Shortage of subspecialists, increased demand complicate future of pediatric care

The current shortage of pediatric medical subspecialists and a potential deficit in graduate medical education positions for children’s hospitals cast uncertainty on the future viability of the pediatrician workforce, a recent policy statement from the AAP Committee on Pediatric Workforce warned.

Photo courtesy of Seattle Children’s Hospital

Furthermore, current issues within the workforce, such as the increasing number of children with chronic health issues, struggles with work-life balance and incongruences in financial compensation compared with other medical specialties could compound and encumber the sustainability of the child health care system.

To explore the complexities of this issue, Infectious Diseases in Children spoke with pediatricians, workforce experts and graduate medical education (GME) experts about the difficulties the current pediatrician workforce faces and the path to overcoming these issues to ensure the next generation of child care.

Increased training burden

Gary L. Freed, MD, MPH, of the child health evaluation and research unit at the University of Michigan, said the issues leading to the current shortage of pediatric medical subspecialists and pediatric surgical specialists do not seem to affect the number of general pediatricians who specialize in primary care. In fact, research by Freed and colleagues found that almost 90% of newborns and the majority of adolescents are cared for by general pediatricians.

“Interestingly, there are not fewer people going into pediatrics today than there have been in the past,” Freed told Infectious Diseases in Children. “It’s not an issue of pediatrics losing people to other specialties that would have gone into pediatrics otherwise. So, you almost have to think of general pediatricians and pediatric subspecialists as two different workforces.”

According to Mary Ellen Rimsza, MD, FAAP, professor of pediatrics at the University of Arizona College of Medicine, however, the shortage issue is intensifying among pediatric subspecialists and surgical specialists because fewer medical students are pursuing careers in the pediatric subspecialties.

“We have a very high number of medical students interested in training in pediatrics,” Rimsza said during an interview. “The issue for the subspecialties is that graduate students finish their general pediatric residency, but then do not decide to stay on longer for a fellowship in a medical or surgical subspecialty area.”

To become a board-certified pediatrician, Rimsza said, students must complete 4 years of medical school followed by 3 years of residency training. After completion of residency training, GME students can continue their medical education by pursuing a fellowship position in a pediatric subspecialty; however, this typically consists of an additional 3 years of training.

“In order to be a good pediatric infectious disease specialist, you first have to be a good pediatrician and have the general knowledge that other pediatricians have,” Rimsza said. “However, for many of the medical subspecialist fields of pediatrics, such as infectious disease, there is no additional financial return for those extra years of training.”

Rimsza also said the time commitment required for becoming a pediatric subspecialist could be dramatically impacting the decision-making process for GME students entering the pediatric workforce.

“By the time they finish their general pediatric residency training, they are probably about 30 years old and have started a family, and they want to settle down into a lifestyle and not continue to be in ‘training mode’ for additional years,” Rimsza said. “They want to get on with having a job.”

Furthermore, William Moskowitz, MD, FAAP, FACC, FSCAI, of the department of pediatrics at the Children’s Hospital of Richmond at Virginia Commonwealth University and the current chair of the AAP Committee on Pediatric Workforce, explained that the additional time burden taken on by GME students seeking a subspecialty also comes with an additional financial burden. He said this often does not pay off financially for the student.

“You can’t forget about the indebtedness that people are carrying after they go through medical school,” Moskowitz told Infectious Diseases in Children. “The average student enters a pediatric residency with a mean debt of $242,000 for their medical education. If you look at what a general pediatrician makes coming out of residency, it’s about $150,000 a year. So they are being paid that amount and have $230,000 hanging over their head. This makes it difficult to go into a subspecialty, which presumably would pay more, but with certain specialties the payment is not there.

An unhealthy financial decision

Pediatrics ranks among the lowest paid medical specialties, with a median starting salary of $162,000, according to a 2013-2014 salary survey by Profiles Physician Database. In addition, when comparing the national 6-year median salary of a general pediatrician ($204,500) to the 6-year median salary of a pediatric endocrinologist ($189,000), the idea of spending more time and money in school to pursue a subspecialty may seem fiscally unwise for GME students.

“It’s been no secret for the last 25 years that I’ve been a pediatrician, that pediatricians are among the lower paid of specialists, and that has not changed,” Freed said. “I think people always would like to be more highly compensated, and I believe that there is a national bias that reimburses care of children less than it reimburses the care of adults. I don’t find it acceptable or rational.”

According to Moskowitz, a pediatric cardiology specialist, current compensation patterns in pediatrics do not align with the complex and delicate health issues that children can face.

“It always irks me that I deal with kids with heart failure, kids that require heart transplants, have more complicated hearts congenitally than adults do — who typically inflicted their coronary disease on themselves — and I get paid less for taking care of those patients with the same CPT code that adults have,” Moskowitz said.

He also said this compensation bias is institutional in nature, because identical procedures are billed differently between Medicaid and commercial insurance.

“If you look at Medicaid payments, cardiologists get paid 70 cents on the dollar in Virginia for taking care of heart failure in a child compared to commercial insurance,” Moskowitz said. “However, it’s not about the money. Kids with heart disease typically will get better when I take care of them, and they have their entire lives in front of them. It is a more uplifting and gratifying profession.”

Unfortunately for GME students deciding between a career in pediatrics or a pediatric subspecialty, this extrinsic value may be hard to quantify. According to Rimsza, specific subspecialties, such as infectious disease and mental health, have the largest need for new GME students. Compensation may play a part in this issue, with child psychiatry ranked among the lowest of all pediatric specialties, at $159,000 annually, according to the 2013-2014 salary survey.

Rimsza said this deficit is partly caused by a lack of billable procedures in these specialties. This affects both compensation for career specialists and the ability for teaching hospitals to fund GME positions for these specialties.

“It tends to be the fields that are more procedural-based that have less of a need, such as cardiology and intensive care,” she said, “while the specialties that are more strictly cognitive-based, such as infectious disease, have greater shortages. This is because the more procedural specialties can charge for the procedures that they do during that training, which allows the training programs, and the hospitals and universities to recover some of the cost of training.”

Rimsza said low starting salary is a problem somewhat unique to pediatrics.

“It doesn’t lead to higher earnings, so you kind of have to do it because you want to do it — you love it — rather than to make more money,” she said. “This is different than in other fields, such as internal medicine where you are going to be looking forward to a higher income level later in your career, so it helps balance out the lower pay of being a fellow.”

According to Maneesh Batra, MD, MPH, associate director of the Pediatric Residency Program at Seattle Children’s Hospital, choosing to subspecialize can be a difficult decision for GME students who have just completed an exhaustive education in general pediatrics.

“Within the pediatrics specialties, looking ahead at 3 more years of training is a hard pill to swallow, when the workforce right out of residency is such that you can make pretty much the same amount of money working in general pediatrics or as a hospitalist as you would after 3 more years of training,” he said.

A generational shift in professional philosophy

Research by Liselotte N. Dyrbye, MD, MHPE, and colleagues found that the majority of early career pediatricians are women and also noted that men are more likely than women to experience satisfaction with work-life balance. While Amy J. Starmer, MD, MPH, and colleagues reported that factors such as having children were not associated with a higher likelihood of burnout or poor work-life balance, they also observed that career satisfaction was lower among female pediatricians. These factors suggest that the majority of the workforce may be more susceptible to issues with work-life balance. According to Rimsza, the prospects of increased work-life balance issues brought on by training in a subspecialty could be a driver for decreased interest.

“Work-life balance is certainly a big issue,” she said. “If you are in a fellowship, you have much less control over your day-to-day schedule and how many hours you work, compared to if you are in your own practice.”

Furthermore, research by Freed and colleagues found an increased likelihood of working part time among female pediatricians, with nearly one-fourth of the overall workforce working part time. Freed said that while the overall proportion of pediatricians working part time is likely starting to stabilize, part-time work is becoming more prevalent among pediatric subspecialists.

“Somewhere between 20% to 25% of general pediatricians work part time with a larger proportion being women,” Freed said. “We know that probably somewhere between 8% to 12% of pediatric subspecialists work part time — again, the largest proportion being women. We are starting to get the sense that part-time work, although predominately a gender issue, may also begin to become a generational issue.”

Moskowitz suggested that this “generational issue,” has to do with work-life balance being valued more among millennials entering the physician workforce than it was among previous generations.

“There is a mindset over the last 5 years or so that now pediatrics trainees are millennials who are more interested in work-life balance than just working 18 hours a day,” Moskowitz said. “So, there is a greater increase in the number of people doing part-time practice right out of the chute.”

Recent research by Starmer and colleagues found that 43% of early career pediatricians have problems with work-life balance, and 30% experienced burnout. Feelings of burnout may play a role in the lack of general pediatricians deciding to pursue a subspecialty, according to Batra.

“We are seeing more and more that residents aren’t going directly into subspecialty training, and instead are opting to take more interim positions for a year or two, before they go into a subspecialty,” Batra said. “When we ask them about it, they say that they want a bit of a break and that they want to find their reconnection with their desire to become a subspecialist.”

According to Batra, the sudden attention garnered by the issue of burnout is not due to the fact that the current generation perceives burnout more frequently than previous generations, but instead that a cultural shift in the medical field may now allow for more openness.

“There are some traits of millennials that have been described in a pejorative light, but my thesis would be that there are actually some really reassuring things about the millennials,” he said. “It could be that there is a cultural effect, because our hospitals, universities, institutions, accrediting bodies, societies and the public have normalized physicians talking about their feelings and have normalized this open awareness that to be the best physician you can be, you have to take care of yourself.”

Fewer pediatricians, more pediatric patients

According to the AAP, the shortage of pediatric subspecialists is likely to detrimentally impact the care of children with chronic health conditions, as this population is growing. According to a report by the Children’s Hospital Association, the pediatric subspecialist shortage directly affects patient care through decreased access and increased wait times, such as an average 14.5-week wait time for an appointment with a developmental/behavioral medicine expert.

“Currently, because of the lack of subspecialists, much of the responsibility for the care of children with serious chronic illnesses falls to the general pediatrician because there aren’t enough specialists available in their community to take care of children with diabetes or other chronic illnesses,” Rimsza said.

Moskowitz added that the issue of increased chronic-care demand is likely to worsen as modern advances in medicine increase the survival rate of neonatal patients with complex medical issues at birth.

“We are now saving babies who were born at 24 to 25 weeks’ gestation weighing less than 1,000 grams,” he said. “Unfortunately, a majority of these individuals will have chronic health conditions.”

According to Rimsza, the demand for more pediatric subspecialists also increased as a side effect of the enactment of the Affordable Care Act.

“The Affordable Care Act greatly increased the number of children who are insured and further increased their access to care, and thus increased the demand for care for both general pediatricians and specialists,” she said. “We have a greater need as more kids get insured because parents didn’t bring their children in for care before. They were not getting the preventive and ongoing care that they needed.”

Freed, Moskowitz and Rimsza all identified rural areas of the United States as a major component of the pediatrician subspecialist shortage. Lack of specialty medical facilities and lack of training in rural parts of the country create inconsistencies in the patient-to-doctor ratio.

“There are areas of the country that do not have medical schools or residency programs,” Moskowitz said. “So instead they go to surrounding areas, like Washington state or Oregon. Then, they try and have them come back to provide care, but it is difficult to do that.”

Rimsza said it is also difficult to sustain specialty-specific medical centers in rural locations due to insufficient patient populations.

“The biggest shortages are in the more rural communities where there aren’t sufficient patients to fully support a subspecialist because there just aren’t enough children that need that type of care,” Rimsza said. “So, if you are a physician working in a smaller community, you are going to have to take care of those children yourself or use some telemedicine approach.”

Moskowitz added that the issues of low compensation and work-life balance also may decrease interest in pursuing a pediatrics career in rural areas.

“A decreasing number of people are moving to the rural areas because there is an increasing number of people who want part-time practice and if you are the only person in a rural area, the job is 24 hours a day, 7 days a week, 365 days a year,” he said.

Solutions for a better future

According to a policy statement on financing graduate medical education, authored by Rimsza, the AAP recommends additional funding for GME positions for children’s hospitals, which will fund the entirety of a student’s training. It also recommends that all entities that gain from a robust pediatric workforce, such as pharmaceutical and insurance companies, pay into the GME fund.

“We recommended that the training programs be fully funded for the full length of a fellowship training just as they are fully funded for a general pediatric residency training,” Rimsza said. “The source of funding for GME should be broader, it shouldn’t be just the federal government. We felt like all those who benefit from having a well-trained pediatric workforce should be supporting it.”

Moskowitz proposed loan forgiveness programs as a means to easing the debt burden on GME students who pursue careers in pediatric subspecialties or in rural areas. Compensation issues also need to be resolved in order to spur interest in subspecialties.

“Unless we change the payment structure, enact loan forgiveness or have some incentive for individuals to spend those extra 3 years in training, I don’t think things are going to change,” he said.

Batra said burnout can be mediated both on the institutional level and the individual physician level.

“If there were one way to think about reducing burnout, which all interventions have in common, they are about promoting resilience,” Batra said. “They are about building and modifying people’s resilience so that they are able to take what they are experiencing and see it as an opportunity.”

Reducing this burnout is a crucial component of ensuring a viable future for the pediatric workforce, he said.

“It’s important for the pediatric workforce to not burn out these doctors who it takes a long time to train to do the kind of work that they do,” Batra said. “It’s really important to not burn them out because of attrition, turnover, and at the very worst, because of suicide. Our goal here is to help our physicians stay resilient throughout their training so that they can go on to be the best doctor that they can be, which allows them to provide the best patient care, but also allows them to derive the most joy from their work.”

According to Freed, the key to bolstering the pediatrics workforce is to structure pediatrics training to be challenging, rewarding, and allow for better work-life harmony.

“I think that in order for pediatrics to be a compelling career choice, we need to provide both a stimulating training environment and a structure within the profession that allows people the freedom to be able to structure their professional lives, so that they can have rewarding careers and rewarding personal lives,” Freed said. “We want pediatrics to be a rewarding career choice. Understandably, rewarding career choices can be quite challenging.” – by David Costill

• References:
• Children’s Hospital Association. Pediatric Specialist Physician Shortages Affect Access to Care. https://www.childrenshospitals.org/issues-and-advocacy/graduate-medical-education/fact-sheets/2012/pediatric-specialist-physician-shortages-affect-access-to-care. Accessed May 11, 2016.
• Dyrbye LN, et al. Mayo Clin Proc. 2016;doi:10.1016/j.mayocp.2013.07.016.
• Freed GL, et al. Pediatrics. 2016;doi:10.1542/peds.2015-4242.
• Freed GL, et al. J Pediatr. 2010;doi:10.1016/j.jpeds.2010.01.003.
• Profiles. Physician Database. The online database of graduating physicians. http://www.profilesdatabase.com/resources/2013-2014-physician-salary-survey/. Accessed May 11, 2016.
• Rimsza ME, et al. Pediatrics. 2016;doi:10.1542/peds.2016-0211.
• Starmer AJ, et al. Pediatrics. 2016;doi:10.1542/peds.2015-3183.

• For more information:
• Maneesh Batra, MD, MPH, can be reached at maneesh.batra@seattlechildrens.org.
• Gary L. Freed, MD, MPH, can be reached at gfreed@med.umich.edu.
• William Moskowitz, MD, FAAP, can be reached at william.moskowitz@vcuhealth.org.
• Mary Ellen Rimsza, MD, FAAP, can be reached at mrimsza@aap.net.

Disclosures: Batra, Freed, Moskowitz and Rimsza report no relevant financial disclosures.

The story isn’t over…

Click here to read comments from experts whom Infectious Diseases in Children asked for their opinion on why pediatricians choose academic research over clinical care and vice versa, to understand what motivators, pros and cons are associated with each decision, and why one ultimately appealed to doctors more than the other. We also welcome you to share your own impressions of this topic.