1

Introduction

For many children, pediatric subspecialty care is essential to their survival, health, and well-being. 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. In particular, 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. Tremendous advances in pediatric care have resulted in an increasing number of children living with chronic health conditions or surviving illnesses that previously would have meant death, a shortened lifespan, or a poor quality of life. Pediatric subspecialists focus their clinical practice on the ever-increasingly complicated subpopulation of acutely and chronically ill children. Primary care clinicians such as general pediatricians, advanced practice providers (e.g., advanced practice registered nurses, physician assistants), and family medicine physicians work closely with subspecialists in a way that complements the subspecialists’ expertise. However, widespread inefficiencies are present in the interactions between primary care and subspecialty care.

Tremendous advances in research have resulted in a pediatric population with new and complex challenges. The resultant changing health care needs of children and the increasing complexity of their care—combined with perceived shortages of primary care clinicians, pediatric subspecialty physicians, and pediatric physician–scientists, as well as changing practice patterns—raised concerns about the current and future availability of

pediatric subspecialty care and research (Mayer and Skinner, 2009; Stockman and Freed, 2009; Vinci, 2021) and adverse impacts on child health.

STUDY ORIGIN AND STATEMENT OF TASK

Several health care organizations with an interest in pediatric care approached the National Academies of Sciences, Engineering, and Medicine (National Academies) to examine clinical subspecialty workforce trends related to the health care needs of infants, children, and adolescents, and the impact of those trends on child health and well-being as well as trends in the pediatrician-scientist pipeline and the impact on the scope of child and adolescent health research. Those organizations included

• American Academy of Pediatrics,
• American Board of Pediatrics,
• Association of Medical School Pediatric Department Chairs,
• Children’s Hospital Association,
• Council of Pediatric Subspecialties,
• Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD),
• Robert Wood Johnson Foundation, and
• The Annie E. Casey Foundation.

In response, in 2022 the National Academies formed the Committee on the Pediatric Subspecialty Workforce and Its Impact on Child Health and Well-Being. The sponsors’ charge to the committee is presented in Box 1-1.

DEFINITIONS AND TERMINOLOGY

The following sections provide a framework of definitions and distinctions in terminology used throughout this report.

Infants, Children, and Adolescents

A policy statement from the American Academy of Pediatrics (AAP) states that “pediatrics is a multifaceted specialty that encompasses children’s physical, psychosocial, developmental, and mental health” (Hardin et al., 2017, pg. 1). The field of pediatrics covers a broad age range, and several groups have developed guidelines for defining the ages for the stages of infancy, childhood, and adolescence (FDA, 2022; Hardin et al., 2017; NIH, 2022a; Williams et al., 2012). However, these guidelines lack overall consensus. Furthermore, the upper limit of “pediatric” care has increased

over time, and more recent efforts have expanded the scope of adolescent medicine to define “adolescent and young adult medicine,” which includes patients up to age 25 (Moreno and Thompson, 2020). However, in some cases, patients outside of these age ranges may continue to be cared for by pediatric providers. For the purposes of this report, the committee uses the terms “pediatric” and “child” to refer to individuals roughly under age 21; ages are included as appropriate in citation of specific studies.

Generalists, Specialists, and Subspecialists

Generalist physicians who are involved in the care of children include physicians such as general pediatricians and family physicians. Specialist physicians who care for children include professionals such as psychiatrists, surgeons (all types), and anesthesiologists, who complete a general residency and then receive training in the care of children and adolescents. The largest group of specialists who care for children complete a pediatric residency and then pursue additional training in discrete areas of medicine (e.g., rheumatology, endocrinology, adolescent medicine). In this report, the committee primarily uses the term “pediatric subspecialist” to refer to physicians with certification in specialty areas granted by the American Board of Pediatrics, the American Osteopathic Board of Pediatrics, or, in some cases, by another American Board of Medical Specialties (ABMS) board (see later in this chapter for a discussion of pathways for subspecialty certification). The committee’s definition of the term excludes general pediatricians, family physicians, advanced practice providers (e.g., advanced practice registered nurses, physician assistants), adult-trained subspecialists, and others who provide specialized care for children. See later in this chapter for a discussion of the committee’s focus, including primary attention to medical subspecialties (as opposed to surgical subspecialties).

Underrepresented Populations

The Association of American Medical Colleges (AAMC) defines underrepresented in medicine (URiM) as “those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the population” (AAMC, 2023). The AAMC recognized the need to allow the term to be used flexibly in response to changing demographics, including variation at the regional or local level. In their workforce-related demographic data collections used widely in this report, the American Board of Pediatrics (ABP) includes the following categories: American Indian or Alaska Native; Black or African American; Hispanic, Latino, or Spanish Origin; and Native Hawaiian or Other Pacific Islander (ABP, 2023a). For the purposes of this report, the committee uses URiM broadly to allow for

inclusion of a wide array of groups and not necessarily based on racial and ethnic demographics alone. For example, individuals from economically disadvantaged backgrounds may be considered to be URiM and would be included in this broad definition. However, the committee separately refers to this population in certain discussions (e.g., loan repayment).

The National Institutes of Health describes populations underrepresented in the extramural scientific workforce (including the biomedical, clinical, behavioral, and social sciences workforces) (NIH, 2022b). This includes certain racial and ethnic groups, individuals with disabilities, individuals from economically disadvantaged backgrounds, and others (depending upon the discipline). While the committee uses URiM throughout the report, they note that underrepresentation may be different for the clinical subspecialties than for subspecialists who focus on research.

High-Priority Subspecialties

In their 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, while 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 non-procedural pediatric subspecialties. The number and proportion of individuals who are extramurally funded physician–scientists vary substantially by pediatric subspecialty. Waiting times to access care also vary among pediatric subspecialties, from days for some to months for others, and by geographic location. While there are 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 chapters and recommendations will differ within the specific context and may change over time. Thus, this report does not employ a single definition for “high-priority.”

STUDY CONTEXT

The pediatric-specific pattern of disorders, infancy’s anatomic challenges, children’s rapid physical, cognitive, and socioemotional development, and the triadic clinician-parent-child relationship create unique challenges and provide strong justification for a pediatric health care system with its own workforce. To examine whether the current and future pediatric workforce is adequate to meet children’s needs, it is important to understand the history of children’s health, have a general overview of the

health and demographics of today’s children, and understand the development and evolution of pediatrics and pediatric subspecialties.

History of Children’s Health

In the nineteenth and twentieth centuries, infant, child, and adolescent morbidity and mortality fell dramatically because of awareness of and improvements in public health (e.g., sanitation) as well as the impact of poverty and child labor (Bhatia et al., 2019; Connolly, 2023). The U.S. Children’s Bureau was established in 1912 to improve the health of mothers and children, and the Sheppard-Towner Act, enacted in 1921, provided grants to states to develop health services for mothers and children (Brosco, 2012; Mahnke, 2000). However, due to opposition to the Act, it lapsed in 1929 (Mahnke, 2000).

The advent of antibiotics in the mid-twentieth century, combined with the development and routine immunization of the majority of children with effective vaccines, led to reduction of serious morbidity and mortality due to infectious diseases (Bhatia et al., 2019; Brosco, 2012; Thompson, 1984). This was followed by the development of effective drugs to treat childhood leukemias and other cancers, and advances in technology such as incubators and ventilators for the care of premature infants (Jessop, 2015; Thompson, 1984). As noted by Phoon (2018), “the establishment of the [NICHD] in 1962 underscored the importance of investigating human development throughout the entire life process, starting even before birth and with a critical role of health in childhood.” With substantial improvement in child survival, there has been a conceptual shift to address the needs of children with chronic medical conditions and more recently, children with special health care needs. There has also been a growing understanding of the mental, behavioral, and developmental needs of children, as well as their comorbidity with physical health. (See Chapter 2 for more on children’s changing health care needs.)

Overview of Children’s Health and Demographics Today

The health of today’s children sets the foundation for the future health of the nation (NRC and IOM, 2004). A child’s health and well-being (or lack thereof) can have lifelong health effects (Barker, 2004; Boyce et al., 2021; Halfon and Hochstein, 2002; Halfon et al., 2014; Halfon et al., 2018; Lebrun-Harris et al., 2022; Shonkoff et al., 2021). Investing in children’s health enhances the nation’s future economic productivity, reduces rates of adult disorders and their associated disability, and improves the well-being of the children and their families. However, children face a host of threats

linked to unhealthy lifestyles and diets, injury and violence, inequality, pollution, and climate change (WHO, 2020). Furthermore, many children live in families and communities that experience stress associated with poverty, language barriers, interpersonal and structural racism, and adverse social influences on health, which directly harm children and create challenges for parents and health care providers (Beech et al., 2021; NASEM, 2017; Trent et al., 2019). The COVID-19 pandemic exacerbated many of these problems for vulnerable children, and increased the burden of mental, emotional, and behavioral health as summarized in a recent National Academies report (NASEM, 2023).

In 2020, children (individuals younger than 18 years) in the United States numbered more than 73.1 million and accounted for 22.1 percent of the total population (U.S. Census Bureau, 2021). This represents a 1.4 percent decrease (more than 1.075 million children) since 2010, when children younger than 18 years represented 24 percent of the population. However, children today are increasingly diverse. In 2020, only 53 percent of the population under age 18 reported race as “White alone” (compared with 65.3 percent of children in 2010 and compared with 74.7 percent of adults 18 years and older) (Jones et al., 2021). Furthermore, 15.1 percent of children reported being “two or more races” in 2020 (compared with 5.6 percent in 2010). These changing demographics are particularly important because racial and ethnic disparities in children’s health are persistent, widespread, and long lasting (Braveman and Barclay, 2009; Cheng et al., 2015; Flores and The Committee on Pediatric Research, 2010) and have great influence on the need for pediatric subspecialty care.

Organizations such as AAP have issued policy statements that emphasize the need for strategies to address health and development issues across the pediatric lifespan regarding ethnicity, culture, and circumstance, issues that are critical to reducing health disparities (Trent et al., 2019). In addition, children remain the poorest population subgroup in the United States. In 2021, the child poverty rate (for people under age 18) was 16.9 percent, 4.2 percentage points higher than the national rate (Benson, 2022). The large proportion of U.S. children who live in poverty, coupled with structural racism, has significant negative effects on children’s health and wellbeing (Trent et al., 2019). Compared with other advanced nations, U.S. children experience more unfavorable outcomes across numerous health and social indicators such as mortality, family poverty, access to health care, and exposure to crime and violence (Anderson et al., 2022; Martorano et al., 2014; Thakrar et al., 2018).

Brief History of Pediatrics and the Development of Medical Subspecialties

The earliest pediatricians in the United States championed the importance of preventive medicine, the interrelationship between child and maternal health, and social determinants of health to reduce child and maternal mortality and morbidity (Faber and McIntosh, 1966; Mahnke, 2000). In 1860, Dr. Abraham Jacobi first lectured on the diseases of childhood (Connolly, 2023). At the time, specialists focused on a specific organ or technology, but Jacobi argued that the role of pediatricians should go beyond diseases and instead look holistically at child health. In 1880, a group of physicians founded the American Medical Association’s section on the diseases of children, followed in 1888 by the American Pediatric Society (APS, 2022; Connolly, 2023). In the late 1800s, children’s hospitals, originally designed for social welfare, began to focus more on the care of children with medical and surgical needs (Connolly, 2023).

In the early twentieth century, physicians could “self-declare” as a pediatrician without completing any specific training (ABP, 2023b). In response to such concerns, medical schools began offering training in certain specialties, and specialty boards were developed (ABP, 2023b). In 1931, the AAP was formed, followed by ABP in 1933 (ABP, 2023b,c). The ABP focused on “reviewing accreditation of training programs, developing criteria for those to be certified, and examining applicants” (ABP, 2023b). Originally, pediatricians were certified once, at the beginning of practice. In 1988, ABP began to require certification every 7 years; the time requirement changed in 2006 to align with the maintenance of certification requirements of the American Board on Medical Specialties, and as of 2019, pediatricians must recertify every 5 years (ABP, 2023b).

The development of pediatric medical subspecialties and the requirements and expectations for training and certification in those subspecialties have reflected the consensus of the pediatric community and specialty organizations on how best to address medical needs of children and advances in their diagnosis and care. Pediatric subspecialties grew out of clinics within medical schools in the 1930s and 1940s (ABP, 2023b). Before 1978, trainees were eligible for subspecialty certification after fellowship training following a minimum of 2 years of general pediatric training (Jones, Jr., et al., 2001; Stevenson et al., 2014). During these years, most fellowships would be best described as apprenticeships where trainees and mentors, usually partnered by reputation, areas of expertise, and personal connections would work together using broadly defined expectations of the field in the clinical and research activities of the mentor. Oversight by regulatory bodies was present, but less distinctly outlined, as the definition of program requirements did not develop until after the founding of the ACGME in 1981.

In 1978, the Task Force on the Future of Pediatric Education (FOPE) drove sweeping changes in pediatric residency training, including the need for a 3-year residency program; enhanced experiences in ambulatory settings; increased attention to developmental, behavioral, and adolescent health; and improved skill development in team-based care (Kempe et al., 1978). In 2000, The Future of Pediatric Education II (FOPE II) stated that subspecialty training should embrace providing experiences in clinical care, teaching, and research; the report also reconfirmed many of the recommendations and concepts provided in 1978 and continued to underscore the uneven geographic distribution of U.S. pediatricians (Chang and Halfon, 1997; DeAngelis et al., 2000; Gruskin et al., 2000).

Medical Subspecialty Certification Today

As shown in Table 1-1, the first subspecialty in pediatrics to be recognized by ABP for certification was cardiology (in 1961) followed by hematology/oncology, nephrology, and endocrinology (all in the 1970s) (Macy et al., 2021). The ABP currently grants certification for 15 medical subspecialties. For more on pediatric subspecialty education and training, see Chapters 4 and 5.

In addition to the 15 ABP-certified subspecialties, ABP recognizes 5 subspecialties administered by other co-sponsoring ABMS boards, and offers several combined training programs and non-standard pathways for subspecialization (see Table 1-2) (ABP, 2023d,e,f). The American Osteopathic Board of Pediatrics (AOBP) grants subspecialty certification in neonatology and adult and pediatric allergy and immunology (AOBP, 2023a,b). Other ABMS boards offer medical subspecialty certification in the care of children without collaboration with ABP (e.g., pediatric dermatology). Some subspecialties do not have formal certifications but are widely recognized by the pediatric community (e.g., obesity medicine). A variety of surgical subspecialties are also involved in the care of infants, children, and adolescents.

STUDY FOCUS

The committee recognizes the important contribution of many different types of clinicians towards 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 1-3). 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

TABLE 1-1 Pediatric Medical Subspecialties by First Year of Certification

SOURCES: ABP, 2023d; CoPS, 2022a,b,c,d,e,f,g,h,i,j,k,l,m,n,o; Macy et al., 2021.

committee also considered other pediatric medical subspecialties, including those certified by the American Osteopathic Board of Pediatrics (AOBP), subspecialties that are cosponsored by ABP but certified by other boards within the American Board of Medical Specialties (ABMS), subspecialties that are pursued through ABP non-standard pathways and combined training programs, subspecialties that are certified by other ABMS boards (without collaboration of ABP), and emerging medical subspecialties.

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 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.

TABLE 1-2 Pediatric Medical Subspecialties Engaged with ABP and AOBP

NOTE: *indicates subspecialties (in addition to “academic generalist”) represented in the Council of Pediatric Subspecialties (CoPS, 2023).

SOURCE: Committee generated.

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 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

TABLE 1-3 Primary and Secondary Focus of Report

NOTE: *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.

SOURCE: Committee generated.

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.¹

PREVIOUS WORK OF THE NATIONAL ACADEMIES

Many previous National Academies reports are relevant to this current study. For example:

• Children’s Health, the Nation’s Wealth (2004) reflects on inadequacies in the ways in which the nation monitors and optimizes the health of children. Specifically, the report notes the need to measure and monitor trends in health, in part to anticipate the need for specific services (NRC and IOM, 2004).
• Graduate Medical Education That Meets the Nation’s Health Needs (2014) highlights concerns about a mismatch between population health needs and the specialty makeup of the physician workforce, physicians’ geographic maldistribution, insufficient diversity, gaps between new physicians’ knowledge and currently required competencies, and a lack of fiscal transparency (IOM, 2014).
• The Promise of Adolescence: Realizing Opportunity for All Youth (2019) emphasizes that adolescents undergo complex neurobiological and sociobehavioral transformations as they develop. Equity is brought to the forefront in ensuring the “promise of adolescence” for all adolescents and bridging the disparities in resources and supports that disadvantaged youth face (NASEM, 2019).
• Implementing High-Quality Primary Care (2021) aims to make high-quality primary care available to everyone by modifying payment approaches, expanding accessibility, strengthening community-based training of the workforce, improving the use of health information technology, and monitoring implementation of recommended approaches (NASEM, 2021).
• Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families (2023) recommends improved data collection to monitor ongoing effects of COVID-19 on children and families and strengthening and expanding Medicaid at the federal level to ensure access to high-quality care (NASEM, 2023).

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¹ 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).

STUDY APPROACH

The Committee on the Pediatric Subspecialty Workforce and Its Impact on Child Health and Well-Being consisted of 17 members with a broad range of expertise, including general and subspecialty pediatrics, primary care, family medicine, nursing, clinician training and education, health services research, clinical research, bench research, health policy, health disparities, and health economics. Appendix A provides brief biographies of the committee members and staff.

The committee deliberated during seven hybrid meetings, many working group calls, and multiple ad hoc meetings between May 2022 and June 2023. Additionally, the committee held six virtual public webinars and invited speakers to offer comments or make presentations to inform the committee’s deliberations. The speakers provided valuable input on a broad range of topics, including patient and family perspectives, emerging issues in child health, innovative approaches in education and training, early career perspectives on the subspecialty pipeline, meeting community needs, modeling the future subspecialty workforce, the pediatric physician–scientist and research pathway, and innovative clinical practices to improve access.

The committee also completed an extensive search of the peer-reviewed literature and the gray literature, including publications by private organizations, advocacy groups, and government entities. In addition, the committee established an online system for collecting narratives on patient and family experiences with pediatric subspecialty care as well as perspectives from clinicians on why they selected their subspecialty and what barriers they faced. This “call for perspectives” was posted on the project website, announced at all public meetings, and shared with project sponsors; it included two open-ended questions. Patients and families were asked to comment on “what has been your experience with seeking pediatric subspecialty care?” Trainees and clinicians were asked “why do you want or why did you decide to go into your chosen pediatric subspecialty? What barriers, if any, do you or did you face?” There was also an opportunity to submit any additional thoughts on pediatric subspecialty care. A total of 166 sets of comments were submitted, and most came from the pediatric subspecialty trainees and clinicians themselves. Selected quotes from these narratives are included in boxes throughout this report.² Finally, the committee commissioned a data analysis to better understand the patterns of children’s uses of medical subspecialty care. The commissioned analysis examined health plan administrative files for commercially insured individuals. Two other data analyses were submitted to the committee: one examined patterns for children who received subspecialty care in academic medical centers while

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² The full list of submissions can be found in the project’s public access file.

the other examined subspecialty care based on a dataset of Medicaid beneficiaries. All three of these data analyses, as well as the narratives described above, are included in the project’s public access file.

Vision of High Quality of Care

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 Medicine³: 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 fully addressed 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 patients, families, and clinicians are considered partners in determining 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 practice at the top of their scope with appropriate reimbursement for their administrative and clinical work. Increased opportunities are needed for implementation of innovative delivery system models and health care technologies, and flexible training pathways are needed to train the workforce in response to the changing medical and behavioral health needs of infants, children, and adolescents.

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³ 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.

Data Limitations

Concerns about significant shortages in the availability of the entire pediatric workforce, which may affect access to care, are prevalent in the literature. However, research and data on the pediatric subspecialty workforce remain limited in many key areas (which are noted throughout the report). Previous studies on the pediatric subspecialty physician workforce are often outdated (i.e., more than 10 years old), use limited sampling methods, have low response rates to surveys (leading to concerns about response bias), and do not distinguish between subspecialists and general pediatricians.

The committee also noted several other challenges of the literature. First, there is mixed use of the terms “specialist” and “subspecialist,” and many reports and datasets do not use a standard set of subspecialties when speaking to subspecialties broadly in their research. In some cases, only a subset of ABP-certified subspecialties are included, or they are included in combination with other pediatric subspecialties, or even in combination with specialties and subspecialties outside of pediatrics. As noted by Laurel Leslie, vice president of research for ABP, in her presentation to this committee in a public webinar:

Additionally, for some surveys, the definition of a specialist might be subject to interpretation by patients and families. For example, the National Survey of Children’s Health defined specialists as “doctors like surgeons, heart doctors, allergy doctors, skin doctors, and others who specialize in one area of health care” (CAHMI, 2023). Finally, the committee noted a lack of robust data on patient outcomes associated with subspecialist care and lack of standard definitions for measures within those studies.

Organization of the Report

The committee structured its report around the main issues challenging the pediatric medical subspecialty workforce. This introductory chapter has described the study context, charge to the committee, and the scope and methods of the study. Chapter 2 provides an overview of access to pediatric subspecialty care and its connection to child health while Chapter

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⁴ The webinar recording can be accessed at https://www.nationalacademies.org/event/11-02-2022/the-pediatric-subspecialty-workforce-and-its-impact-on-child-health-and-well-being-webinar-3.

3 presents the three data analyses considered by the committee to better understand the usage of pediatric subspecialty services. Chapter 4 focuses on the pediatric subspecialty workforce itself, including basic demographics and how subspecialists are trained, and offers a high-level summary of the overall health care workforce for children. Chapter 5 considers the factors that influence the choices of physicians to pursue a career in a pediatric subspecialty, and Chapter 6 specifically explores the pediatric subspecialty research workforce. Chapter 7 explores the interface between pediatric subspecialists and the broader child health care workforce, particularly the interface between primary care clinicians and pediatric subspecialists. Finally, Chapter 8 examines financing of child health. In addition to the main report, Appendix A contains committee, fellow, and staff biographies.

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