I haven’t actively practiced pediatrics for a few years, but one of my favorite things to do is to be an on-call physician for friends’ and colleagues’ kids. While most of their issues I can address over the phone, some need a recommendation for a pediatrician for in-person care. In the last few years, though, making such connections has been frustrating. Many pediatricians that I recommend can’t take on new patients.
There aren’t enough pediatricians right now, and because of that, some kids are unable to get the care they need. In Nevada, children can wait weeks or months for an appointment. In New Jersey, children who need a developmental pediatrician wait a minimum of three months. In Philadelphia, kids can wait three to six months for a pulmonologist and four months to see an allergist, and many can’t see a developmental pediatrician at all.
Things could get even worse: Fewer graduates from U.S. medical schools want to be pediatricians than we’ve seen in decades.
The results of this year’s medical residency match — a process where medical students are paired with residency programs in U.S. hospitals — were startling. More than 50,000 medical school graduates sought residency training in the 2024 match, an increase of almost 5 percent from the previous year. But the number of students applying to pediatric programs dropped more than 6 percent.
Approximately 30 percent of pediatric training programs failed to fill their available residency slots, leaving 252 positions vacant — a notable increase from just 88 vacant spots last year. This isn’t a minor hiccup; it’s a warning for the future of pediatric care in the United States.
Nurse practitioners and physician assistants could help fill the gap in pediatric primary care. But they cannot easily do so for subspecialty care, such as pediatric gastroenterologists, cardiologists and pulmonologists. “What’s been uniformly concerning for 20 years has been the waning interest in pediatrics subspecialties as the need has grown,” Atul Grover, executive director of the Association of American Medical College’s Research and Action Institute, told me. Because we’ve gotten better at treating many childhood illnesses, the number of children with complex diseases that require ongoing care into adulthood will likely increase.
Last year, a National Academies of Sciences, Engineering and Medicine committee published a report on the future of the pediatric work force and the issue of shortages, especially in rural areas. It underscored the fragmentation in care coordination between pediatric primary care and specialty care exacerbated by geographic barriers and inadequate financial support.
The elephant in the exam room, though, is that pediatricians earn less than specialists in almost every other medical field in the United States. A key reason is that so many children live in poverty and therefore qualify for Medicaid, which pays far less for care than private insurance and even less than Medicare.
More than 37 million children receive coverage through Medicaid or the Children’s Health Insurance Program. This means pediatricians get reimbursed at much lower rates than those in other areas of medicine. Even pediatric subspecialists must deal with this reality. Medicaid isn’t any more generous when children have chronic conditions. That’s no small problem. Estimates suggest that 40 percent of American children have at least one chronic health condition.
Pediatricians attend the same medical schools as those who enter other specialties, and education is expensive. Almost half of those who graduated with over $150,000 in debt 20 years ago have still not paid it off completely. In 2020, the average debt of those completing pediatrics residencies was $264,000.
General pediatricians also train for the same three years of residency as physicians who treat adults, but they earn much less. The American Board of Pediatrics requires that those entering subspecialty care — such as endocrinologists, infectious disease physicians and rheumatologists — train for an additional three years. The American Board of Internal Medicine only requires adult physician specialists to train for an extra one or two years for many specialties. So pediatric specialists train more to earn less.
But money isn’t the only thing on doctors’ minds. “Pediatricians rely on a network of psychiatrists, clinical psychologists and social workers to care for these children, and those fields are facing their own shortages,” Bianca Frogner, a health economist and the director of the University of Washington Center for Health Workforce Studies, wrote me. “Without an adequate referral network in place, providing care as a pediatrician is becoming increasingly complex and likely daunting.”
While some of these issues have worsened in the more than 25 years since I chose to become a pediatrician, many existed even back then. My father, a surgeon, was adamant that I would be financially constrained by my decision, but I felt that my interest in working with families outweighed whatever I might miss by earning less. I also realize my decision was made easier because I was privileged to graduate with very little debt. The financial and systemic pressures have only worsened since then.
There are steps we could take to reverse this trend, and the National Academies report lists many of them. According to Frederick Rivara, a professor of pediatrics at the University of Washington School of Medicine and the report committee’s chair, the most important is raising salaries through Medicaid-Medicare parity and increasing the availability of loan repayment programs for pediatricians. He and the committee also recommend shortening training requirements and promoting collaboration between pediatric primary care providers and subspecialists through telehealth.
We need immediate action to address this crisis and find ways to attract more graduates to pediatrics. Our children are the future, but we sure don’t act like it when it comes to health care.
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