Investing in mentorship for our future patients’ needs

Abstract

This is a great time to be a subspecialty pediatrician. The advances in diagnostics and therapeutics, many of which are published about in the pages of this journal, are breathtaking. Survival and quality of life have dramatically improved for many complex childhood illnesses, and there is greater recognition that earlier intervention can lead to sustained improvements throughout adulthood. In this month’s issue of Pediatric Research, Macy and colleagues share with us their findings that from 2001 to 2018 the number of first-year subspecialty pediatrics fellows increased by about 92% to 1445. This statistic might seem to be a call for celebration until we look a little deeper and consider the implications for future generations of children. The key priorities are making sure that all children have access to high-quality subspecialty care when needed and that there is a sufficient pool of well-trained subspecialists to drive basic and clinical research, quality improvement, and train and educate other clinicians. A recent commentary by Keller and colleagues in Pediatric Research outlined challenges related to the mismatch of demand and supply by geographic region, how counting the number of available clinicians can underestimate the workforce due to factors like part-time work and variations of specific career paths that might limit clinical care, and that creative policy interventions, such as loan repayment or better reimbursement of telemedicine, are needed. Although there is no argument that the pediatric subspecialty workforce should meet clinical needs and be robust enough to push the specific disciplines forward, dynamic workforce studies are difficult to perform and interventions to meet predicted demands based on the expected supply are challenging to implement and evaluate. We believe that workforce modeling to inform policy is important, but it is difficult to assess the validity of the models and the impact of the subsequent work to address workforce needs identified by these models. However, even without complex modeling, there are danger signs. As referenced by the report by Macy and colleagues, the American Board of Pediatrics provides an interactive data portal to assess the workforce (https://www.abp.org/content/data-andworkforce). We encourage readers to visit this website and consider their field within pediatrics, the subspecialists whose consultations they depend on, or the services that their family or friends might need. It will likely be troubling. Consider the subspecialty fellowship statistics—while certain subspecialties have seen tremendous growth in recent years, growth in others has been minimal or relatively stagnant. Even in subspecialties that have seen increased numbers of fellows, there may still be a mismatch between trainee numbers and patient need. For example, in 2018, there were 42 first-year DevelopmentalBehavioral Pediatrics fellows compared to 21 in 2003. It is clear that there are increasing rates of developmental and behavioral problems in children across the country, but it remains unclear if this dramatic appearing relative increase in the number of fellows truly addresses current or future needs. Even with new collaborative models of care with general pediatricians and greater use of nurse practitioners and physician assistants, we doubt the need for subspecialists will decrease. For example, consider the unconscionable wait time and to see a developmental-behavioral pediatrician for children with suspected autism. Consider also the lack of metabolic geneticists, a specialty type not considered in the study by Macy and colleagues, to evaluate and manage individuals identified through newborn screening. Regardless of subspecialty, there remain disparities by geographic region, insurance status, socio-economic status, and race/ethnicity in access to subspecialty care. We believe that there are important activities that pediatricians can do now to support the future of our field that complement the policy-level activities that Macy and colleagues recommend. It is first important to understand the pool of pediatric residents that prime the pipeline of subspecialists. The numbers of intern positions available over the years fluctuates, based on the predicted needs of future pediatricians and resources available to provide training. In 2019, there were 2847 positions offered through the match and 97.6% were filled. In 2018, there were 2768 positions with 97.9% filled. Looking back 20 years, there were 2144 positions of which 95.2% filled. Overall, there has been a modest growth in the number of positions. However, changes over time in the number of pediatric subspecialists seems to have little to do with the number of residents who are trained each year. Another point to understand is that >1 in 4 pediatricians is an international medical graduate (IMG) and IMGs are more likely to become subspecialists. Changes in the number of IMGs entering pediatric training programs due to restrictive immigration policies might have negative consequences for the future subspecialty workforce. The final point to recognize is that a large body of research demonstrates the critical need to ensure a diverse workforce in medicine, and pediatrics is no exception. A diverse workforce has been associated with improved communication, patient satisfaction, and outcomes. Though Macy and colleagues were not able to address racial and ethnic diversity in the current study, it will be imperative to examine this in future studies. As Weyand and colleagues point out, focusing on improving diversity among those already interested in subspecialty training is a “zero-sum game” because it redistributes individuals instead of bringing new individuals to subspecialty pediatrics. Based on these considerations, it is clear that we must focus our efforts earlier in the medical education continuum, with increased attention on high school or even elementary school. These pipeline programs do exist, both in STEM fields more generally