The article “Does Fellowship Pay: What Is the Long-term Financial Impact of Subspecialty Training in Pediatrics?” by Rochlin and Simon,1 published in the February 2011 issue of Pediatrics, correctly highlights an issue of critical importance with implications for our future pediatrician workforce and the pediatric patient population it will be called to serve. The authors found that of 11 pediatric subspecialties evaluated, only 3 (cardiology, critical care, and neonatology) generate positive financial returns with respect to general pediatrics. This finding is especially disturbing when we consider the well-documented shortages that already exist in many subspecialty areas and the impact that research such as this might have on people who are considering additional fellowship training.
We know that the pediatric patient population already suffers from a paucity of subspecialty providers. A 2009 national survey of children's hospitals revealed that many pediatric patients must wait between 5 weeks and 3 months to be seen by certain subspecialists.2 Approximately one-third of all children must travel 40 miles or more to be seen by a pediatrician certified in adolescent medicine, developmental behavioral pediatrics, neurodevelopmental disabilities, pulmonology, emergency medicine, nephrology, rheumatology, or sports medicine.3 Multiple states lack certain subspecialists entirely: 13 states have no practicing pediatric rheumatologists, and 7 states offer no pediatricians who specialize in adolescent medicine.3
Further compounding these shortages are the small numbers of people who are pursuing fellowship training. In 2006, only 21 first-year fellows were training in adolescent medicine, 29 in developmental behavioral pediatrics, and 32 in pediatric rheumatology.4 High levels of student debt and multiple years of training, combined with a struggling economy, make the choice to pursue a pediatric fellowship a daunting mission.
However, although the results of the Rochlin and Simon study are sobering, it is essential that we recognize this moment as an opportunity for change. The American Academy of Pediatrics will continue advocating to improve monetary support for pediatric fellowship training and urges full funding of the pediatric subspecialty loan-repayment program authorized in the Affordable Care Act. We will also vigorously maintain our call for payment parity with adult medicine and particularly focus on insisting that Medicaid reimbursements be at least equal to those of Medicare for equivalent services. The American Academy of Pediatrics is also extensively involved in developing principles and guidelines for pediatricians, including pediatric medical subspecialists and pediatric surgical specialists, who are considering participating in or with accountable care organizations and other integrated clinical practice platforms. These platforms offer considerable opportunity for shared savings and quality-focused incentive payments to improve the incomes of our subspecialty colleagues.
Finally, we call on all advocates for children to join us in encouraging, recognizing, and celebrating those people who choose to pursue a pediatric subspecialty career because they feel a personal calling to work with some of America's sickest children.
This discussion is crucial to the future of our profession and the health of our nation's children. I invite you to help me continue it.
- Accepted February 11, 2011.
- Address correspondence to O. Marion Burton, MD, President, Office of the Executive Director, American Academy of Pediatrics, 141 Northwest Point Blvd, Elk Grove Village, IL 60007-1098. E-mail:
Opinions expressed in this commentary are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.
- Rochlin JM,
- Simon HK
- 2.↵National Association of Children's Hospitals and Related Institutions. Pediatric subspecialty shortages affect access to care. Available at: www.childrenshospitals.net/Content/ContentFolders34/BenchmarkingData/AnnualSurvey/pediatric_subspecialty_poster.pdf. Accessed February 4, 2011
- Mayer ML
- 4.↵American Board of Pediatrics. Workforce Data: 2007. Chapel Hill, NC: American Board of Pediatrics; 2007
NO ORDINARY LEAP: We have had plenty of snow in Burlington, Vermont, this year. Periodically, I have to jump over small drifts or puddles of slush to get to my car. The other morning, I faced a particularly wide expanse of slush. I coiled, sprang, and cleared the almost four foot expanse with inches to spare. I was feeling pretty good about myself until I read about how far fleas can jump. According to an article in The New York Times (February 10, 2011: Science), fleas can jump three inches. That may not sound like a great distance, but three inches is 38 times the body length of a flea. In other words, if the flea were my size, it would have jumped more than 221 feet. In order to jump that far, fleas have to withstand a force approximately 100 times that of gravity. I am pretty sure that during my jump I did not have to withstand any significant forces. And many humans pass out at five times the force of gravity. How the flea can jump so far has intrigued scientists since the 17th century. Until the advent of high speed cameras, how the fleas accomplished their feat was purely speculative. In the 1960s, scientists realized that somehow fleas were generating far, far more power than their muscles could actually provide. Dissections of fleas demonstrated that flea leg muscles were connected to pads of stretchy protein called resilin. The additional power came from energy released from this spring-like tissue in their legs. In 2009, scientists filmed 51 flea jumps and then made mathematical models to learn how the energy was released. It turns out that the flea transfers the energy stored in the legs to the tarsi, the most distal portions of their legs where it is then released. The fleas are not unique in using such a biomechanical device. Other jumping insects also layer resilin pads over hard cuticle. The sandwich efficiently stores energy and keeps the cuticle from cracking. Still, nobody knows quite how fleas manage to coordinate their jumps so well. When I am a little off balance in my jump, I might land a bit awkwardly; however, without perfect timing, fleas would spin wildly out of control. It seems we have a lot to learn about jumping from the flea.
Noted by WVR, MD
- Copyright © 2011 by the American Academy of Pediatrics