The Pediatric Subspecialty Workforce:

A Policy Primer

Ethan Alexander Jewett, MA

Senior Health Policy Analyst

July 2005

What are pediatric subspecialists?

“Pediatric subspecialists” is a global term that refers to the wide range of medical subspecialists, surgical specialists, and other specialist physicians that care for children.

These physicians care primarily for children with complex and chronic illnesses, as well as children with special health care needs.

How many kinds of pediatric subspecialists are there?

This is not an easy question to answer. Increasing subspecialization within medicine has led to an explosion of subspecialties within the last couple of decades.

However, subspecialists can be grouped into those that are certified by the American Board of Pediatrics and those that are certified by other specialty boards.

Subspecialty Certification by the American Board of Pediatrics

Adolescent medicine Cardiology Developmental-behavioral

pediatrics Emergency medicine Endocrinology Gastroenterology Hematology/oncology Infectious diseases

Medical toxicology Neonatal-perinatal

medicine Neurodevelopmental

disabilities Nephrology Pulmonlogy Rheumatology Sports medicine

Subspecialty Certification by Other Specialty Boards

Adolescent medicine Child and adolescent

psychiatry Pediatric emergency

medicine Pediatric otolaryngology

Pediatric pathology Pediatric rehabilitation

medicine Pediatric radiology

Pediatric surgery

Some pediatric subspecialists, particularly pediatric surgical specialists, are certified by other specialty boards. In a couple of cases, these boards offer certification in pediatric subspecialties also covered by the American Board of Pediatrics.

Other Pediatric Specialists

Some physicians who provide specialty care to children are not certified as “pediatric specialists” by their primary specialty board. Instead, they are certified in both primary disciplines (eg, pediatrics and medical genetics), or have extensive training or experience in the pediatric aspects of the specialty (eg, urology).

Pediatric allergy Pediatric anesthesiology Pediatric dermatology Pediatric genetics Pediatric neurology Pediatric ophthalmology Pediatric orthopedic

surgery Pediatric plastic surgery Pediatric urology

How many pediatric subspecialists are there?

Because people differ on who qualifies as a pediatric subspecialist, and on which data set to use, doing a “head count” can be difficult.

However, the most expansive definition of “pediatric subspecialist,” which would include surgical specialists and other specialist physicians, would place the number at around 22,000 (AMA, 2003).1

A “Head Count” of Some of the Major Pediatric Subspecialties

Adolescent Medicine 473 Medical Genetics 14

Allergy & Immunology 223 Neonatal-Perinatal Medicine 3812

Anesthesiology 199 Nephrology 453

Cardiology 1741 Ophthalmology 165

Child & Adolescent Psychiatry 6726 Otolaryngology 114

Critical Care Medicine 997 Pathology 78

Emergency Medicine 501 Pulmonology 555

Endocrinology 749 Radiology 635

Gastroenterology 473 Rheumatology 84

Hematology-Oncology 1553 Surgery 789

Infectious Diseases 290 Urology 157

Source: Amer Med Assoc, 20031

How reliable are these counts?

Potential limitations to workforce data:Physician specialty counts are based on data

reported by survey respondents: individual physician’s specialties cannot be verified.

Numbers can count all physicians in a particular subspecialty only those that are active (not retired) only those that are involved in direct patient care only those who are board-certified any of the above, minus residents.

How meaningful are these counts?

“Head counts” are not necessarily the best way to predict the need for physicians.

Poor access to care can be caused by many other factors besides physician supply (eg, lack of insurance, poverty, poor reimbursement for services).

Not all physicians are a “full-time equivalent.” Some work part-time, and some work in areas other than patient care.

Many physicians work in research, teaching, administration, and other professional roles.

Then, why count at all?Physician supply is one factor that determines

access to care. It is important to know whether the number of people entering the subpsecialty workforce is sufficient to replace those that are leaving it.

It is also important to know where these physicians are practicing, so that geographic maldistributions of physicians can be addressed through policy and recruitment activities.

The Pediatric Subspecialty Debate

Since 2000, a great deal of new information has emerged about pediatric subspecialties.

Documentation of workforce shortages has appeared in peer-reviewed journals.

Concern about these shortages has fueled debate.

How do we know there’s a shortage?

Not all subspecialties have the same workforce issues. The neonatology supply, for example, is very robust. However, a number of indicators point to a workforce shortage in many pediatric subspecialties. These indicators have become increasingly visible since 2000.

Documented increases in patient/referral volume.

Long wait times to obtain an appointment.

Difficulty recruiting physicians for vacant job positions.

Articles in journals and the medical press.

Increase in Referral Volume

Specialty + / 0/ - Specialty + / 0/ -Adolescent medicine 30 / 61 / 9 Infectious diseases 25 / 56 / 20

Allergy and immunology 24 / 48 / 28 Neonatology 24 / 63 / 13

Cardiology 34 / 55 / 11 Neurology 44 / 47 / 10

Critical care medicine 44 / 44 / 11 Ophthalmology 34/ 54 / 12

Dermatology 44 / 44 / 11 Orthopedic Surgery 29 / 56 / 15

Developmental-behavioral 36 / 54 / 10 Otolaryngology 28 / 52 / 20

Emergency Medicine 32 / 55 / 14 Plastic Surgery 37 / 48 / 15

Endocrinology 46 / 44 / 11 Pulmonology 47 / 40 / 12

Genetics 37 / 50 / 13 Source: Stoddard et al. 2000.2

Percent of Survey Respondents Who Indicated Change in Referral Volume

Wait Times for Appointments

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In 2004, the National Association of Children’s Hospitals and Related Institutions (NACHRI) reported on the number of weeks a patient had to wait to obtain an appointment to see a particular subspecialist. For many subspecialties, a patient had to wait between 5 weeks and 3 months.

Source: NACHRI, 20043

Recruitment ProblemsRecruitment problems have been

documented for a number of pediatric subspecialties3-8:AnesthesiologyDermatologyGastroenterologyNeurologyRadiologyRheumatology

Some candidate searches last well over a year.

Articles in the Medical PressJournal articles, news stories, and editorials serve as

another indicator of a potential workforce shortage.In the last several years, articles reporting a workforce

shortage for many pediatric subspecialties have increased in number and frequency.

In the aggregate, this evidence, though in many cases only anecdotal, becomes difficult to ignore. Even in the absence of hard data, physicians practicing in the trenches learn from their day-to-day experiences (often supported by other indicators) when a supply problem might be around the corner.

Recent Information about Pediatric Subspecialties

There is a lot of timely information on the pediatric subspecialist workforce, ranging from costs of care to practice characteristics. Of particular significant, was the Future of Pediatric Education II (FOPE II) Project which conducted surveys of 17 subspecialties.

The trick to accessing this information is to search by individual subspecialty or clinical topic. Articles on the subspecialty workforce at large are rare, as it is difficult to do meaningful analysis at such a global level.

Demographic Profile of thePediatric Subspecialist Pipeline

Subspecialty USMG Male USMG Female IMG Male IMG Female TotalAdolescent Medicine 5 (18.5%) 15 (55.5%) 5 (18.5%) 2 (7.5%) 27Cardiology 55 (39.3%) 45 (32.1%) 22 (15.7%) 18 (12.9%) 140Critical Care 65 (41.1%) 52 (32.9%) 21 (13.3%) 20 (12.7%) 158Developmental-Behav 38 (33.3%) 55 (48.3%) 5 (4.4%) 16 (14.0%) 114Emergency Medicine 50 (41.3%) 54 (44.6%) 11 (9.1%) 6 (5.0%) 121Endocrinology 18 (26.5%) 17 (25.0%) 11 (16.2%) 22 (32.4%) 68Gastroenterology 20 (35.7%) 7 (12.5%) 23 (41.1%) 6 (10.7%) 56Hematology-Oncology 61 (42.4%) 51 (35.4%) 15 (10.4%) 17 (11.8%) 144Infectious Diseases 28 (32.6%) 25 (29.1%) 14 (16.3%) 19 (22.1%) 86Neonatal-Perinatal 57 (20.7%) 90 (32.6%) 72 (26.1%) 57 (20.7%) 276Nephrology 6 (18.8%) 7 (21.9%) 10 (31.3%) 9 (28.1%) 32Pulmonology 15 (26.8%) 13 (23.2%) 20 (35.7%) 8 (14.3%) 56Rheumatology 4 (19.0%) 11 (52.4%) 1 (4.8%) 5 (23.8%) 21

422 (32.5%) 442 (34.0%) 230 (17.7%) 205 (15.8%) 1299

Source: American Board of Pediatrics, First-time Applicants for Subspecialty Certification Examinations, 2003-4. 9

How much do pediatric subspecialists earn?

Pediatric subspecialty/specialty

Salary (2003)

Child psychiatry $165, 437

Pediatric allergy $136,429

Pediatric cardiology $213,933

Pediatric endocrinology $130,245

Pediatric gastroenterology $167,391

Pediatric hematology/oncology $162,002

Pediatric infectious diseases $146,382

Pediatric intensive care $174,088

Pediatric nephrology $173,453

Pediatric neurology $159,044

Pediatric orthopedic surgery $339,650

Pediatric pulmonary disease $169,662

Pediatric surgery $270,000

Compensation for pediatric subspecialists varies by region, practice type, and a number of other factors. This variability is reflected in the different numbers generated by salary surveys, one of which is presented here. Source: AMGA, 2003, Medical Group Compensation and Productivity Survey.10

What does subspecialty care cost?JT Smith et al. (1999) found that for closed femoral shaft

fractures, length of stay was shorter and hospital charges were less when the child was treated by a pediatric, rather than an adult, orthopedic surgeon.11

Isaacman et al (2001) demonstrated that young children treated for fever spent 2.26 hours in the pediatric emergency department, compared to 3.0 hours in the adult emergency department.12

Alexander (2001) showed that children with significantly perforated appendicitis have lower complication rates and shorter lengths of stay when treated by pediatric surgeons as compared with HMO adult surgeons.13

What does subspecialty care cost? Hampers and Faries (2002) calculated that pediatric

emergency medicine physicians treating croup reduced length of stay by 40 minutes and direct costs by $90 when compared to the same treatment delivered by adult emergency medicine physicians.14

Kokoska et al. (2004) found that younger children treated by pediatric surgeons with appendicitis had significantly shorter hospital stay and/or decreased hospital charges than younger children treated by general surgeons for the same condition.15

Recruiting Residents into Pediatric Subspecialties

Pan et al. (2002) analyzed career choice by gender16: female residents, US medical graduates, underrepresented

minorities, and residents married to non-physicians were more likely to report an interest in primary care careers.

international medical graduates and male residents are more likely to pursue subspecialty training, regardless of educational debt.

Cull et al. (2002) learned that 42% of graduating female residents in 2000 were interested in part-time practice, compared with only 14% of graduating male residents.17

Recruiting Residents into Pediatric Subspecialties (cont.)

Cull et al. (2003) found a strong association between pediatrics’ residents towards research and the pursuit of subspecialty fellowship training.18

Harris et al. (2005) determined that career decisions for pediatric residents are complex.19

Those interested in generalist careers are driven more by lifestyle and personal/financial considerations.

Career decisions for subspecialists, in contrast, are attracted by the teaching, research, and technical skills associated with subspecialty practice.

What can be done about the pediatric subspecialist shortage?

Many subspecialties are increasingly using telemedicine to address the workforce shortage, particularly in rural areas.

Changes to fellowship training and subspecialty practice that address the lifestyle concerns of residents are likely to foster subspecialization.

Opportunities for shared or part-time fellowships make encourage more women to subspecialize.

The medical press provides suggestions to increase the supply of subspecialists and improve access to care:

Jewett, et al. (Pediatrics,in press)In 2005, Jewett et al. provided an overview of the

current pediatric subspecialty workforce and identified 5 forces that were likely to shape the workforce in the near future20:Changes in the demographics of physicians and patient

populations.Physician debt load and lifestyle considerations.Competition among providers of pediatric subspecialty care.Equitable reimbursement for subspecialty services.Policies aimed at regulating specialist physician training and

supply.

Jewett et al.: RecommendationsRestructure fellowships and practices to

accommodate the lifestyle priorities of a workforce that is increasingly female.

Expand diversity/cultural competency training.Expand federal loan repayment and other

financial incentive programs (eg, NHSC).Train nonphysicians, as appropriate, to provide

some subspecialty care in underserved areas.Reform reimbursement for subspecialty care.Advocate for responsible workforce policy.

References1. Pasko T, Smart DR. Physician Characteristics and

Distribution in the US, 2005 Edition. Chicago, Ill: American Medical Association; 2005.

2. Stoddard JJ, Cull WL, Jewett EAB, Brotherton SE, Mulvey HJ, Alden ER. Providing pediatric subspecialty care: a workforce analysis. 2000 Dec;106(6):1325-33.

3. Donna Shelton. Written communication. September 28, 2004.

4. Hester EJ, McNealy KM, Kelloff JN, et al. Demand outstrips supply of US pediatric dermatologists: Results from a national survey. J Am Acad Dermatol. 2004 Mar;50(3):431-4.

5. Forman HP, Traubici J, Covey AM, Kamin DS, Leonidas JC, Sunshine JH. Pediatric radiology at the Millennium. Radiol. 2001 Jul;220(1):109-114.

6. Werner RM, Polsky D. Strategies to attract medical students to the specialty of child neurology. Pediatr Neurol. 2004;30(1):35-8.

7. Laureta E, Moshe SL. State of training in child neurology 1997-2002. Neurol. 2004 Mar;62:864-9.

8. Mayer ML, Mellins ED, Sandborg CI. Access to pediatric rheumatology care in the United States. Arthritis Rheumatol. 2003 Dec;49(6):759-765.

9. American Board of Pediatrics. Workforce Data, 2004-2005. Chapel Hill, NC: American Board of Pediatrics; March 2005.

10. American Medical Group Association. Physician Compensation: 2003 Medical Group Compensation and Productivity Survey, Median Compensation. Available at: http://www.cejkasearch.com/ content.asp Accessed January 16, 2004.

11. Smith JT, Price C, Stevens PM, Masters KS, Young M. Does pediatric orthopedic subspecialization affect hospital utilization and charges? J Pediatr Orthop. 1999 Jul-Aug;19(4):553-5.

12. Isaacman DJ, Kaminer K, Veligeti H, Jones M, Davis P, Mason JD. Comparative practice patterns of emergency medicine physicians and pediatric emergency medicine physicians managing fever in young children. Pediatrics. 2001 Aug;108(2):354-8.

References (cont.)13. Alexander F, Magnuson D, DiFiore J, Jirosek K,

Secic M. Specialty versus generalist care of children with appendicitis: an outcome comparison. J Pediatr Surg. 2001 Oct;36(10):1510-3

14. Hampers LC, Faries SG, Practice variation in the emergency management of croup. Pediatrics. 2002 Mar;109(3):505-8.

15. Kokoska ER, Minkes RK, Silen ML, et al. Effect of pediatric surgical practice on the treatment of children with appendicitis. Pediatrics. 2001 Jun;107(6):1298-1301.

16. Pan RJ, Cull WL, Brotherton SE. Pediatric residents’ career intentions: data from the leading edge of the pediatrician workforce. Pediatrics. 2002 Feb;109(2):182-8.

17. Cull WL, Mulvey HJ, O’Connor KG, Sowell DR, Berkowitz CD, Britton CV. Pediatricians working part-time: past, present, and future. Pediatrics. 2002 Jun;109(6):1015-20.

18. Cull WL, Yudkowsky BK, Shipman SA, Pan RJ. Pediatric training and job market trends: results from the American Academy of Pediatrics Third-Year Resident Survey, 1997-2002. Pediatrics. 2003 Oct;112 (4):787-92.

19. Harris MC, Marx J, Gallagher PR, Ludwig S. General vs. subspecialty pediatrics: factors leading to residents’ career decisions over a 12-year period. Arch Pediatr Adolesc Med. 2005 Mar;159:212-6.

20. Jewett EA, Anderson MR, Gilchrist GS. The pediatric subspecialty workforce: public policy and forces for change. Pediatrics. [in press].

For more information on workforce issues, please visit the AAP Committee on

Pediatric Workforce Web page:

http://www.aap.org/workforce