risks and conditions in childhood often influence adult health^32,36–38  and serves as a reminder that the long-term health of our nation depends on how we care for its children. The model acknowledges that our society, as a result of our nation’s history, continues to perpetuate racial and ethnic, cultural, geographic, disability, sex and gender, and socioeconomic discriminations, leading to health inequities. Considering the social–ecological model in clinical care can help us move beyond “race-based medicine”³⁹  and other forms of discrimination by attending to the system and societal structures that can preferentially benefit and disenfranchise individuals from certain communities.

Greater diversity in the medical workforce has been linked to higher quality of care.⁴⁰  Physician–patient racial concordance is associated with decreased morbidity among Black newborns, improved patient–provider communication, and increased medication adherence in adult populations.^41–43  However, actualizing this goal of greater diversity requires understanding the current status of the career pathway into the pediatric subspecialties from medical school through fellowship, pediatric subspecialist retention, and leadership development, as discussed below.

A diverse pediatric subspecialty workforce begins well before medical school. However, many barriers exist for individuals from populations experiencing discrimination to pursue a career as a pediatric subspecialist. The pathway to medical school is long and requires significant support at each stage of the journey. Unfortunately, not all children have equal access to the social and financial resources, educational, volunteer, work opportunities, or mentorship necessary to dream of becoming a pediatrician, let alone realize their dream by attending college and medical school.

Given the substantial financial barrier that entering medical education represents, it is critical to consider the socioeconomic diversity of medical school applicants and matriculants. The representation of medical student applicants from households with an annual income of ≥$200 000 increased from 2014 to 2019, whereas individuals from households with <$75 000 income have decreased.⁴⁴  Individuals from households in the highest income bracket had twice the odds of acceptance to medical school relative to individuals from households in the lowest bracket.⁴⁴  Socioeconomic diversity can intersect with other dimensions of diversity, including race and ethnicity. Individuals identifying as Black or Latino have the most educational debt^45,46  and frequently have less generational wealth.⁴⁷  This has the potential to deter such individuals from pursuing these careers due to financial obstacles.⁴⁸ 

Additional data reveal that for racial and ethnic minority students, multiple barriers exist in pursuing a career in medicine beyond the cost of education, including lack of exposure to medicine, limited mentorship, inadequate education preparation, and “stereotype threat,” defined as an internalized feeling of not being able to succeed.⁴⁹  These barriers have led to a situation in which gains in racial and ethnic diversity within medicine have largely stalled. In the past 4 decades, medical school matriculant gains from racial and ethnic minority groups have been incremental, at best, and have, in the worst case, decreased. Over a 4-decade period, women identifying as Black or Latino experienced increased matriculation into medical schools from 3.6% to 4.4% and 0.7% to 3.2%, respectively. Among men, there was a slight decrease among individuals identifying as Black (3.2% to 2.9%), whereas the representation of individuals identifying as Latino remained stagnant.⁵⁰  For AI/AN students, although medical school matriculants increased from 1996 to 2017, the number of medical school graduates did not.⁵¹  These matriculation and graduation statistics further reinforce the current state in which the overall physician workforce does not represent the racial and ethnic diversity of our nation or its children.⁵⁰  Additionally, they do not capture the negative experiences of racism and discrimination students who identify as Black, Latino, or Asian may experience throughout their training, career, and personal lives.^52,53 

Challenges also exist across other dimensions of diversity, as experienced by international medical graduates (IMG), women, SGD individuals, and individuals living with disabilities. For IMGs, additional barriers include a lower probability of being selected for residency interviews despite higher US Medical Licensing Examination scores, restrictive immigration policies, the availability of residency training positions for IMGs, and antiimmigrant racism.⁵⁴  Of note, despite being US citizens, Puerto Rican applicants to residency programs face the same biases as IMGs, despite the national need for more Latino physicians, including subspecialists and faculty.⁵⁵  Women have made tremendous strides at earlier stages of the pediatric subspecialty pathway. According to 2019 Association of American Medical Colleges (AAMC) data, women represent more than one-half of medical school matriculants, as well as the majority of pediatric residents, and have an increasing representation in the pediatric subspecialty workforce.^56,57  However, inequities emerge at more distal points along the career pathway. Women face discrimination and bias, are less likely to have leadership positions, and encounter barriers to academic productivity.^58,59  Individuals from the SGD community also face obstacles in identifying mentors, fear of sharing identity with peers and colleagues, poor visibility of SGD faculty during medical school, and concerns about discrimination and bias;⁶⁰  however, robust data are lacking for medical school applicants and matriculants who self-identify as SGD. This underscores the need to understand SGD applicants’ experiences better and support them through the medical school admission process.⁶¹  An additional dimension with little available information is individuals with disabilities.⁵⁸  Anecdotally, this community faces barriers in identifying and accessing reasonable accommodations during medical training.

According to data from the American Board of Pediatrics (ABP) from academic year 2022 to 2023 for all fellows across the 15 pediatric subspecialties certified by the ABP (n = 4728, Table 2), gender composition was 27.9% male and 71.9% female. A total of 4 individuals did not disclose their gender and 2 self-identified as nonbinary. Only 16.8% of fellows across the 15 subspecialties identified as underrepresented in medicine (URiM).⁶²  Of the URiM categories, 5.2% identified as Black, 8.9% identified as Latino, and ∼0.1% identified as AI/AN or Native Hawaiian or other Pacific Islander.⁶²  Those identifying as Asian comprised 22.0%; a little more than one-half (52.5%) of all fellows identified as white.

The ABP also collects data on medical school location and degree type. Most (61.5%) were American medical school graduates (AMGs) with a Doctor of Medicine (MD) degree, 12.8% were AMG graduates with a Doctor of Osteopathy (DO) degree, 13.7% were IMGs with an MD degree, and 6.8% were IMGs with an international degree, such as Bachelor of Medicine, Bachelor of Surgery. The remaining 3.4% had an unknown degree. No data were available with respect to disability status.

Table 2 reveals these variables for each pediatric subspecialty. Most displayed similar proportions by gender, reflecting the increasing numbers of women entering pediatrics. Adolescent medicine had the highest representation of individuals who identify as URiM. Several subspecialties included higher proportions of IMGs than others.

Among certified pediatric subspecialists (n = 28 280, Table 3) in 2023, 63% identified as female, slightly less than the current fellowship cohort. Although women represent more than one-half of the pediatric subspecialty workforce, this representation does not translate into more women in leadership roles.^58,59  Survey data from pediatric department chairs published in 2015 revealed that women held only 33.6% of division head, 37.7% of vice chair, and 26.2% of chair positions.⁵⁸  Women may face parenting and household management pressures not expected of their male partners, which can impede professional growth, as highlighted during the coronavirus disease 2019 (COVID-19) pandemic.⁶³ 

ABP data from 2018 to 2023 reveals that, among the current subspecialty workforce, 4.9% identify as Black, 6.0% identify as Latino, 0.1% identify as AI/AN, 60.8% identify as white, and 19.7% identify as Asian. The proportion of individuals from URiM backgrounds among the current workforce is lower compared with the recent fellowship cohort, suggesting growing URiM representation in future pediatric subspecialists.

ABP data from June 2023 reveal that 70.6% of pediatric subspecialists are AMGs with an MD degree, 5.3% are AMGs with a DO degree, 13.7% are IMGs with an MD degree, and 10.40% are IMGs with an international degree, suggesting there are more DOs and fewer IMGs with international degrees entering pediatric subspecialty fellowships. DOs are increasing in numbers across pediatrics, including the pediatric subspecialties.⁶⁴  IMGs contribute significantly to the pediatric subspecialty workforce, comprising 25.4% of pediatric subspecialties overall⁶⁵  and a substantial proportion of the gastroenterology, nephrology, endocrinology, and hematology–oncology pediatric subspecialty workforce.^66–69  Despite the role of IMGs in providing subspecialty care, IMGs who are not US citizens face numerous policy barriers, including work and length of stay limitations and administrative delays.⁷⁰ 

Data from the pediatric department chairs survey in 2015 revealed that <1% of residents, fellows, and faculty self-identified as SGD, including 1% of division heads, 2.0% of vice chairs, and no department chairs. This same data set revealed little representation of individuals with physical disabilities in Departments of Pediatrics.⁵⁸ 

The 2003 National Academies of Medicine report, Unequal Treatment, recommended increasing the racial and ethnic diversity of the health workforce.⁷¹  Two decades later, little progress has been made.⁷²  The murder of George Floyd in 2020, the negative health impact on Black and Latino communities of the COVID-19 pandemic, and anti-Asian rhetoric⁵³  cumulatively prompted a heightened awareness of the impact of racism and discrimination on children and their families and the medical workforce. Yet, 2 recent US Supreme Court cases, “Students for Fair Admission Inc v President and Fellows of Harvard College” and “Students for Fair Admission, Inc v The University of North Carolina,” underscored a wavering national commitment to addressing racial injustices, at least at the governmental level. Recent legislation at the state level has further challenged a commitment to an evidence-based approach toward children who may be exploring their sexual and gender identity. These actions stall progress toward health equity and diversity in the workforce.

In preparation for this article, the authors applied the Strength, Weaknesses, Opportunities, and Threats framework to organize our view of DEI in pediatrics, analyze the current situation, and inform future directions (Table 4). In our analysis, a major strength of current DEI efforts among the pediatric subspecialty workforce is the intentional focus on and support of multiple pediatric-focused institutions and entities. Many pediatric departments have developed programs to increase diversity among trainees, educators, researchers, and general and subspecialty clinicians. The ABP, AAP, Academic Pediatric Association (APA), American Pediatric Society (APS), Association of Pediatric Program Directors, Society for Pediatric Research, and Association of Medical School Pediatric Department Chairs have all affirmed their commitment to DEI.^2,5,73–75  Weaknesses continue to include a lack of awareness of the extent of racism and discrimination across several dimensions of diversity and complacency with the status quo. Potential external opportunities build on established efforts among national organizations to diversify the pediatric subspecialty workforce and address pediatric health inequities. Potential external threats to current DEI efforts stem from rising political opposition, insufficient acknowledgment of the history of racism and discrimination in the United States, and antiimmigration and SGD policies, all resulting in inaction and regression from previous advances in health care for all children.

The diversity of the nation’s children is increasingly recognized as is the need for a pediatric subspecialty workforce highly attuned to their evolving health needs. Although this workforce is small compared with the adult subspecialty workforce, it remains an integral part of efforts to improve pediatric health equity now and adult health equity in the future. Supporting this workforce will require dedicated attention, given that market forces and current social movements in the United States may not support enhancing DEI.⁸  The recommendations below address specific changes in training and education, practice, policy, and workforce research to improve child health equity.

The future pediatric subspecialty workforce will only partially represent the diverse and varied experiences of the patients and families it serves. To address this reality, it is important to ensure that educational opportunities regarding health equity and culturally appropriate care are offered across the career pathway of medical students, residents, fellows, and pediatric subspecialists.⁴⁰  A single-site study of clinical experiences in underserved communities revealed that (1) residents who participated were more comfortable using interpreters and discussing cultural issues, (2) attending physicians were more likely to believe cultural bias affects care, and (3) both residents and attending physicians felt that didactic training in cultural competency was inadequate to preparation for work in underserved communities.⁷⁶  Training in cultural humility and health equity could begin in medical school and continue during training and through continuing education and lifelong learning activities for pediatric subspecialists, such as maintenance of certification.^2,10,77  Available resources and experiential learning opportunities could be better leveraged and made available to individuals, residency programs, and institutions to foster lifelong learning regarding DEI and its implications for pediatric health equity.

In addition to educational innovations, other tools could be employed.⁴⁰  Mentorship programs specifically designed for residents could be used to introduce trainees to the numerous career trajectories within the pediatric subspecialty workforce and provide faculty and peer mentorship.^78,79  Intentional, data-informed steps could be taken to recruit, retain, and support junior faculty who are underrepresented in academic medical centers and more midcareer subspecialities in achieving leadership positions.⁸⁰ 

Steps should be taken to ensure that children and families seeking pediatric subspecialty expertise receive care that promotes health equity. This involves actively studying barriers to care experienced by patients and families from diverse backgrounds. Although cultural- and linguistic-appropriate services are required for programs receiving federal funding, a study examining interpreter use in the pediatric emergency department for families whose preferred language is not English revealed that a little more than one-third of encounters involved professional interpreters and only 11% of encounters for procedures involved professional interpreters.^81,82  Efforts are needed to both document disparities and employ quality improvement methodologies to intervene to address these inequities. Such efforts could incorporate published guidelines and expectations regarding the care of patients from diverse backgrounds along diversity dimensions of race and ethnicity, SGD, and immigration status.^13,83,84  Increased awareness and implementation of these tools into current practice could move pediatric subspecialty care a step closer toward health equity.

Policy interventions at multiple levels and involving invested entities should be considered. Although the COVID-19 pandemic put children’s health at risk, a robust federal response to increase and maintain enrollment in Medicaid improved access to health care, including subspecialists. The gains in coverage among children, especially in states that had not expanded Medicaid, are currently at risk.⁸⁵  Vigorous advocacy for Medicaid expansion should continue, given the importance of insurance coverage in children’s access to subspecialty care.⁸⁶  In addition to ensuring insurance for children, policies encouraging health systems to screen for and address SDoh will be important, given the influence of factors outside of the clinic or hospital on child health.^87,88 

Policy efforts that address barriers to pediatric subspecialty training and practice would aid in addressing the diversification of the pediatric subspecialty workforce. Data revealing that annual household income is positively associated with medical school acceptance⁴⁴  suggest the need for a holistic medical school admission process and access to opportunities well before application to medical school. This process would allow selection committees to better understand the individual context of the applicant and account for differential access to experiences and opportunities due to differences in financial circumstances. Efforts to reduce the cost of medical school through tuition-free medical schools or the reduced duration of medical school could also be considered. The pediatric specialty loan repayment program from the US Department of Health and Human Services is a step toward decreasing the debt burden for those who undertake pediatric subspecialty training. However, the limited number of awardees (150 in fiscal year 2023) is unlikely to change the financial calculation for many individuals; some of the work requirements may limit applicability to pediatric subspecialists who see patients and also engage in education, quality improvement, administration, and research.⁸⁹  Additionally, Medicaid payment parity⁹⁰  with Medicare could substantially improve pediatric subspecialty compensation relative to adult subspecialty and reduce the negative lifetime earning potential that most pediatric subspecialty training represents.⁹¹  Policy interventions that recognize and support the contributions of IMGs in the pediatric subspecialties^66–69  include expanding work locations and length of stay and processing time of visas.⁷⁰  Finally, as medical entities invest and promote DEI in the workforce at large, it will be important to revisit the AAMC’s definition of “underrepresented in medicine” and consider including individuals who self-identify as SGD in that definition.⁶¹ 

The need for robust data on child health inequities continues and for interventions to address them. Up-to-date data on child demographics and characteristics, geography, health needs, access, and outcomes will be necessary to guide the implementation of care and community prevention models to improve health and mitigate disparities and efforts to enhance training. Reliable and uniform collection of SDoH data would help these efforts further. As interventions in response to data are developed, quality improvement and implementation science methods can be applied to test interventions, monitor progress, and ensure that interventions are not inadvertently worsening existing inequities.⁹² 

National surveys to understand the composition and experiences of the current pediatric subspecialty workforce should continue. An important variable to monitor is the educational debt faced by recent fellow graduates due to the asymmetric burden placed on minoritized individuals. Future research should also evaluate the Pediatric Specialty Loan Repayment program. Data on the representation of providers from the SGD and IMG communities should continue to be collected in a non-stigmatizing and confidential manner. A better understanding of the representation of individuals with disabilities and neurodivergence should begin. Together, this information will provide a better understanding of the demographics of the pediatric subspecialty workforce, barriers faced, and opportunities to support the pediatricians who make up this workforce. Interventions concerning recruitment, training, education, and workplace environment improvements should be studied to determine what works. These interventions should not just target the pediatric subspecialist members of the care team but the myriad of other health care providers interacting with these children to provide their care.

As the US child population evolves and becomes more diverse, pediatric subspecialty training, care, policy, and research must adjust to meet the needs of all the children pediatricians aim to serve. Success in doing so will require a multipronged approach across all pediatric subspecialties, including (1) addressing the needs of our increasingly diverse child population through clinical care and research, (2) providing career development for the next generation of diverse pediatric subspecialty clinicians, researchers, and leaders, and (3) offering effective professional development on DEI topics. Medical history is replete with examples of systems and policies that created or reinforced racism, discrimination, and inequity on the basis of race and ethnicity, sexual and gender identities, immigration status, and disabilities. We have a tremendous opportunity and obligation to reconcile history and reverse its trends. Together, we can work to create an equitable workforce with diverse, culturally competent, family-focused pediatric subspecialists working with teams, including families, to eliminate inequities and provide experiences of respect and dignity, resulting in the highest quality of pediatric subspecialty health care.

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

AAMC

Association of American Medical Colleges

AAP

American Academy of Pediatrics

ABP

American Board of Pediatrics

AI/AN

American Indian or Alaska Native

AMG

American medical school graduate

APA

Academic Pediatric Association

APS

American Pediatric Society

COVID-19

coronavirus disease 2019

DEI

diversity, equity, and inclusion

DO

Doctor of Osteopathy

IMG

international medical graduate

MD

Doctor of Medicine

SDoH

social drivers of health

SGD

sexual- and gender-diverse

URiM

underrepresented in medicine