Driving myself to a practice subspecialty exam, I wondered whether I had finally grown icy to the perennial medical training stick-more-than-carrot of board exams. I wondered why a subspecialty practice exam cost $160 and required proctoring at an outside site, even as my general boards practice exams were done without a fee, during resident school, and proctored by one of my attendings. The smoke and mirrors of pediatrics subspecialty certifications had reached their climax for me and seemed to suggest yet another reason why we have a shortage of pediatric subspecialists.
The American Board of Pediatrics (ABP) mandates that all pediatrics fellowships be three years in duration — everything from hematology oncology to adolescent medicine. This is despite pediatric subspecialties being among the lowest paid fellowships and three year fellowships typically representing surgical subspecialties. Unlike other specialties, subspecialty care often leads to lower salaries than general pediatricians. For example, based on public data, a pediatric oncologist at one state academic hospital posts an assistant salary of $135,000, while a general pediatrician at the same hospital has a salary of $159,000, despite the former having endured at least another three years of training and likely more for research requirements often demanded by pediatric oncologists. In contrast, a general internal medicine physician makes around $242,190 and the median salary for an adult oncologist in 2021 was $481,250, meaning that subspecialty training nearly doubled one’s annual salary. On a Doximity report released this year, the lowest paying subspecialties were pediatric subspecialties.
Pediatric subspecialties perhaps not coincidentally also have a physician shortage. The state of New Mexico, where I trained for residency, had no developmental pediatricians and one adolescent-boarded pediatrician. Adolescent medicine, the field in which I train, only recruits around 30 physicians a year to elect for subspecialty training. This creates harm for both patients and trainees. Patients do not have the ability to receive subspecialty care, leaving the bulk of care on already overtaxed primary care physicians, and pediatric trainees are left with few incentives to pursue passions that prolong being paid a trainee’s salary and delay life events such as becoming married and starting a family.
The history of pediatric subspecialties has not always been so rigid. The pediatric hospitalist fellowship only recently affected residents graduating after 2019. For those who graduated residency after 2019, there was no longer an opportunity to sit for boards after a qualifying number of hours to become board certified in hospital medicine. One had to instead complete a three year hospital medicine fellowship. This was despite concerns from trainees that after residency — a time when a pediatric resident works around 80 hours a week in a hospital system — additional training did not seem to suggest a particular additional benefit. Arguably, one is most qualified to work as a hospitalist immediately after the rigorous demands of postgraduate medical education.
Furthermore, the costs of obtaining and maintaining additional board certification through the ABP are an additional barrier. The general pediatrics boards already cost trainees $2,265, as compared to a generally higher paid internal medicine generalist whose boards cost $1,430, nearly a thousand dollars less. The general boards are required for subspecialty boards, which in pediatrics costs $2,900 in 2023. Meanwhile, the pass rate of the general pediatrics boards in 2022 is around 80% based on the bell curve (they have not posted this officially, though a program director tweeted about it earlier this year). For general internal medicine, the pass rate is 87% (between 87%-93% since 2018). This means that it is already more difficult to become a board-certified general pediatrician (board certification is typically required in academic institutions as well as for increased salaries and promotions), compared to general internal medicine counterparts who pay less for their boards, have higher starting salaries, and pass at higher rates. Pediatricians who do not pass need to pay hefty fees associated with repeating boards, and general boards are also necessary for writing subspecialty boards which are often not offered every year. Failing general boards could prolong one’s certification in a subspecialty board associated with increased pay and leadership. Prolongation of board certification may be particularly difficult as trainees are navigating their early-mid 30s, a time where people elect to start families or may have to care for aging parents or other loved ones. In fact, in an early 2000s survey of pediatric residents and their desire for subspecialty training, 63% of women did not desire subspecialty training primarily for family planning reasons in a field that is 75% women.
The current system of pediatric subspecialty recruitment is not working. In 2021, 22.5% of programs did not fill for a pediatric subspecialty. There are pediatric subspecialty departments at academic institutions who did not recruit a single trainee.
We need to think more broadly about how to build up a subspecialty workforce in an increasingly complicated world for young people. Having qualifying hour-based certification for some subspecialities or even a non-academic shorter track may be some low-hanging fruit to recruit more clinicians. Condensing many pediatric subspecialties from three to two years and targeting loan repayment for pediatric subspecialists has been suggested in the past, as most pediatric subspecialties were noted to be a poor financial decision. Attempting to create more fellowships or prolong training (such as in the case of hospital medicine) seems counterintuitive. Retention of subspecialty clinicians is more complicated: pediatrics typically gets reimbursed at much lower rates than their adult counterparts, despite being the first link to overall cost-saving measures for public health. Having reimbursement occur with public health gains such as preventive care may take more seismic shifts in the health care landscape, but would certainly raise the compensation of pediatric subspecialists.
Pediatrics has always had a reputation of attracting some of the most compassionate advocates in medicine. It also has the reputation for being inclusive. Medicine has demonstrated in the last decade it can be changed by larger cultural movements: White Coats for Black Lives, DEI initiatives, the change of Step 1 to pass/fail. The current structure of pediatrics board subspecialty training is still contingent on the fact that a combination of one’s good will and financial stability are enough to maintain supply of these clinicians — a center which cannot hold.
How would you restructure pediatric subspecialty training?
Megana Dwarakanath is a third-year adolescent medicine fellow in Pittsburgh where she lives with her husband, Rahul, their young daughter, Meera, and their dog, Milo. When she is not spending time with friends and family, she likes to run, swim, and bike as well as read for as long as she can in one go. Dr. Dwarakanath is a 2022–2023 Doximity Op-Med Fellow.
Animation by Jennifer Bogartz
