Two pediatric fellows start on the same day, both entering three-year subspecialty training. One is preparing for a career in pediatric emergency medicine, where clinical intensity is immediate, unpredictable, and continuous across shifts. The other is drawn to medical genetics, a field increasingly defined by molecular diagnostics, gene-targeted therapies, and collaboration with biotechnology. Their future work will look fundamentally different. Their training, however, follows nearly the same structure and duration.
This uniformity reflects historical design more than present-day need. Most pediatric subspecialties default to three years of fellowship, a structure that took shape in the 20th century to standardize training and reinforce academic credibility. While that goal was reasonable, the assumption that time-based uniformity equates to appropriate preparation is increasingly difficult to defend. Subspecialties now vary widely in clinical intensity, research expectations, and workforce demand, yet the training model has remained largely unchanged.
The differences between fields are not subtle. Pediatric emergency medicine functions as a frontline access point for acute care, with high patient volume, rapid decision-making, and a constant need for diagnostic efficiency under uncertainty. Workforce discussions within organizations such as the American Academy of Pediatrics and the American College of Emergency Physicians have highlighted ongoing concerns around crowding, throughput, and clinician burnout in emergency settings. In contrast, fields such as medical genetics face a different challenge. A 2020 workforce report estimated that the U.S. has fewer than 1,500 board-certified medical geneticists, with demand projected to grow as genomic testing and rare disease therapeutics expand. These fields are not simply variations of the same career. They represent distinct professional archetypes that require different forms of preparation.
The current training model does not fully account for this divergence. In clinically dominant fields such as pediatric emergency medicine, extended research requirements may not align with the responsibilities graduates ultimately assume. Surveys of pediatric subspecialists have shown that a substantial proportion of fellows entering clinical careers do not continue research as a major component of their work, raising questions about how training time is allocated. At the same time, research-intensive fields may require deeper or more integrated scientific training than a fixed three-year structure can provide, particularly as translational science becomes more closely linked with industry. There is also a growing set of hybrid roles that fall outside traditional categories. Pediatricians commonly work in the arenas of informatics, quality improvement, and systems leadership. These roles are central to how care is delivered in modern health systems, yet they are rarely formalized within fellowship training. Many physicians acquire these skills informally, often after completing training that was not designed with these competencies in mind.
The consequences of this misalignment extend beyond structure. They are economic and behavioral. Pediatric subspecialists earn significantly less on average than their adult counterparts. Data consistently show lower compensation across pediatric subspecialties, often by hundreds of thousands of dollars annually. At the same time, fellowship delays entry into peak earning years. Analyses of physician career earnings have demonstrated that each additional year of training carries a substantial lifetime opportunity cost, particularly when compounded by educational debt. For trainees weighing career options, these factors are not theoretical. They influence specialty choice, subspecialty selection, and long-term retention.
Workforce trends reflect this pressure. The NRMP commonly reports unfilled positions in several pediatric subspecialties, including fields with significant clinical need. While multiple factors contribute to this pattern, the structure and duration of training are part of the equation. When training pathways feel prolonged and misaligned with eventual roles, they can deter otherwise interested candidates. Clinical practice is also evolving, though unevenly, with increasing use of decision support tools and data-driven workflows. These changes reinforce a simple point. Training should prioritize the skills physicians will actually use, rather than assuming that a fixed period of time will produce them.
A more durable approach would move toward differentiated, competency-based pathways. A clinically focused track could allow trainees to progress once they demonstrate mastery in rapid decision making, procedural skills, and team leadership, rather than requiring a fixed duration. A research and innovation track could offer extended or flexible training with structured integration into translational science and industry partnerships. A hybrid pathway could formalize training in informatics, quality improvement, and health system leadership, preparing physicians for roles that are already essential but insufficiently supported. These pathways would not lower standards. They would clarify expectations and align training with real-world roles. Competency-based medical education has already been adopted in other areas of training, with organizations such as the ACGME promoting milestones and entrustable professional activities as frameworks for progression. Extending this approach to fellowship structure is a logical next step.
Implementation will require careful coordination. Accreditation bodies, specialty boards, and training programs will need to allow flexibility while maintaining rigor. Pilot programs in selected subspecialties could test differentiated tracks, with outcomes informing broader adoption. The goal is not to dismantle the current system, but to refine it so that it reflects both present realities and future demands. Pediatrics has long defined itself by its commitment to thoughtful, patient-centered care. That same commitment should extend to how the field trains its physicians. A uniform training model may once have served that purpose. Today, it risks obscuring important differences, delaying professional development, and discouraging entry into fields that are already under strain. A more intentional approach would better serve trainees, the workforce, and ultimately the children who depend on both.
Do you think it’s time to move beyond the three-year fellowship model? Share in the comments.
Dr. Chris Horvat is a pediatric intensivist, clinical informatician, and learning health systems researcher in Pittsburgh, PA. His path to medicine began as a contractor in the high-purity quartz mines of western North Carolina, likely making him the only informatician who once helped extract the raw materials powering today’s digital workflows in health care. Dr. Horvat is a 2025–2026 Doximity Op-Med Fellow.
Illustration by Jennifer Bogartz
