Two years ago, the RSV epidemic shook pediatric hospitals across the country along with the pediatric residents in them. One of us, Faith, was a resident at the time, and she and her colleagues refer to it as the dark ages: Whether they were arriving for their morning shifts or leaving their night shifts, the number of patients they took care of would not change for weeks at a time. Hospitals were completely filled, and resources were limited. Though the media reported the hospital’s challenges during this time, no one thought of the impact this epidemic would have on the developing pediatric workforce.
This experience led many pediatric residents to decide not to further sub-specialize within pediatrics. It also likely dissuaded many rotating medical students from a career in pediatric medicine. These interactions left a permanent imprint on their opinions of the specialty, as we now see in the outcome of this year’s National Residency Match, with 30% of pediatric residency programs going unfilled.
The combination of political apathy, limited support, chronic underfunding, and limited self-advocacy among pediatricians over decades has made pediatrics one of the nation’s largest health care skeleton crews. Per the Children’s Hospital Association, though all pediatric subspecialties are experiencing shortages, developmental-behavioral, neurology, genetics, and child and adolescent psychiatry are among the worst with more than 40% of in-hospital positions vacant. Without an immediate intervention, pediatric care in the United States will experience an unprecedented decline.
To truly understand the complexities of pediatric health care, it’s crucial to examine the broader political landscape.
Conservative politicians are less likely to support legislation that actively improve children’s lives. Fifteen Republican-controlled state legislatures have not supported Summer Electronic Benefits Transfer for Children to feed children during the summer, blocked the expansion of the Child Tax Credit to reduce childhood poverty, supported the “zero tolerance” policy that separated children from their families at the Southern Border, and backed abortion bans that do not include exceptions for children who become pregnant after being raped. Infant mortality in Texas has risen since the state enacted one of the strictest anti-abortion laws in the nation.
In addition to the pain these policies cause families, especially children, they also create more work for those of us who work in pediatrics.
Forty-seven percent of Medicaid and Children Health Insurance Program enrollees are infants, children and adolescents. Though Medicaid spending was around $800 billion in 2022, only around 17% of Medicaid dollars was spent toward pediatric health care. This leaves children’s hospitals with less resources for the almost 40 million children on Medicaid across the nation who are at the mercy of federal-state funding.
Freestanding children’s hospitals, which teach half of all general pediatricians and pediatric subspecialist trainees nationwide, are not able to receive funding through general medical education funding through Medicaid. In 1999, Congress established the Children’s Hospitals Graduate Medical Education program to address this issue, but congressional funding for this program has so far been always half the amount given to GME. The 59 children hospitals under this program providing 33% of children’s inpatient services nationwide are left to teach future pediatricians with limited funding, which has led to bed shortages and closures within pediatric hospitals.
The most notable pediatric hospital closure, Tufts Children’s Hospital in 2022, showed how both closure and bed shortages are a chronic issue within pediatric medicine as inpatient children beds were converted to adult ICU beds. Research has shown that inpatient pediatric units across the country have decreased by almost 20% leaving few options for children, especially those within rural areas. With less access to children’s hospitals, 1 in 4 children nationwide are forced to travel greater distances to receive care.
Medical students are well aware that children’s hospitals are grappling with bed shortages and even closures. Meanwhile, education funding remains scarce, and pediatricians, especially subspecialists, receive inadequate compensation. As a result, fewer and fewer are opting to consider pediatric medicine as a career choice as this year, applications for pediatric medicine went down 6%. This is a clear sign of things to come as medical students want to choose a profession that is simply less of a headache.
With a new administration about to arrive, it’s time for pediatricians to be proactive and not reactive on funding pediatric education to help increase their workforce. Not taking immediate action can have detrimental impact on the future of our workforce.
Jared E. Boyce, ScM, is an M.D.-Ph.D. candidate in the Medical Scientist Training Program at the University of Wisconsin School of Medicine and Public Health. Faith Crittenden, M.D., M.P.H., is a pediatric endocrinology fellow at Yale New Haven Children’s Hospital and a 2023 public voices fellow with the OpEd Project and the National Black Child Developmental Institute.