I speak to a desperate father on the phone. His daughter’s migraines are making her miss school but the earliest pediatric neurology appointment is six months out. A young teen likely needs growth hormone therapy but the pediatric endocrinologist isn’t available for another seven months. An exasperated mother whose child’s constant outbursts are leading to failing classes must drive two hours to see the only available developmental pediatrician. As a primary pediatrician, these are frequent conversations in my clinic as our pediatric specialists are too few and far between.
Although there is plenty of news on the primary care shortage and the large aging population that will need them, we also have a worsening specialist shortage in the pediatric world. There are several reasons for this. Unlike adult medical specialties where subspecialization usually results in a boost in pay, many pediatric specialists often earn less than their general pediatrician counterparts despite three extra years in fellowship training. Even for the more lucrative pediatric specialties like cardiology or gastroenterology, which do result in higher pay than general pediatrics, the salary is still significantly less than their adult counterparts despite the same years invested in training and debt burden. To add salt to the wound, several specialties such as endocrinology, rheumatology, and infectious disease are usually two years in length in the adult world. Yet, the same specialties in pediatrics require a mandatory three years.
I still remember rounding as a resident in the hospital with a brilliant pediatric infectious disease specialist who treated a teenager with a complicated UTI. That specialist made such a big impact that the teenager said they would like to become a pediatric infectious disease doctor one day as well. The specialist simply responded saying they would likely make more money as a nurse practitioner and gently discouraged the teenager from pursuing the harder longer path to become a pediatric specialist.
According to Chartis, despite a record number of residency applicants this year, medical students applying for a pediatric residency dropped by more than 6% compared to the year before. This was the largest decrease in a decade following an already steady pattern of decline. One third of pediatric residency programs went unfilled as a result. Of the limited number of pediatric residents, even fewer go on to specialize for the reasons mentioned above. I still recall our chiefs reaching out to pediatric residents after the fellowship match to ask if anyone wanted a fellowship spot because so many positions went unfilled.
Sadly, the American Academy of Pediatrics, despite all the advocacy it does for children, has done seemingly very little to support pediatricians and address this shortage. The fact that pediatricians are now pushed to complete a fellowship in hospitalist medicine after residency, while internal medicine residents can immediately practice as hospitalists post graduation with no fellowship requirements, shows just how out of touch our leadership in pediatrics has become.
The most important steps to addressing this shortage and enticing applicants back to pediatrics would be to address the training and wage imbalance. Since many children are on Medicaid and the Children’s Health Insurance Program, offering better reimbursement to pediatricians from these programs is vital. Although cash-based practices, which remove insurance programs from the equation, are helpful, this typically only works for primary care and not for pediatric specialists dependent on children’s hospitals for employment. Employers should also pay their pediatric physicians equal to their adult counterparts. Although invasive treatments and procedures bring in more money, they are not as common in pediatrics where counseling and less invasive interventions are generally preferred. Structuring billing and insurance reimbursements to allow for better reimbursement for time spent counseling patients would also make a big difference. Finally, many pediatric specialties such as infectious disease or rheumatology should be shortened to two years like their adult counterparts.
Until the pediatric specialty shortage is addressed, the burden will continue to fall on us general pediatricians. Despite overbooked schedules with short visit times and growing administrative burdens, many of us are learning to manage more complex specialized issues beyond our scope to fill in for specialists. Other times, we are desperately calling speciality offices and trying to get our patients squeezed in sooner. All of this is further contributing to the growing problem of burnout among general pediatricians who are also paid less than their adult counterparts and in shorter supply as a result.
With issues such as obesity and mental health conditions on the rise among children, and a growing population of children with more complex medical needs, the demand for pediatric specialists is greater than ever. Yet, these children have limited access to care. Children do not pay taxes or vote and they do not have a voice as a result. Failing to care for children now in their youth when preventive medicine is most effective will certainly lead to more severe illnesses and comorbidities in adulthood. This will further stress an already broken health care system and raise health care costs in the future. In a time when physicians across all specialties are becoming undervalued, pediatricians are among the hardest hit.
Dr. Shadman Sinha is an actively practicing board certified pediatrician. His passion is to raise awareness about issues in our health care system through TikTok, Instagram, and Youtube under the handle ShaddyMD and @docshaddymd.
Illustration by Jennifer Bogartz
