We often hear about the shortage of general practitioners when it comes to adult medicine. Our newly minted doctors are foregoing primary care and opting to pursue further fellowship training in preparation for careers as subspecialists following their residency training in internal medicine. Interestingly, pediatrics has the opposite problem. Adult medicine has 36 specialists for every 100,000 patients whereas pediatrics only has 13 specialists for every 100,000 pediatric patients. We have a gross shortage of pediatric subspecialists ready to take care of the complex medical problems which are beyond the scope of practice for the general pediatrician.
Based on research performed by the Children’s Hospital Association in 2012, neurology, developmental/behavioral pediatrics, gastroenterology, surgery, and neurosurgery were the pediatric subspecialties with physician shortages that most affected their ability to provide care. Emergency medicine, genetics, psychiatry, endocrinology, and pulmonology were other specialties noted to also have significant shortages.
The shortage has made it difficult for families to obtain the care they need for their children. For example, the average wait time to see a pediatric neurologist is 8.9 weeks, an endocrinologist 7.3 weeks, and a geneticist 10.8 weeks. Sadly, there are even several states in the United States that do not have access to certain pediatric subspecialties. There are not any endocrinologists in Alaska, Idaho, Wyoming, or Montana nor are there any gastroenterologists in Montana, Vermont, or Wyoming. Additionally, when families do have access to subspecialists, they often have to travel long distances to reach them. According to data by Mayer, children have to travel on average 60 miles to reach a pediatric rheumatologist, 44 miles to reach a developmental pediatrician, and 32 miles to reach a pediatric gastroenterologist.
There are likely several factors that contribute to this shortage of pediatric subspecialists. First, once physicians complete their three years of pediatric residency training after four years of medical school, they must undergo two-three more years of fellowship training. Secondly, Medicaid reimbursement is another contributing issue. Historically, Medicaid has reimbursed thirty percent less than Medicare. In effect, many physicians have to take a pay cut when making the decision to practice a pediatric subspecialty in lieu of general pediatrics. By choosing fellowship training, physicians miss out on three years of attending level compensation. In addition, while pediatricians practicing primary care have more flexibility in choosing whether or not to see Medicaid patients, subspecialists are generally less able to pick and choose resulting in a higher percentage of the poorly reimbursing Medicaid population. Lastly, the return on investment of the additional years of the training is not present for most of the pediatric subspecialties. An article published in Pediatrics in 2011 showed that the only pediatric subspecialties worth pursuing from solely a financial perspective were cardiology, critical care, and neonatology. Thus, physicians would be better off financially pursuing a career as a general pediatrician regardless of their extra years of fellowship training rather than pursuing fellowship training in emergency medicine, gastroenterology, pulmonology, hematology/oncology, rheumatology, nephrology, endocrinology, and infectious disease.
Several things can be implemented to help solve this problem. First, fellowship training could be decreased from three to two years in length as a large portion of fellowship training is focused on research and not on clinical training especially for those interested in private practice. Secondly, Medicaid reimbursement to physicians could be increased to make subspecialty training more attractive. Lastly, the recently passed health care law has a provision for the pediatric subspecialty loan repayment program which would offer loan repayment of $35,000/year for up to three years for those pursuing pediatric subspecialty training in underserved areas. The funds have not yet been appropriated, but if they were to be, more physicians would pursue subspecialty training and the pediatric subspecialty shortage would be reduced.
The pediatric subspecialty shortage is a pressing concern, but the solution to the problem is within reach. We cannot let this problem continue as our children will suffer from not being able to access the care they need. It is time for us to look out for the future of our children as they deserve nothing less.
Jaeon J. Abraham, M.D.
For more information:
Mayer, Michelle L. Are We There Yet? Distance to Care and Relative Supply Among Pediatric Medical Subspecialties Pediatrics 2006 118: 2313-2321
Rochlin JM, Simon HK. Does fellowship pay: what is the long-term financial impact of subspecialty training in pediatrics? Pediatrics.2011;127(2):254–26