Philip C. Carullo

Pediatric anesthesiology is a deeply rewarding specialty, and the job market remains favorable for the trainees who choose it. However, the U.S. pediatric anesthesiology workforce is facing a convergence of challenges, including declining fellowship recruitment, increasing nonoperating room anesthesia (NORA) and complex surgical volume, expanding clinical demands, and migration of physicians from academic hospitals to ambulatory and contract-based practice models. These trends threaten access to specialized pediatric perioperative care, weaken educational and research missions, and strain the ability of children’s hospitals to care for medically complex patients. This article examines the drivers of current U.S. workforce instability and proposes a framework for recruitment, retention, and long-term sustainability. Key recommendations include improving work–life integration through flexible scheduling, aligning compensation with clinical and academic contributions, investing in physician wellness, strengthening leadership engagement, leveraging technology to optimize staffing, and expanding mentorship and pipeline development initiatives. Sustaining the pediatric anesthesiology workforce will require deliberate institutional investment to ensure continued access to high-quality care for children.

Background: Anesthesiology continues to attract growing interest among medical school graduates, yet its subspecialty fellowships remain chronically underfilled. Pediatric anesthesiology illustrates the pattern clearly, with unfilled fellowship positions rising more than fivefold between 2017 and 2023. Compensation is often cited as a driver but does not appear to fully explain the trend. Aims: This Perspective examines when subspecialty interest actually develops and argues that the traditional assumption that it forms during residency may already be too late. Findings: National Academies data indicate that a substantial share of pediatric subspecialists chose their field at the start of medical school, well before meaningful clinical exposure. A national survey of anesthesiology residents found that many enter their fellowship decision year without a subspecialty direction, and that adequate exposure during pediatric rotations was among the strongest predictors of fellowship pursuit, though such exposure varies widely by program. National efforts, including the Society for Pediatric Anesthesia's SPAERS committee and the Minds on Peds platform launching in early 2027, aim to standardize exposure earlier in training, in part through social media outreach to preclinical students. Fellowship fill rates have improved over this period of expanded outreach, although direct evidence linking social media exposure to subspecialty interest is still lacking. Conclusions: Residency‐level interventions alone are unlikely to resolve the fellowship pipeline problem. The field should extend and standardize subspecialty exposure into the medical school years and build a deliberate, authentic presence on the platforms where trainees already learn.

The physiologic benefits of high-flow nasal cannula (HFNC) therapy are well documented in the intensive care literature, yet only a handful of case reports describe its perioperative use. Our single center experience explored comprehensive applications of HFNC in the perioperative setting. Over a ten-month period, HFNC was used in the care of 85 medically complex patients either as an adjuvant or main oxygen therapy during induction of general anesthesia, maintenance of deep intraoperative sedation, and during early postoperative care. Here, we illustrate clinical scenarios in which HFNC therapy made patient care safer and describe a framework for integrating this technology into the anesthesia practice at our institution.