PEDIATRICS Vol. 110 No. 3 September 2002, pp. 647-648
Pediatric Career Choices
To the Editor.—The article by Pan et al1 is highly revealing in terms of its observations regarding the future aspirations and visions of our present trainees in pediatric programs in the United States. Clearly, issues of gender, geography, marital status, and economics are important determinants of pediatric career choices. However, I would like to suggest some other trends that are probably equally critical areas for investigation that I have noted in my experience as a residency program director.
First, data from several recent surveys demonstrates that in many regions of the United States, the employment opportunities in primary care pediatrics are very limited. As a result, graduates of pediatric programs are either underemployed, unemployed, or selecting alternative career pathways. This trend is accentuated by the industrialization of pediatrics involving corporate practice purchases and mergers and only began to significantly effect resident’s own long-term goals in 2000 to 2001.
Second, as Pan et al1 demonstrate, 9% to 16% of the residents in his sample had no position at the time of the survey. Although the timing of the survey and associated family and/or visa issues may play a role here, it also, in my experience, is the harbinger of changes in the fundamental fabric of our specialty. Such changes are evidenced in declining interest in primary care in general and the increased push towards hospitalist careers and subspeciality training. I would submit that an analysis of those with no position not only in Pan’s sample but presently would be most insightful.
Third, pediatric residents with significant relationships either in medicine or another field are not free to pursue positions in rural and underserved nonmetropolitan areas because of a dearth of employment opportunities for the career needs of both. Thus, although here in Pennsylvania, pediatric opportunities exist in small towns and rural areas, most pediatric residents still see the need, for lifestyle and family considerations, to locate in larger metropolitan areas where the primary care employment marketplace has been decimated in recent years.
Finally, it is apparent to me, as a residency director and corroborated by other program directors, that lifestyle and personal considerations are definitely and markedly different in recent years than they were previously. Events even such as 9/11 have solidified for many the choice of staying close to family and valuing the personal, even at the cost of a particular fellowship or practice opportunity. Such a trend will clearly impact on the needs for pediatricians and their workplace desires.
Pan has opened the door on the future of pediatrics. Much work remains to be done to track the definable trends. Clearly, efforts to strengthen the fabric of generalist pediatric training need to be adjusted when one looks at what residents value, what the marketplace for employment supports, and the rapid evolution of hospital-based opportunities for recent graduates. These trends require new skills and a higher intensity than the emphasis on the "new morbidity" seemed to suggest. The move towards a more "British" model for pediatric practice style seems to be defining the emerging changes on the horizon.
Bradley J. Bradford, MD
Mercy Children’s Medical Center
Mercy Hospital of Pittsburgh
Pittsburgh, PA 15219, USA
REFERENCE
- Pan RJ, Cull WL, Brotherton SE. Pediatric residents’ career intentions: data from the leading edge of the pediatrician workforce.
Pediatrics.2002; 109
:182
–188
[Abstract/Free Full Text]
In Reply.—
We appreciate the observations made by Dr Bradford as a department chair and residency program director. Recent survey findings by the Center for Health Workforce Studies presented to the Council on Graduate Medical Education (COGME) have indicated that employment opportunities in primary care pediatrics are more limited than in other specialties within New York and California. As Dr Bradford pointed out, our study indicates that family considerations, including spousal employment, may take greater precedence over individual career opportunities and may limit the mobility of recent residency graduates. The role of managed care in creating a physician surplus,1 including that of pediatricians, has been called into question by new studies projecting physician shortages.2 Unfortunately, the shortages likely will occur in areas that are less desirable to residents and their families.
As for the respondents who report not having a position at the time of the survey, approximately half reported not receiving a satisfactory offer and less than a fifth reported visa issues. Approximately one-third reported taking time off for personal reasons. Our study indicates continued interest by pediatric residents in primary care, and we have no evidence to suggest that this situation represents an increased interest in subspecialty or hospitalist positions. Dr Bradford’s observations, however, are consistent with declining interest in primary care in recent NRMP match data.3
We agree that pediatrics needs to adapt to both the demographic changes in the pediatric workforce and economic changes in the healthcare environment. Greater flexibility in practice opportunities to allow a better balance between career and family obligations, including part-time arrangements, better accommodations for parental and family leave, and improved child care, are needed. In addition, characteristics of the health care environment such as capitation and decreased inpatient care have given pediatricians even greater responsibility for the overall health of a population of children; thus the need to teach residents how to care for the "new morbidity" is as important as ever. Residency education in behavior and development, evidence-based medicine, child advocacy, and care coordination now have even greater importance. It would be premature to assume an evolution toward a "British" model of pediatric practice in the United States and narrow the scope of pediatric education to hospital-based care.
Richard J. Pan, MD, MPH
Department of Pediatrics
University of California Davis Medical Center
Sacramento, CA
William L. Cull, PhD
Sarah E. Brotherton, PhD
AAP Committee on Pediatric Workforce
Department of Practice and Research
Elk Grove Village, IL 60007
REFERENCES
- Weiner JP. Forecasting the effects of health reform on US physician workforce requirement. Evidence from HMO staffing patterns.
JAMA.1994; 272
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–230
[Abstract/Free Full Text] - Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic trends signal an impending physician shortage.
Health Aff (Millwood).2002; 21
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–154
[Abstract/Free Full Text] - Pugno PA, McPherson DS, Schmittling GT, Kahn NB Jr. Results of the 2001 National Resident Matching Program: family practice. Fam Med.2001; 33 :594 –601[Web of Science][Medline]
PEDIATRICS (ISSN 1098-4275). ©2002 by the American Academy of Pediatrics
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