Healthcare Insights: Where Are All The Pediatricians?

This month, I experienced the miracle of my daughter giving birth to her first child, a beautiful baby girl. I now have the honor and privilege to be a grandparent for the second time.

My daughter and our extended family recently had a great deal of interaction with the medical system designed to support women’s health through pregnancy, delivery, and post-partum care.  Now that our new arrival is thriving in the world, I want to turn my attention to her pediatric care.

I have paid some attention over the years to the severe shortage of pediatricians in our country. Listen to this NPR interview with Dr. Sallie Permar of Cornell Weill Medical School which describes some of the root causes and associated consequences of the shortage of pediatricians we have in the United States.

Here are some central themes from the interview:

• The number of pediatric residencies for medical school graduates upon completion of medical school have been falling precipitously. We have had a shortage of pediatricians for some time across the country in both rural areas and in big cities. A major cause of this shortage is the lack of interest in in this speciality for current medical students, which has resulted in pediatric residency decreasing at a faster rate than ever before.
• Medical school graduates accumulate hundreds of thousands of dollars of education debt. Education for a pediatrician takes the same amount of time and costs the same as any other medical education. However, the salaries for pediatricians are much lower than for other specialties. In brief, becoming a pediatrician is much more precarious financially.
• We know from the data that a majority of children born in the United States are born into families on Medicaid. Medicaid reimbursement rates for children are much lower than Medicare and commercial insurance reimbursement rates for adults. Based on low payment for pediatric services, it is very difficult for a pediatrician to pay off the high cost of education, along with the high costs of running a medical practice. The result is our current severe shortage of pediatricians.

What is the impact on children and society of a shortage of pediatricians?

Medical practice and research have greatly advanced over the past 40 years.  We have learned so much more about the risks of childhood and youth disease and illness which both accentuates the need for more care at the early stages of life as well as understanding the consequences of adult disease and illness related to the failure to prevent disease and illness in children and youth:

“Achievements in pediatric research in the past 40 years have driven solutions that have dramatically reduced childhood morbidity and mortality (Cheng et al., 2016). However, this progress is now under threat as evidenced by rising morbidity and mortality rates (Ely & Driscoll, 2022). Many see persistent inequities in child health, high rates of adverse childhood experiences (Camacho & Clark Henderson, 2022), and rising rates of mental and behavioral health conditions and obesity as contributing to this threat (see Chapters 2, 3, and 4). The pandemic made clear that the United States is at a crisis point regarding poor physical and mental health among the nation’s children and youth (Bauer, Chriqui, et al., 2021; Cheng, Moon, & Artman, 2020; National Academies, 2023b; Parolin & Wimer, 2020). High rates of childhood poverty; racism in health care and outcomes; and growing health problems and mortality among working-age adults have major implications for the nation’s economic productivity and prosperity. Rising rates of mortality and disability among youth and working-age Americans reflect outcomes of not providing the care that children and youth need. The U.S. military has raised concerns about the eligibility of young Americans for military service, with the largest increase in reasons for disqualification for mental health and overweight conditions (Department of Defense [DoD], 2020). The contrast between the opportunities presented by scientific and health knowledge and the clearly worsening health of young Americans shows the urgency of addressing child and adolescent health care transformation now.”

The article goes on in great detail about how the failure to treat illness and disease early in life is not only a moral and ethical imperative, there are unnecessary preventable costs associated with the downstream effect on adult disease and illness

“While prevention and health promotion have long been a cornerstone of child and adolescent health care, the current national situation, given the evidence of poor health outcomes downstream, calls for even greater investment in these efforts. Prevention can save money as well as lives and health. (emphasis added). For example, vaccines save both costs in medicine and millions of lives (National Academies, 2024c). Routine immunization of children born from 1994 to 2023 has been projected to prevent nearly 1.6 million early deaths, 508 million illnesses, and 32 million hospitalizations, and to save nearly $2.9 trillion in total societal costs—more than $5,000 for each American (Andre et al., 2008; Centers for Disease Control and Prevention [CDC], 2024j,p; Stack et al., 2011; Zhou et al., 2014). For example, the incremental lifetime medical cost of an obese 10-year-old child relative to a child who maintains a healthy weight through adulthood is $19,000. Multiplying this by the number of obese 10-year-olds yields a total direct medical cost of obesity of $14 billion for this age alone (Finkelstein, Graham, & Malhotra, 2014). Oral health care for children is another crucial component of preventive care. Regular preventive dental visits improve oral health and reduce later costs, particularly for children at high risk of dental disease (Downing et al., 2022; National Institutes of Child Health and Human Development, 2021; Rowan-Legg, 2013). Fluoride treatments, increasingly given in primary care, significantly decrease dental caries in children (Downing et al., 2022; National Institutes of Child Health and Human Development, 2021; Rowan-Legg, 2013). Economic studies show that adverse childhood experiences are associated with trillions of dollars of costs from adult physical, mental, and behavioral health problems and loss in quality of life. (emphasis added). Preventing and mitigating the impact of adverse childhood experiences can likely decrease these long-term costs (CDC, 2019b,d; Peterson et al., 2023). Regarding mental health, universal and targeted school-based cognitive behavioral therapy programs reduce depression and anxiety symptoms in children (Werner-Seidler et al., 2021). Exciting scientific advancements in developmental origins of health and disease, genomics, and predictive artificial intelligence all emphasize the potential of early intervention, prevention, and health promotion.

Re-building the Pediatrician Workforce

In this video from Dr. Bob Vinci, Chief of Pediatrics at Boston Medical Center and Chair of Pediatrics at Boston University Medical School, we learn some of the highlights of both the need and what it will take to meet the challenges of the shortages in pediatric medicine.

Dr. Vinci emphasizes that there is currently a 20-40% gap in the number of pediatric sub-specialty residencies available and those that are filled.  These include critical sub-specialties such as endocrinology and infectious disease, among others.

For this year, 2025, The Association of Medical School Pediatric Department Chairs (AMSPDC) has issued a report calling for major reforms and initiatives to re-build the workforce of pediatricians in the U.S. Key recommendations in the consensus study include:

• Overhauling the Medicaid system to provide more appropriate support for our nation’s pediatric workforce
• Medicare/Medicaid Parity 
• Lobbying Congress for enhanced financial support for the Pediatric Specialty Loan Repayment Program,
• Reforming the graduate medical education payment system, 
• Increasing the number of federally funded pediatric career development research awards for young pediatrician-scientists,
• Developing innovative models of care to more effectively use the pediatric subspecialty workforce,
• Creating new models of pediatric training that are more effectively designed to prepare the workforce to address the evolving physical and mental health needs of the pediatric population.
• Changes to the RVU (incentive payments) model for pediatric care 
• Reduction of barriers to international medical graduates’ participation in the pediatric subspecialty workforce  
• Early exposure to pediatrics and subspecialties
• Explore innovative models for education in Undergraduate Medical Education (UME)
• Targeted early recruitment of a diverse workforce 
• Pediatric role models 
• Expand UME opportunities in pediatric research 

As part of the research and preparation for this article I had the privilege to interview Dr. Patricia Poitevien.

Dr. Poitevien serves as Senior Associate Dean of Diversity, Equity & Inclusion in the Brown University Alpert School of Medicine.  She graduated from Brown Medical School with a specialty in pediatrics, she then performed her residency and became Chief Resident at Bellevue Medical Center in New York City. She continued to practice pediatric medicine at Bellevue for 15 years as part of the NYU faculty.  She later served as a pediatrician at Hasbro Children’s Hospital in Providence before joining the faculty of Brown Medical School. 

In her long career in pediatrics, she has become a national leader in pediatric medicine. She is the past president of the Association for Pediatric Program Directors which is the national organization that oversees all pediatric and pediatric sub-specialty residencies in the nation. She has lectured nationally on disparities in medical education and in healthcare and has led numerous workshops on building diverse and inclusive environments within academic medicine. She has published on professional identity formation and belonging for underrepresented in medicine (UIM) learners, using a competency based medical education framework to advance anti-racist medical education and utilizing simulation in faculty development to address bias in the clinical learning environment.  Her interests include recruitment and mentorship of UIM trainees and faculty, competency based medical education and professional identity formation for UIM learners.

Dr. Poitevien reminds us that “everyone knows someone who is caring for a child.” 

She stresses some very important and disturbing realities about how the nation views pediatric medicine.

The choices of specialty by medical school graduates has nothing to do with NEED for the nation’s population. It is very tragic that specialty choice is largely driven by the need for financial remuneration to allow medical students to pay off enormous educational debt.  Additionally, there is very limited exposure to medical students by pediatric practitioners as nearly all faculty are adult providers.

There is a cultural bias against pediatrics that is part of medical education and practice that Dr. Poitevien calls “reputational prestige”.  There is a bias in favor of specialties such as general surgery, plastic surgery, or cardiology as examples.  In these specialties there is an emphasis on medical practice that is procedural and intervention-based.  Pediatrics by contrast is a practice which emphasizes observation, teaching, and coaching, often seen as less prestigious in the fields of medicine.

Dr. Poitevien is also concerned about the long-standing impact of lower reimbursement rates creating a trend among some leaders in medicine to see the future of pediatrics practiced more and more by Nurse Practitioners and Physicians Assistants.  

While she recognizes the high level of knowledge and professionalism that advanced practice professionals bring to pediatrics, she is also concerned about the falling numbers of pediatric medical school graduates to fill the need for doctors who have the training and experience to keep up with the major advances in medical research, technology, genetics, therapies, and surgical procedures that require medical school education. Dr. Poitevien fears that as the healthcare industry continues to see pediatrics as a lesser specialty than others, thousands, even millions of children and youth will miss out on the advanced medical treatments which can curtail illnesses and diseases at the earliest ages.

She also reminds us that the growing need for pediatric sub-specialties (infectious disease, pulmonology, endocrinology, gastroenterology, and surgery as examples) are severely threatened by the trend of pediatric residency slots going unfilled.  A pediatric sub-specialist cannot be certified without being first certified as a pediatrician.  It is also the case that a pediatric subspecialist is paid lower than an adult sub-specialist.  These lower payments are baked into the coding systems for procedures which institutionalizes lower payments for pediatric care even though the care for patients requires equivalent training and knowledge.

Dr. Poitevien and I discussed the need for state-based campaigns to re-build our pediatric labor shortage.  It is at the state level where Medicaid funds originate and make up large shares of state budgets. As a result, it is at the state level where the data and the reality of lack of pediatric care can build upon profound community interest.  States have more direct control over how healthcare is actually delivered than the federal government, and as such, can utilize its “close-to-the problem” proximity to raise support for solutions. 

The severe and growing shortages of pediatricians in our country reminds us that our healthcare system is, as former Surgeon General Jocelyn Elders noted,  “a sick care system”, not a healthcare system.  A sick care system is expensive and less effective than a healthcare system based on prevention and patient education.  Pediatric medicine is at the heart of what a true healthcare system ought to be:  a system in which children and youth have access to prevention of conditions that only become more complex as children grown into adults.

In the last several articles in this column, I have addressed critical issues: (medical debt and expensive and abusive long-term care) that can incentivize common cause among and within our communities which are so often portrayed as divided and polarized, it is apparent to me that the crisis in pediatrician shortages ought to be another central theme of common cause.  We can come together and reduce divisions in our communities by creating campaigns that solve our most important needs.

Campaigns to attain high quality, affordable, and easily accessible pediatric care address an obvious need that can bring unity and purpose to our communities.

John August is the Scheinman Institute’s Director of Healthcare and Partner Programs. His expertise in healthcare and labor relations spans 40 years. John previously served as the Executive Director of the Coalition of Kaiser Permanente Unions from April 2006 until July 2013. With revenues of 88 billion dollars and over 300,000 employees, Kaiser is one of the largest healthcare plans in the US. While serving as Executive Director of the Coalition, John was the co-chair of the Labor-Management Partnership at Kaiser Permanente, the largest, most complex, and most successful labor-management partnership in U.S. history. He also led the Coalition as chief negotiator in three successful rounds of National Bargaining in 2008, 2010, and 2012 on behalf of 100,000 members of the Coalition.