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The Pediatric Workforce: What to Expect

Beth A. Pletcher, MD, FAAP Committee on Pediatric Workforce Member

While the numbers of medical students who enter training in pediatrics continues to climb slowly over time, how this relates to workforce adequacy in the future remains a mystery. In 1991, there were 7,455 pediatric trainees in the “pipeline,” whereas, in 2007, the number increased to 10,517. The percentage of trainees who choose general pediatric practice has vacillated over the past 2 decades, with 62% selecting this path in 2007. Gender trends are also of interest, with females representing more than two thirds of trainees in 2007. An even greater percentage of women than men planned to enter general practice, with 10% of those completing training opting for part-time practice. With increasing numbers of women entering pediatrics and more practitioners looking for part-time positions, this is a trend that could potentially impact the pediatric workforce landscape and render the absolute numbers of trainees less reliable in workforce calculations.

Unlike manufacturing enterprises, supply and demand do not necessarily drive physician distribution. Physicians coming out of training are far more likely to enter practice in a high supply versus low-supply region, resulting in access problems for pediatric patients across the United States. Statistics indicate that more than 50% of children and adolescents in this country live in a primary care service area (PCSA) that has no pediatrician at all, and 10% live in a PCSA that has no pediatrician or family practitioner.
While pediatricians are best positioned to provide a comprehensive medical home and care for the sickest children, and make decisions about when and where to refer patients to subspecialists, there are a number of potential threats to pediatric practice. There are increasing time constraints and the need to care for more medically fragile and complex pediatric patients, which is compounded by increasing numbers of uninsured or underinsured patients. Alternative locations for receiving immunizations and well-child care undermine the medical home and potentially threaten the health of our patients. Pressure to see more patients in a day to make ends meet could result in a lower threshold for referral to subspecialists, and limit the time available to keep abreast of medical advances or introduce clinical guidelines into daily practice.
Reduced training hours may result in young colleagues feeling less confident in caring for patients in a busy pediatric practice and having less experience working with advanced practice nurses or physician assistants in an office setting. Mentoring and guiding a new partner in a practice may take time away from direct care of patients.
In light of increasing pressures in pediatric practice and, in, some instances, burnout, some pediatricians are opting for a new model of practice—boutique, or concierge, care. For an annual retainer fee paid by parents, physicians in this practice model care for only about one tenth of the usual numbers of patients, and may even forego insurance billing. Patients still are required to carry insurance for other care, but their pediatric services are covered by this yearly expenditure. While there are just a few of these practices popping up around the United States (primarily in metropolitan areas), if this trend continues, it also has the potential to alter pediatric workforce predictions.
In summary, although there are increasing numbers of pediatric trainees entering practice, and, as more and more women choose pediatrics, we need to be cognizant of how part-time practice may influence the numbers needed to provide care for children in this country. Maldistribution remains a huge barrier to access to health care for infants, children, and adolescents. Pediatricians who are just coming out of training may need additional help integrating into a busy practice because of reduced work hours during residency. Primary care physicians continue to struggle with decreasing reimbursement and increasing time constraints; pediatricians continue to speak up for children as well as their health care providers. While clearly not a direct workforce issue, it is evident that pediatricians need to send a message to policy makers on a local, state, and federal level that no health care investment has greater potential to ensure long-lasting and more favorable outcomes than investing in the health of our children. 
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