Summary

The health of today’s children sets the foundation for the future health of the nation. When children require preventive care or experience illness, injury, or a limitation in their functioning, a wide variety of health professionals provide expert care to maintain and promote their health and well-being. Pediatric subspecialists (physicians who typically complete a pediatric residency and then receive additional fellowship training in discrete areas) are critical to ensuring state-of-the-science care and pursuing research to improve prevention, diagnosis, and treatment for children. Pediatric subspecialists augment the care provided by primary care clinicians, such as general pediatricians, advanced practice providers (e.g., advanced practice registered nurses, physician assistants), and family medicine physicians by caring for children who require technical procedures or have health conditions that occur too infrequently for primary care clinicians to gain and maintain up-to-date clinical knowledge. For many children, pediatric subspecialty care is essential to their survival and a flourishing life. Approximately 10–20 percent of U.S. children visit a pediatric subspecialist each year. However, there are substantial disincentives to pursuing a career as a pediatric subspecialist—in both the clinical and research settings. These challenges are often heightened for individuals from groups underrepresented in medicine (URiM). Notably, there has been very little change in the proportion of URiM pediatric residents and fellows over the past several decades, and the pediatric workforce does not reflect the growing diversity of the pediatric population.

Tremendous advances in pediatric care have resulted in an increased number of children living with chronic health conditions or surviving

illnesses that previously would have meant a poor quality of life, a shortened life span, or even death during childhood, leading to a pediatric population with new and complex challenges. These changing health care needs and increasing care complexity—combined with perceived shortages of primary care clinicians, pediatric subspecialists, and pediatric physician–scientists and changing practice patterns—have raised concerns about the current and future availability of pediatric subspecialty care and research and the potential ramifications for child health and well-being. In 2022, the National Academies of Sciences, Engineering, and Medicine (National Academies), with support from a coalition of sponsors, formed the Committee on the Pediatric Subspecialty Workforce and Its Impact on Child Health and Well-Being to recommend strategies and actions to ensure an adequate pediatric subspecialty physician workforce to support broad access to high-quality subspecialty care and a robust research portfolio to advance the health and health care of infants, children, and adolescents.¹

STUDY FOCUS AND CONTEXT

The committee recognizes the important contribution of many different types of clinicians toward the care of children; however, based on the statement of task and discussions with study sponsors, this report focuses on the medical subspecialty physician workforce. The committee particularly focused on the 15 medical subspecialties certified by the American Board of Pediatrics (ABP) (see Table S-1). These represent the bulk of pediatric subspecialty physicians and share common pathways for education and training; furthermore, many of these subspecialties experience significant challenges in recruitment and retention. When appropriate and relevant, the committee also considered other pediatric subspecialty physicians. As a secondary focus, the committee discussed the interaction and collaboration between pediatric medical subspecialty physicians and primary care clinicians because these types of physicians commonly collaborate with each other on patient management. Other members of the health care workforce—including pediatric surgical subspecialists, adult-trained subspecialists who provide some care for children, and child and adolescent psychiatrists, among others—are also involved in the care of infants, children, and adolescents but not a primary focus for this report.

The committee recognized that advanced practice providers are increasingly used to provide both inpatient and outpatient pediatric subspecialty care and an important part of the pediatric workforce, especially in children’s hospitals. However, their training and certification is separate from that of pediatric physicians and therefore not a primary focus in this

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¹ The complete statement of task is presented in Chapter 1 of this report.

TABLE S-1 Primary and Secondary Focus of Report

NOTES: *Although the ABP recognizes a combined training program for child and adolescent psychiatry, very few physicians choose this pathway, so it is not included as part of the committee’s primary focus. See Chapter 1 for a fuller description of the range of pediatric subspecialty physicians.

report. The committee is also aware that scientists conducting research on conditions that occur in the pediatric age group represent a diverse group of individuals. Following the charge, the committee’s focus for research was on the recruitment, training, funding, and retention of pediatric physician–scientists.

The committee’s task was not to redesign the overall health system of pediatric care delivery, including transitions to adult care, but rather to focus on equitable access to pediatric subspecialty care. Furthermore, the committee recognizes the importance of high-quality primary care as a foundation for high-quality subspecialty care. Although the committee did examine some new models of subspecialist–primary care clinician interaction for patient care, the 2021 National Academies report Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care specifically addresses strategies to improve primary care broadly, including the use of interprofessional teams, and the committee considered its work to build upon that study. The committee also recognizes a study in progress at the National Academies that is charged to address “innovations that can be implemented in the health care system to improve the health and wellbeing of children and youth,” including workforce development and team-based care.²

CHALLENGES IN ENSURING AN ADEQUATE PEDIATRIC SUBSPECIALTY WORKFORCE

Whether patients obtain subspecialty care, and the timeliness of that care, depends on a complex mix of patient, family, clinician, health system, and societal influences. Some of the major influences include demand for subspecialty care, referral patterns, organization of services, geography, and health care financing. Furthermore, the adequacy of the workforce itself is also affected by children’s changing health care needs, how well primary care clinicians and subspecialists are prepared to address those needs, the number of subspecialists, the influences on an individual’s decision to pursue subspecialty training, how subspecialists interact with the larger health care workforce, and how pediatric subspecialists are reimbursed.

Access to Care

A high-quality health care workforce needs to be organized and prepared to ensure adequate access to care for both common and uncommon

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² For more information, see https://www.nationalacademies.org/our-work/improving-the-health-and-wellbeing-of-children-and-youth-through-health-care-system-transformation (accessed July 7, 2023).

acute and chronic health problems. Patients and families may consult with their primary care clinician about the need for referral to a subspecialist or directly seek subspecialty care (self-referral). Subspecialists can also create additional demand through extensive follow-up of patients more appropriately followed by primary care clinicians and cross-referring to other subspecialists. Judicious use of referrals can improve access to needed subspecialty care, but unnecessary or uncoordinated subspecialty care may lead to overuse of these services and thus prolonged wait times for appointments.

Type of insurance (i.e., Medicaid, Children’s Health Insurance Program [CHIP], commercial/private), insurance status (insured versus uninsured), and families’ out-of-pocket costs can affect whether patients can access subspecialty care and with what frequency. For example, although children enrolled in Medicaid/CHIP have higher use rates of medical subspecialty care (as compared with those who are commercially insured), evidence shows that these children experience more challenges in obtaining new appointments. Other cultural and economic factors contribute to disparities in timely access to subspecialty care, including language barriers and opportunity costs (e.g., ability to take time off work). Furthermore, many adolescents with chronic conditions experience fragmented care as they transition from pediatric to adult subspecialty care.

Geographic barriers to pediatric subspecialty care vary by region and type of subspecialist. Patients and families may experience difficulty in accessing subspecialists because of long travel times or a lack of transportation. Factors contributing to such regionalization include the larger percentage of children living in urban areas (versus rural), the inability to support a practice in some locations because of the lower prevalence of many disorders, and certain technologies being more available in larger, centralized care centers. In addition, a subspecialist who is interested in teaching and research is likely to have limited opportunities to pursue these interests outside of an urban academic center. More than half of ABP-certified pediatric subspecialists work primarily in medical school or university settings, and most report some form of academic faculty appointment. Some, but not all, of these geographic barriers can be lessened via telehealth and other innovations, such as outreach clinics.

Education and Training Model

Although the most common health conditions that affect children today are acute and recurrent illnesses, a growing proportion of children have long-term medical and behavioral health conditions. Chronic pediatric conditions traditionally have been stratified as physical or mental. However, over the past decades, there has been greater awareness of the holistic nature of health and the common co-occurrence of physical and mental

health conditions. Finally, new illnesses may still emerge that will require related changes in education and training.

However, the model of education and training has not evolved substantially in response to the changing context of society and medical practice, including pediatric patients’ health needs and practice patterns. In particular, the model of education and training for pediatric medical subspecialists has limited flexibility in the design and length of fellowship; nearly all ABP-certified fellowships require 3 years of training, including a minimum of 12 months of clinical training and 12 months of scholarly activity (e.g., research). Although all subspecialty fellows are required to participate in scholarly activity, nearly half of practicing subspecialists report not being involved in any research activities, and very few spend a substantive percentage of their time on research. Furthermore, although ABP provides a limited number of alternate, streamlined pathways for trainees who are committed to careers in research, similar pathways do not exist for trainees who are committed to careers in clinical practice.

Influences on Pursuing a Career in a Pediatric Subspecialty

Many factors can influence the choice to pursue subspecialty training, including:

• Exposure to the complete array of board-certified pediatric subspecialties and subspecialists (e.g., before medical school, during medical school, during residency);
• The presence of role models from subspecialty fields, particularly for URiM trainees (which may be scarce owing to the small numbers of subspecialists);
• The length of fellowship training;
• The requirement for scholarly activity during fellowship;
• The debt burden of education and training;
• Relatively lower salaries, particularly for some pediatric medical subspecialties compared with general pediatricians in outpatient practice and adult medical subspecialists; and
• Lifestyle factors (e.g., work–life balance, job satisfaction, burnout).

As a result of lower salaries and longer training, many pediatric subspecialists face a high debt burden, which can discourage pediatricians from pursuing careers in lower-paid subspecialties. The retention of pediatric subspecialists is also important; longevity may be predicted by personal or professional factors, such as concerns surrounding financial considerations (e.g., educational debt and compensation) and clinician burnout, well-being, and job satisfaction.

Challenges exist in ensuring the adequacy of both the clinical and pediatric physician–scientist research workforces. Pediatric research is the cornerstone of evidence-based care delivery, and advances in pediatric research are central to improving the lives of children. However, specific challenges for pediatric research include a paucity of subspecialty-specific workforce data; lack of a robust mentorship environment, particularly for early career investigators; financial considerations that affect trainees’ decisions to pursue research; lack of dedicated research time; competing clinical responsibilities; and inadequate research funding.

The Primary Care–Subspecialty Interface

In high-functioning health systems, primary care clinicians and pediatric subspecialists work collaboratively at the interface of primary and specialty care to provide the appropriate level and full spectrum of care for children with complex and atypical acute and chronic disorders. However, there are widespread inefficiencies and variability in the connections between primary care and subspecialty care. Communication and coordination between primary care clinicians and physician subspecialists is frequently absent or fragmented, leaving parents as the main link between them. Productivity demands on primary care clinicians may prompt some to refer patients even though the condition could have been managed entirely in primary care with additional time or resources. Additionally, primary care clinicians often refer patients for short-term consultation for advice on diagnosis or management, but the subspecialist takes over the care for the referred problem. There is virtually no evidence base to guide decision making on the frequency and timing of return subspecialty visits versus transition care back to a primary care clinician, resulting in wide primary care and subspecialist practice variation. Allowing adequate time and reimbursement and preparing primary care clinicians to provide some part of the care they might otherwise refer to a subspecialist would allow subspecialists to focus on the more severe, complex, or rare cases or procedure-based care that primary care cannot best deliver.

Several promising evidence-based models can increase access to pediatric subspecialty care and support the judicious use of all members of interprofessional pediatric care teams without necessarily changing the number of subspecialists. Innovations include integrating primary and subspecialty care (e.g., integrated behavioral health and primary care, embedding generalists into subspecialty clinics and vice versa, active co-management, development of a pediatrician’s skills to manage more complex care, referral and treatment guidelines), using telehealth (e.g., electronic consults [e-consults], telementoring), facilitating access through nurse-led models of care, and financing innovations to support primary–specialty care collaborations.

However, the implementation and scaling of these models face several barriers, including a lack of payment mechanisms; limitations of practice due to state-based regulations (including for telehealth); and a lack of education and training in team-based care, making appropriate referrals, and the use of more innovative care models and modalities.

Financing Children’s Health

Medicaid covers 35 percent of children overall and a substantially higher share of the children with complex medical needs treated by pediatric subspecialists. Comparisons of Medicaid and Medicare fee schedules generally find Medicaid rates to be substantially lower, with some variation across states, specialties, or services. Additionally, productivity-based fee schedules (i.e., relative value units [RVUs]) provide greater levels of remuneration for procedure-based subspecialties and undervalue the increased time needs per clinical interaction, increased pre- and post-service time, and higher practice expenses for most subspecialty care, particularly pediatric subspecialty care. The exact methods through which pediatric subspecialists’ salaries are set are subject to complex formulas that vary by institution, but expected revenue is a major factor. The large percentage of children covered by Medicaid, especially those cared for by subspecialists, coupled with low payment rates, adversely affects reimbursement. This results in lower salaries for many pediatric subspecialties compared with internal medicine subspecialty counterparts; particularly in medical subspecialties, this can influence the career decisions of trainees pursuing pediatrics and pediatric subspecialty training.

VISION, GOALS, AND RECOMMENDATIONS³

Ideally, the subspecialty workforce would be adjusted in both numbers and skills to fully meet children’s subspecialty care needs. Attracting physicians to pursue training in many of the pediatric medical subspecialties has been problematic, and a variety of mechanisms will be needed to generate and maintain a diverse array of subspecialists. However, a larger workforce alone will not solve the problems of meeting children’s subspecialty health care needs. Rather, intentional efforts are needed to recruit and retain subspecialists in specific areas of clinical care in combination with judicious use of all members of the health care team in effective models of team-based care.

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³ The committee’s recommendations are numbered according to the chapter of the main report in which they appear. Thus, Recommendation 2-1 is the first recommendation in Chapter 2.

In its evaluation of the available data, the committee concluded that the need for interventions to support and optimize the pediatric subspecialty workforce varies substantially and dynamically across subspecialties over time. Some subspecialties receive many fellowship applicants, but others have a dearth. The anticipated earnings vary by subspecialty, and individuals who train in critical care and other procedure-based subspecialties have incomes that are far above those for nonprocedural pediatric subspecialists. The number and proportion of extramurally funded physician–scientists vary substantially by pediatric subspecialty. Waiting times to access care also vary among pediatric subspecialists, from days for some to months for others, and by geographic location. Despite few URiM pediatric subspecialists, some fields have been more successful in advancing diversity. Given these variables, the groups referenced as “high-priority subspecialties” in the ensuing recommendations will differ by specific context and may change over time. Thus, this report does not employ a single definition for “high-priority.”

A Vision of a High-Quality Pediatric Subspecialty Workforce

To achieve the goal of a high-quality pediatric subspecialty workforce for clinical care and research, the committee envisions an accessible and efficient health system that enables all children to receive the appropriate type and amount of primary and specialty care whenever they need it. Such a system would value high-quality care for all children, with care that embodies the six elements for quality defined by the Institute of Medicine⁴: safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness. High-quality pediatric subspecialty care is safe when the referral, or lack of referral, does not result in harm. It is timely when diagnosis and treatment alleviate anxiety and symptoms as quickly as feasible and avoid delays that exacerbate symptoms or functional limitations attributable to the disease or its course. It is effective when patient and family questions and concerns are addressed fully and it produces the best possible health outcomes. It is efficient when the diagnostic and treatment journey does not create unneeded testing or treatments or delays in delivery of appropriate services. It is equitable when the access to necessary knowledge and the use of appropriate treatment is provided according to patient need rather than social determinants of health. It is patient- and family-centered when

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⁴ As of March 2016, the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine (National Academies) continues the consensus studies and convening activities previously carried out by the Institute of Medicine (IOM). The IOM name is used to refer to reports issued prior to July 2015.

patients, families, and clinicians are considered partners in determining the goals of care and shared decision making is incorporated when appropriate.

High-quality pediatric subspecialty care requires a well-supported, superbly trained, and appropriately used primary care, subspecialty, and physician–scientist workforce achieved through effective education and training, well-designed care models, and continued attention to the changing health care and economic landscapes. In addition, all clinicians need to be able to provide care that aligns with the full extent of their education and training and receive appropriate reimbursement for their administrative and clinical work. Increased opportunities are needed to implement innovative delivery system models and health care technologies, and flexible training pathways are needed in response to the changing medical and behavioral health needs of infants, children, and adolescents.

The committee developed four goals with associated recommendations to help achieve its vision of a high-quality pediatric subspecialty workforce with a robust research portfolio to advance the health and health care of infants, children, and adolescents:

1. Promote collaboration and the effective use of services between pediatric primary care clinicians and subspecialty physicians;
2. Reduce financial and payment disincentives;
3. Enhance education, training, recruitment, and retention; and
4. Support the pediatric physician–scientist pathway.

The committee re-emphasizes the importance of high-quality primary care for achieving high-quality subspecialty care. Although the following recommendations are focused on improving the delivery of subspecialty care, many will also help to support primary care clinicians.

Goal 1: Promote Collaboration and the Effective Use of Services Between Pediatric Primary Care Clinicians and Subspecialty Physicians

Improved monitoring of children’s changing health care needs and demands, the status of their access to needed care, disparities, and trends in workforce composition are all essential to inform future workforce planning efforts. Understanding these trends will help determine the appropriate education and training needed to prepare the pediatric workforce to work collaboratively toward meeting children’s health care needs and which subspecialties should be prioritized for different interventions or programs (e.g., loan repayment) and inform innovative models of care to improve access. Therefore, the committee provides the following recommendation:

RECOMMENDATION 2-1 The Agency for Healthcare Research and Quality should submit a biennial report to the Secretary of the Department of Health and Human Services summarizing the changing demands and needs for pediatric primary and subspecialty care, status of access to that care, and disparities in receipt of those services. This report should include information on the pediatric generalist and subspecialist workforce broadly (including data on clinicians from backgrounds underrepresented in medicine).

Pediatric subspecialists need to focus on their essential role in the care of children with complex, severe, and rare disorders or requiring technical procedures, while collaborating with primary care clinicians. However, in general, both groups of clinicians are not optimally trained about their role and responsibilities in the referral process. Many children with common and lower-complexity or -severity diagnoses referred to subspecialists could be managed by primary care clinicians either alone (with appropriate time, financial resources, and training) or through active, collaborative comanagement with the subspecialist. In addition, the COVID-19 pandemic has shown how rapidly technology, such as telehealth, can be implemented and widely adopted. The use of new technologies and methods of care can increase patient access; improve care coordination; strengthen the role of the primary care clinician; and allow subspecialists the time to provide inpatient and outpatient care in a manner that is feasible, fulfilling, and financially sustainable and best for children. However, barriers in payment and regulation prevent the full implementation and scaling of current evidence-based models of team-based care. Finally, innovative models of care are needed to reset the relationship between pediatric subspecialty physicians and primary care clinicians, making them greater partners in care of children. Enhanced communication at the interface of primary and subspecialty care is essential within these models. Therefore, the committee provides the following recommendations:

RECOMMENDATION 7-1 American Academy of Pediatrics, the Council of Pediatric Subspecialties, and other pediatric professional societies should collaboratively develop, disseminate, and implement testing, management, and referral guidelines for health conditions commonly managed by subspecialists. This should include when to consult, when to co-manage, and what the appropriate follow-up roles are for both the primary care clinician and the subspecialist.

RECOMMENDATION 7-2 Public and private health insurance payers should adequately reimburse evidence-based care delivery models that improve interprofessional, integrated, team-based care to enhance

access to pediatric subspecialty care. These models include but are not limited to

• E-consults (with payment for both the referring and the receiving clinician);
• Telehealth visits (both within and across state lines); and
• Integrated care teams that support mental and physical primary and specialty health care clinicians and include advanced practice providers, social workers, and care coordinators.

RECOMMENDATION 7-3 The Centers for Medicare & Medicaid Services (in conjunction with state Medicaid agencies), private foundations, and health systems should sponsor the development, implementation, and evaluation of innovations (including new models of care delivery and reimbursement) in the primary–specialty care interface and the pediatric subspecialty referral and care coordination processes.

Goal 2: Reduce Financial and Payment Disincentives

Expansions in insurance coverage over the past decades, including via CHIP, expanded Medicaid eligibility for children, and the Affordable Care Act, have successfully removed the barrier of uninsurance for most U.S. children. However, the typically lower rates of Medicaid reimbursement for many of the children that pediatric medical subspecialists treat, coupled with low RVU-based payment rates, contribute to their comparatively lower salaries. As noted, these challenges are especially prominent for pediatric subspecialists because of the relatively higher percentage of patients covered by Medicaid. The federal government has used Medicaid financing to achieve broad policy goals through the program, but low Medicaid payments represent a significant underinvestment by federal and state governments in children’s health. Finally, the committee notes that the Pediatric Specialty Loan Repayment Program was authorized at $30 million per year but has not yet been fully funded at this level. Overall, the financial realities of educational debt (particularly for students from URiM and/or economically disadvantaged backgrounds), along with the relatively low salaries and added time demands for some training pathways, require considering ways to remove financial disincentives to entering and staying in pediatric subspecialty careers. Therefore, the committee provides the following recommendations:

RECOMMENDATION 8-1 To invest in children’s health and address the factors that contribute to limited access to pediatric subspecialty care, Congress should allocate additional federal funding to increase payment for pediatric services.

• Within 5 years, Congress should provide federal funds to states to increase Medicaid payment rates for pediatric services to achieve or exceed parity with Medicare payment rates.

These federal funds should be provided to all states, and the federally funded payment increases should be mandatory. The committee recognizes that this recommendation may be difficult to implement immediately, but it should be phased in as soon as possible. The committee also recognizes that states can increase payments for pediatric services themselves, but many states have not done so on their own, which is why federal action is necessary.

RECOMMENDATION 8-2 CMS should prioritize attention to pediatric services in assigning relative value units that accurately reflect the time and resource use for pediatric subspecialty care.

RECOMMENDATION 5-4 Congress should increase funding for the Pediatric Specialty Loan Repayment Program to $30 million as originally authorized. The Health Resources and Services Administration should focus on loan repayment for high-priority pediatric medical subspecialties as well as subspecialists from underrepresented in medicine and/or economically disadvantaged backgrounds.

Goal 3: Enhance Education, Training, Recruitment, and Retention

The preparation of the subspecialty workforce has not evolved to fully meet the demands of the 21st century’s population of infants, children, and adolescents, with limited ability to change education and training models quickly in response to emerging challenges. The committee notes that the biennial report called for in Recommendation 2-1 could be used to help inform adjustments in curricula to meet these evolving needs. Furthermore, the model of education and training for pediatric medical subspecialists includes a single model for most graduates with a focus on creating subspecialists who demonstrate competency in all aspects of academic careers, including clinical care, research, and education. However, pediatric subspecialty care would benefit from a workforce that is differentiated in skills and effort in each of these three areas. Increased flexibility in fellowship design and length could encourage more residents to pursue careers in a pediatric subspecialty by allowing them to tailor their training in accordance with their career goals. The design of residency and fellowship training programs also faces barriers from the structure of Medicare-funded graduate medical education (GME) and Children’s Hospitals GME (CHGME) program funding. Pediatric training programs increasingly depend on discretionary

CHGME funding that may limit the number of slots, and Medicare-funded GME in general does not place any institutional requirements on types of clinicians. Finally, recruitment and training needs to evolve to enhance the number of URiM clinicians in the pediatric subspecialty workforce to mirror the diversity of the children and families it serves. Therefore, the committee provides the following recommendations:

RECOMMENDATION 4-1 The Association of Medical School Pediatric Department Chairs should periodically convene representatives from the American Board of Pediatrics, the Accreditation Council for Graduate Medical Education, all pediatric professional societies, and major pediatric education and training organizations (including, but not limited to, child and adolescent psychiatry, family medicine, and advanced practice providers) to review and adjust educational and training curricula (e.g., continuing education, standardized pediatric subspecialty training, and specialty recognition and certification) for pediatric residents and fellows. The goal of these convenings is to ensure that residency and fellowship programs are preparing a workforce that can address the evolving physical and mental health needs of the pediatric population.

RECOMMENDATION 5-1 The American Board of Pediatrics, the American Osteopathic Board of Pediatrics, and the Accreditation Council for Graduate Medical Education should develop, implement, and evaluate distinct fellowship training pathways, including a 2-year option for those who aspire to a career with a primary focus on clinical care.

The committee emphasizes multiple novel pathways should be considered and that a pathway focused on clinical training, for example, does not mean that the trainees will receive no academic training or experience in research principles. Rather, distinct pathways would allow for tailoring training programs for specific career goals, as already exist for the alternative pathways for research.

RECOMMENDATION 5-2 Congress should reform graduate medical education (GME) formulas and programs, including Medicare GME and Children’s Hospital GME, to ensure equitable and sufficient support for pediatric GME. Funding should be distributed to address priority pediatric workforce needs, such as increased inclusion of clinicians from underrepresented in medicine backgrounds, high-priority

subspecialties, geographic shortages, and enhanced training for new models of care.

RECOMMENDATION 5-3 Pediatric department chairs, medical school deans, and health systems should develop, implement, and publicly report on plans and outcomes to attract, support, and retain students, residents, fellows, and faculty from underrepresented in medicine backgrounds in pediatric subspecialties.

• These plans should include efforts to further the development and growth of recruitment programs for pre-college URiM students and initiatives to make learning and working environments more inclusive at all levels of the subspecialist career pathway.
• The responsible individuals and entities above should publicly report annual metrics on the demographics of their pediatric subspecialty workforce.

Goal 4: Support the Pediatric Physician–Scientist Pathway

Advances in child health require a highly skilled research workforce in which all disciplines pursue improved outcomes. For the purposes of this report, the committee focused on the role of the pediatric subspecialty physician–scientists who are crucial in research to improve subspecialty care and related health and organizational outcomes. Training this workforce cannot be fully accomplished during the 12 months of scholarly activity required within a 3-year overall fellowship. Rather, physician–scientists need extended training accompanied by adequate research support at the beginning of their careers. Specific and deliberate efforts are needed to encourage and facilitate entry into research careers and foster their early phases of career development for pediatric physician–scientists, especially for those who are underrepresented in the extramural scientific workforce. However, more evidence is needed on funding trends, unmet research needs, quality of research mentorship, and outcomes from pediatric physician–scientist career development pathway programs to inform future efforts to support careers in research. Therefore, the committee makes the following recommendations:

RECOMMENDATION 6-1 The National Institutes of Health (NIH) Pediatric Research Consortium, with leadership from the National Institute of Child Health and Human Development and input from the NIH’s Scientific Workforce Diversity Office, and with appropriate additional funding, should engage with other government and nongovernment pediatric research funders to create and maintain a publicly

available central repository for qualitative and quantitative data on pediatric physician–scientists’ funding and success throughout their careers (e.g., tracking research funding rates and attrition rates by pediatric subspecialty), including the development of new measures as needed to understand the initial success and retention of pediatric physician–scientists. The Association of Medical School Pediatric Department Chairs should provide supplemental data as needed.

Examples of data needed include the following:

• Quantitative data on the funding rates of career development and subsequent awards and the tracking of research careers by demographic factors, such as sex/gender, race, ethnicity, disability status, geography, type of science across the research continuum (e.g., basic, clinical, translational, implementation, health services research), topic/subspecialty, and professional background of the principal investigator; and
• Qualitative data on successful researchers and those who leave the research track, including the quality of relationship with mentors; types of support received from their institutions; availability of statistical, epidemiologic, academic and grant writing training and support; availability of funding to present and publish research; satisfaction with career progression; and reasons for attrition or retention.

RECOMMENDATION 6-2 The National Institutes of Health and the Agency for Healthcare Research and Quality should increase the number of career development grants in pediatrics, particularly institutional training awards (e.g., the Pediatric Scientist Development Program), the Pediatric Loan Repayment Program, and K awards, with attention to providing such grants to physician–scientists from backgrounds that are underrepresented in the scientific workforce and for high-priority subspecialties in pediatric research. Funding for individual K awards should be increased to reflect current salaries and research project expenses and should include additional explicit funding for mentorship.

CONCLUSION

The current health care system is expensive, not equitably accessible, and not fully satisfying to either the people who work in it or the patients and families it is intended to serve. This report outlines recommendations that, if fully implemented, can improve the quality of pediatric medical

subspecialty care and the quality of the care experience for patients, families, and clinicians. Achieving a robust subspecialty workforce will require concerted efforts across federal and state governments, pediatric professional societies, major pediatric education and training organizations, medical schools and fellowship programs, and health systems, with input from patients and families. It will also require a willingness to adapt to the changing needs of children and clinicians and a changing health care delivery system, while investing in the necessary time and resources. Implementing all of these recommendations in combination with other necessary supports to primary care will result in a health care system that serves the needs of all children and improves the health of the nation.

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