Gary L. Freed

The decision by pediatricians to pursue fellowship training, and if so, which subspecialty to choose, has been a focus of interest among leaders in the field.^1,2 Perceptions of shortages in specific subspecialties have created an urgency in determining the factors informing this decision and resulted in a plethora of potential policy options to designed to impact the pediatric workforce, mostly in the financial arena.^3-7 However, many studies have demonstrated that residents do not report that potential compensation is a primary factor in their decision to pursue specific fellowship training^8-11; yet, the accuracy of such disclosures is unknown. Although previous research has demonstrated that the decision regarding whether or not to pursue fellowship training is made during their internship or even earlier for most pediatricians,¹² there has also been considerable interest in the impact that experiences and knowledge of the subspecialties during residency can play in this process. However, the overall number of trainees pursuing fellowship training has increased every year for at least the past 30 years,¹³ the proportion pursuing specific subspecialties is not equally distributed.¹⁴

Background National Resident Match Program (NRMP) data are often used to identify the pediatric subspecialty pipeline. Other data sources may provide greater accuracy. Methods Analysis of data from the NRMP and the American Board of Pediatrics (ABP) for 14 pediatric subspecialties from 2008 to 2020. We calculated, within each subspecialty, the annual number of first-year fellowship positions offered, the NRMP match rate, the actual number of fellows entering training (ABP data) relative to the number of positions in the match (fill rate), and the actual number of matriculating first-year fellows each year. Results For all subspecialties and years, the fill rate was greater than the match rate. All subspecialties had an increase in the relative and absolute number of first-year fellows, with the largest increases seen in emergency medicine (73.3%) and critical care (68.9%). Except for adolescent medicine, all subspecialties had an absolute increase in the number of positions offered, with the largest increase in pulmonology (32.1%). Conclusions NRMP data underestimate the actual number of first-year fellows entering subspecialty training. For all subspecialties, the number of first-year fellows has increased over time, indicating continued expansion in the pipeline for most. However, there remains great variation across subspecialties. Impact Perceptions of the pipeline for the pediatric subspecialty workforce vary depending on the data source. The use of NMRP match data alone underestimates the number of matriculating trainees. The number of unmatched fellowship positions has created a perception of a diminishing number of pediatric subspecialty fellows. This study uses multiple data sources to better understand the actual number of fellows entering pediatric subspecialty training and demonstrates that the NRMP match rate alone underestimates the pipeline of the pediatric subspecialty workforce.

When attempting to provide lessons for other countries from the successful Israeli COVID-19 vaccine experience, it is important to distinguish between the modifiable and non-modifiable components identified in the article by Rosen, et al. Two specific modifiable components included in the Israeli program from which the US can learn are (a) a national (not individual state-based) strategy for vaccine distribution and administration and (b) a functioning public health infrastructure. As a federal government, the US maintains an often complex web of state and national authorities and responsibilities. The federal government assumed responsibility for the ordering, payment and procurement of COVID vaccine from manufacturers. In designing the subsequent steps in their COVID-19 vaccine distribution and administration plan, the Trump administration decided to rely on the states themselves to determine how best to implement guidance provided by the Centers for Disease Control and Prevention (CDC). This strategy resulted in 50 different plans and 50 different systems for the dissemination of vaccine doses, all at the level of each individual state. State health departments were neither financed, experienced nor uniformly possessed the expertise to develop and implement such plans. A national strategy for the distribution, and the workforce for the provision, of vaccine beyond the state level, similar to that which occurred in Israel, would have provided for greater efficiency and coordination across the country. The US public health infrastructure was ill-prepared and ill-staffed to take on the responsibility to deliver > 450 million doses of vaccine in an expeditious fashion, even if supply of vaccine was available. The failure to adequately invest in public health has been ubiquitous across the nation at all levels of government. Since the 2008 recession, state and local health departments have lost > 38,000 jobs and spending for state public health departments has dropped by 16% per capita and spending for local health departments has fallen by 18%. Hopefully, COVID-19 will be a wakeup call to the US with regard to the need for both a national strategy to address public health emergencies and the well-maintained infrastructure to make it happen.

BACKGROUND AND OBJECTIVES: A near vacuum exists for credible information regarding specialty-specific demography, including gender, years since training completion, current employer, academic affiliation, and hours worked in specific tasks. Understanding the current status and changes to the medical workforce and its work patterns is essential to assessing whether the supply and distribution meets the needs of patients, institutions, society, and educational programs. METHODS: A self-administered electronic survey sent to all pediatricians at the time of their enrollment in the Maintenance of Certification program in 2013–2014. The survey focused on exploring trends associated with career choice, career paths, time spent in professional activities, and current practice characteristics. Logistic regression and χ2 analyses were conducted. RESULTS: The response rate was 87.2% (N = 15 351). Of those who completed the survey, 9253 (64%) self-identified as general pediatricians. An increased likelihood of working part-time was seen among women (odds ratio [OR]: 12.21), those without an academic appointment (OR: 1.32), and those not working in a private/independent practice (OR: 1.15). Overall, 89% (n = 8214) of respondents stated that their current allocation of professional time was approximately what they wanted. Those more likely to be involved in quality improvement in the past year did not work in independent/private practices (OR: 1.78) and worked full-time (OR: 1.16). CONCLUSIONS: Understanding the current nature of the pediatric workforce is a first step in providing data to guide future workforce planning and the training experiences required to maintain and shape the workforce to meet the current and future needs of children.

There is concern about whether general practice registrars gain sufficient exposure to, and confidence in caring for, many pae-diatric conditions during their apprenticeship training. General practice registrars' referral patterns for paediatric conditions over-all or for specific conditions, including behavioural or mental health diagnoses, are unknown. The aim of this study was to assess the relative rates of referral by general practice registrars for children, compared with adults, specifically for those with behavioural or mental health diagnoses. A secondary analysis of 83,445 encounters from the Registrar Clinical Encounters in Training (ReCEnT) dataset was undertaken. More than half of children (52%) with a behavioural or mental health problem were referred to specialty care, compared with only 23% of adults. For all other conditions, only 9% of children received specialty referral, compared with 12% of adults. Although a certain proportion of behavioural or mental health issues in children may require either diagnostic assistance or aid in management, it is unclear whether more than half are unable to be cared for by a general practice registrar without referral.

OBJECTIVES: The issues of importance in selecting a first job for new pediatric subspecialists, and their ability to find positions that match their professional and clinical goals, are unknown. The objectives were to (1) describe current employment patterns, practice characteristics, factors influencing choice of first position, and future work goals of new pediatric subspecialists; and (2) examine the relationship of these variables with the actual professional time allocation and clinical responsibilities compared with the desired first job. METHODS: The authors surveyed 3010 individuals sitting for ≥1 of the 14 subspecialty certification exams. The main outcomes were (1) most important factors in choosing employment; (2) ability to gain employment in positions that matched their goals; and (3) variation in employment characteristics among men versus women, time since completion of training, and part-time versus full-time status. RESULTS: Response rate was 97%. Lifestyle/spousal or family considerations was the factor identified as most important in the choice of first position after fellowship training for half of respondents (50%; n = 1277). There was a median of 75% of actual time spent in direct and/or consultative inpatient or outpatient care, with 5% in medical education, 5% in administration, and 5% in research. A majority (74%; n = 1825) reported this proportion to be approximately what they wanted. Most respondents (89%; n = 2194) reported that their allocation of patient care responsibilities (ie, inpatient versus outpatient) was approximately what they wanted. CONCLUSION: A large majority of pediatric subspecialists found initial positions matching their goals for professional responsibilities and clinical care.

Two important considerations arise from this IJHPR article from Zimmerman and colleagues. First, is the question regarding what can be considered a “common” procedure in primary care and whether the designation can or should change over time. The second issue is whether it is enough for a doctor to feel comfortable doing a procedure for it to be within their scope of practice, or whether the practice specific outcome for the procedure in terms of safety and efficacy is a more relevant determination of whether the procedure should be performed in a given setting. In other words, just because a doctor “can” or “wants” to do a procedure, may not mean they “should” do a procedure. The role of procedures in a practice of primary care also differs markedly in the care of children vs. the care of adults. This phenomenon is partially the result of the more challenging aspects of the care of infants and small children with regard to the ability to maintain a sterile field for procedures, and the relative infrequency with which procedures are performed on children relative to adults. The scope of practice for pediatricians in the community has changed over time and is likely to continue to change. This paper helps to define the current state of practice for paediatricians with regard to the conduct of 10 specific procedures. It challenges us to think about the appropriateness of the venue of care and its implications for both the status quo and the future of community based primary care.

The population of Australia is ageing. We sought to examine the impact of this demographic trend on the demography of general practices. Descriptive statistics of Medicare claims and census data, 1996-2010. There have been changes in the demography of general practice patients commensurate with changes in the national demography. The proportion of patient visits made by those aged >65 years increased from 18.3% to 23.3%, an absolute increase of 5% but a relative increase of 27.3%. In contrast, the proportion of patient visits to general practices decreased by 16.4% (relative decrease) for those aged 0-4 years and 28.9% (relative decrease) for those aged 5-14 years. As visits for children become a smaller fraction of overall general practice visits, the continued comfort level and competency to provide primary care of acute and chronic illness in children as well as recognition of abnormal development may be affected. To ensure the adequate provision of services to this paediatric population, careful ongoing monitoring of general practices, referral patterns and comfort levels in the care of children must be undertaken.