Why are fewer U.S. MD graduates choosing pediatrics

Merrill Curtis was still awake, trying to get her 7-year-old son to go to bed on the evening of January 3, 2023, when she heard an alarming sound coming from her 13-year-old daughter's bedroom.

She rushed in and saw her daughter, Callie, moving robotically and foaming at the mouth, experiencing a seizure.

Stunned, Curtis called 911, and Callie was rushed to the pediatric emergency room at NewYork-Presbyterian (NYP) Komansky Children's Hospital, which was just a few blocks from their Manhattan home.

The hospital staff worked quickly, ordering an MRI and a CT scan, and by early the next morning, the pediatric neurosurgeon on call had identified the problem: Callie had developed a cavernoma (abnormal cluster of vessels with blood-filled bubbles) in her brain near the speech and language processing center. Callie would need an appointment with a pediatric neurologist and, eventually, surgery.

Curtis promptly called the office of the neurologist the neurosurgeon had recommended, only to be told that the next available appointment was in four months.

Callie's condition was urgent, and Curtis couldn't believe she had to wait so long to get care.

Ultimately, Curtis was able to get Callie an appointment sooner than expected, and she underwent successful brain surgery. She is healthy now, but the experience haunted Curtis.

"NYP is our backyard hospital. And lucky for us, it has the best pediatric ER. Not all hospitals have a pediatric ER. I'm so grateful for that. But I suddenly started thinking, 'That's not available for everybody,'" Curtis says. It woke her up to the challenges facing the pediatric workforce and what could happen to other kids like Callie who are experiencing health crises.

"If we can't recruit the doctors, and if doctors don't want to go into pediatrics, what happens in 5, 10, 15 years? Does pediatric health care cease to exist? You can't have a pediatric ER and a full children's hospital within NYP if you don't have the doctors."

It's an issue that worries not just patients but many leaders in the field of pediatrics.

In March 2024 the National Residency Match Program® (NRMP) announced that the percentage of pediatric-residency positions that were filled through the Match® fell from 97% in 2023 to 92% in 2024. Most of the pediatric-residency positions were ultimately filled through the Supplemental Offer and Acceptance Program (SOAP®), the process through which students who didn't match via the NRMP algorithm can interview for unfilled positions, and programs can choose candidates.

"We were really shaken by the Match®," says Megan Aylor, MD, a pediatric-residency program director at Oregon Health & Science University School of Medicine in Portland, and president of the Association of Pediatric Program Directors. "There's a lot of anxiety among program directors [regarding] the upcoming Match® and the future of the pediatric workforce on the whole. This isn't just about filling positions for three years. It's about cultivating a workforce that meets the needs of our nation's youth."

Aylor says that some pediatric-residency programs had to adjust to support many of the residents who matched through the SOAP process and came into residency with varying levels of experience. In the 2024 Match®, just 48% of pediatric residencies were filled by U.S. MDs, who generally match at higher rates than DOs and International Medical Graduates.

"Many positions were filled by applicants who didn't initially plan to go into pediatrics, or who have little or no clinical experience in the U.S.," she says. "While programs were glad to welcome these trainees into the pediatrics workforce, many had to adapt their orientation and onboarding."

Longstanding decline in student interest

Although the number of pediatric-residency positions available has increased, interest in pediatrics among U.S. MD graduates has been stagnating for years. This is even as the number of medically complex cases in children increases due to advances that save children from what used to be fatal conditions.

"What we saw this year in the Match® was a wake-up call, but it certainly wasn't news to us," says Jesse Hackell, MD, a retired private practice pediatrician who chairs the American Academy of Pediatrics' Committee on Pediatric Workforce. "Over the past four to five years, the number of people matching in pediatrics has been virtually the same, whereas many other fields have grown."

In 2023 the National Academies of Sciences, Engineering, and Medicine (NASEM) released a report, "The Future of the Pediatric Subspecialty Physician Workforce," which highlighted the barriers to physicians pursuing a pediatric subspecialty, including lower compensation than offered by most adult subspecialties, increasing complexity of pediatric patient cases, and less exposure to pediatrics during medical school and before.

Sallie Permar, MD, PhD, a professor of pediatrics and chair of the Department of Pediatrics at Weill Cornell Medicine, and pediatrician-in-chief at NewYork-Presbyterian Komansky Children's Hospital, says that filling fellowships for certain pediatric subspecialties has also been difficult. And with fewer pediatric fellows, the workload for subspecialists at teaching hospitals has increased, thus exacerbating the risk of burnout.

"Those of us in academia have started to see the impacts - not only on the careers of our doctors but also on not being able to provide access to high-quality care for children who have medical complexity," Permar says.

And though there are many facets to the decline, Permar and other experts in the field say that the disparate compensation is one of the most glaring issues.

"Treating children has the highest yield of all professions, the highest potential to support lifelong health and to lower the costs of health care over the long haul," Permar says. "It's going to take a collective effort, using our creativity, to maximize the revenue potential for pediatrics."

Smaller patients, smaller paycheck

Out of all physician specialties, pediatrics falls near the bottom of the list when it comes to compensation. According to a 2024 Medscape report on physician compensation, pediatricians made an average of $260,000 a year in 2023. Specialties in the midrange included OB-GYN, with $352,000, and emergency medicine, with $379,000. The higher-earning specialties, such as cardiology and orthopedics, earned over $500,000 a year. Pediatric subspecialists also often make less than their adult-care counterparts and even general pediatricians, according to the NASEM report.

The lower compensation for pediatricians is the result of two main factors, Permar explains. One is that the Centers for Medicare and Medicaid Services sets rates for services and pays more for procedures than for time spent with patients, and general pediatrics requires a lot of time spent speaking to families (at well-child visits and discussing vaccinations, for instance). The other is that more than half of all children in the United States get their health insurance from Medicaid, which covers families living on low incomes, or from the Children's Health Insurance Program, which offers low-cost insurance for kids in families that make too much to qualify for Medicaid but can't afford other health coverage. According to the American Academy of Pediatrics, Medicaid pays pediatricians at two-thirds the rate of Medicare, which in turn pays less than private insurance.

And while $260,000 a year might still put someone in the top 10% of earners in the United States, the median medical school debt with which a physician graduates is $200,000, not including any other student loans, according to an AAMC report.

"Sometimes I will ask a student interested in a specific specialty, such as infectious disease, if they've considered pediatrics, and their immediate reaction is to tell me about their financial situation, debt status, family, etc." Permar says. "But I wasn't asking about their financial situation. That is exactly where we've left students."

Recruiting for the future

Another barrier to attracting future pediatricians is a lack of early exposure to pediatrics in medical education, says Robert Vinci, MD, a professor of pediatrics at Boston University Chobanian & Avedisian School of Medicine and co-leader of the Association of Medical School Pediatric Department Chairs (AMSPDC) Pediatrics Workforce Initiative.

"It's becoming increasingly apparent that students are using earlier experiences to help them understand the discipline where they may choose to work," Vinci says.

Most medical curricula and clinical time are focused on adult care, limiting the opportunities medical students have to experience the breadth of pediatric subspecialties. Many also lack mentors and role models in pediatrics, which can have a strong influence on a student's career path.

Hackell argues that this does students and their future patients a disservice.

"Pediatric experience in medical school, for many people, has gotten less and less. You spend your time in the neonatal ICU and in inpatient units dealing with kids who are seriously ill, and you may not see the joy and fun part of pediatrics," he says. "Pediatrics deserves the same exposure as cardiology, surgery, or neurology. We deal with little people who don't have their own voice, [and yet] we do have the best opportunity to make a difference before they need to go see all those other subspecialities later on."

The AAMC's 2022 Medical School Graduation Questionnaire found that nearly half of graduating medical students planning to go into pediatrics had already wanted to be a pediatrician when they entered medical school, suggesting that, for many, attraction to the specialty starts earlier in life, the NASEM report stated.

The AMSPDC Pediatrics Workforce Initiative that Vinci is helping to lead has working groups focused on various aspects of recruitment, including enhancing early exposure to pediatrics, exploring innovative models for education, expanding opportunities for research, and rethinking clerkship and fellowship length for pediatric subspecialties, as well as other approaches for bolstering the future of pediatrics.

Still, Vinci says that it can't be left up to the leaders in pediatrics to make all the changes needed to increase the pediatric workforce. This is especially important since shortages of pediatricians could result in poor health, potentially worsening population health and driving up health care costs in the long term, Vinci and Permar wrote in an opinion article for STAT.

"We need health systems to invest more heavily in pediatrics," Vinci says. "We can make changes to educational systems, we can think about how we develop different care models or innovative care models, but at the end of the day, we need the health systems and academic medical centers to be aware of the enormous value of pediatricians and the care of children."

A meaningful career

While they see the challenges facing their field, the pediatricians interviewed for this article did not want to paint an entirely bleak picture of the state of pediatrics. In fact, they believe speaking about the benefits of their profession to be an effective recruitment strategy.

Hackell was one of the people who knew he wanted to be a pediatrician before he even started medical school. He admired his own childhood pediatrician and recalled his easygoing nature, as well as his penchant for wearing shorts, sandals, and 1970s love beads to the office.

"Taking care of children was a total joy for me, and it remained that way for 40-plus years of practice," Hackell continues. "I loved working with families and had relationships that went through three generations."

For Vinci, the joy of a fulfilling career, being able to have an impact on a child's life course, and working with families has kept him enamored with his specialty.

Aylor has enjoyed the challenge and breadth of experience that pediatrics offers and appreciates how it allows her to follow her passion for medical education and training future generations of pediatricians.

And for Permar, who as a physician-scientist and infectious disease specialist has a special interest in vaccines, pediatrics was the area in which she believed she could make the most impact.

"It is the only specialty in which you can provide a lifetime of health, setting children on a trajectory to reach their fullest potential," Permar says. "And we can't deny that children are really adorable, which is also compelling."