By SUSAN ADELMAN, MD
This summer, the New York Times discovered pediatrics. The latest article, on July 7, was headlined “Why Students are Shunning Pediatrics.” In it, we read that in the latest match (when medical students are paired with residencies), there was a 6% drop in students applying for pediatric residencies, and almost a third of the pediatric residency slots in the country went unfilled. That meant 252 positions vacant. The writer, a pediatrician, correctly blamed the relatively low payments for pediatric services, since so many of the children are covered by Medicaid.
I have been there. I can confirm that it is true. Now retired from pediatric surgery, I found that the plastic surgeon who removed a tiny cyst from my face charged more than I ever received for a pediatric hernia, even for a delicate operation on a frail preemie at risk of a lethal bowel strangulation. In fact, I can recite a litany of tiny, dangerous operations for which I received just enough money to pay for dinner at a reasonably nice restaurant.
People who used to ask what my specialty was often would smile knowingly and nod when I said I was a surgical specialist. Little did they know. As a life-long do-gooder, I just accepted this as the price I paid for the privilege of taking care of the smallest and most vulnerable among us. Anyhow, it was Medicaid or nothing, and I could not turn away a child. But, does it need to be that way?
Pediatrics and OB-GYN traditionally were the loss leaders of the medical world, necessary to a full-service hospital, but underpaid. Of interest, in August 2023, the Children’s Hospital Association reported that “In pediatrics, shortages are more prevalent among providers who provide specialized care, such as pediatric advanced practice nurses, pediatric private duty and home care nurses and pediatric medical tech professionals (e.g., pediatric respiratory technicians, pediatric pharmacists, etc.). In contrast—for adults—the largest workforce shortages are among primary care providers.” They also write – and I know this to be true – that “Pediatric specialty care requires extra time, monitoring, specialized medications and equipment, and specially trained health care providers to provide that care.” And what they do not write is that pediatrics has a way of tugging at the heartstrings when things are precarious. The association proposes increasing the number of nurse practitioners, but another problem is the increased survival of children with chronic, complex conditions who in the past might not have survived early infancy.
So, since the system pays pediatric primary care and specialist physicians too little, these tiny patients should have non-physicians taking care of them? But remember, most physicians today are employed, no longer dependent on Medicaid. Hospitals must recognize their responsibility to adequately pay pediatricians and pediatric specialists, even if they lose money on them. Surely, they know that they will not maintain or increase their adult patient population if they do not grow new patients from birth. Adult primary care doctors learn that, even if they start out with a range of patients, as they age, so do their patients, meaning that in time they become geriatricians, while younger practitioners across the street cater to young families in their own age range.
Are there other possible solutions? The number of pediatric residencies has increased, but that may matter little if a high percentage of these slots go unfilled. Some point out that many pediatric specialists are female and that many of them work part-time. True, but that means we need more pediatricians. Advanced practice nurse practitioners can help, but an article by Dr. Vinci from Boston Medical Center, in Pediatrics, June 2021, reports that only 5% of them are certified in pediatrics. Another source of practitioners are IMGs, a high percentage of go into primary care. I remember when every department chair in Children’s Hospital of Michigan was an IMG, all of them superb.
Lifestyle is another factor. My husband and I used to have dinner with one referring pediatrician, returning to their house for coffee, where his kids had stacked up pink slips with numbers to call that evening. I was appalled. I also got calls at night to get up and go to the hospital to operate, but I never received so many routine calls in a normal evening. The solution is a night and weekend coverage rotation, commoner now than before, but essential to today’s young professionals.
One could ask, is it that pediatricians have less prestige than, say, neurosurgeons? Is that why they get less money? Even so, I would suggest that today’s hospital systems pay their pediatricians and pediatric specialists more than Medicaid pays if they want to maintain a robust full-service staff.