Child Health and the US Pediatric Subspecialty Workforce: Planning for the Future.

This article opens a multi-article Pediatrics supplement that provides a rigorous analysis of the projected pediatric subspecialty workforce in the United States. Congenital variations, epigenetics, exposures, lifestyle, preventive care, and medical interventions from conception through young adulthood set the stage for health and wellbeing in adulthood. Although care provided by pediatric subspecialists is associated with better outcomes and lower costs compared with adult providers, the authors of recent articles in the lay and medical literature have questioned the capacity of pediatric subspecialists to meet children's health care needs. This article highlights that, despite numerous advances in prevention, diagnosis, and treatment, the last decade has witnessed increasing numbers of children with acute or chronic physical and mental health disorders, including medical complexity, obesity, type 2 diabetes, anxiety, depression, and suicidality, all of which are exacerbated by poverty, racism, and other social drivers of health. In this article, we then describe the variability in the demographics, practice characteristics, and geographic distribution of the 15 core pediatric subspecialties certified by the American Board of Pediatrics. We then discuss the rationale and approach to the development of a pediatric subspecialty workforce model that forecasts subspecialist supply from 2020 to 2040 for 14 subspecialties at the national and subnational levels (not including the newest subspecialty, pediatric hospital medicine), accounting for US Census Bureau child population projections. The model does not account for the unique physical and mental needs of individual children, nor does it address the increasingly precarious commitment to, and financing of, pediatric subspecialty care in the US health care system impacting market demand.

COVID-19 Pandemic Impact on Pediatricians Entering the Pediatric Workforce.

OBJECTIVE: Determine extent of impact of coronavirus disease 2019 (COVID-19) pandemic on career choice and employment of pediatricians entering pediatric workforce. METHODS: A national, cross-sectional electronic survey of pediatricians registering for the 2021 American Board of Pediatrics initial general certifying examination on the impact of the COVID-19 pandemic on 3 aspects of career (career choice, employment search, employment offers) was performed. Data were analyzed using descriptive statistics and multivariate logistic regression to determine factors associated with the pandemic's impact on career. Thematic analysis was used to generate themes for open-ended survey questions. RESULTS: Over half (52.3%, 1767 of 3380) of pediatricians responded. Overall, 29.1% reported that the pandemic impacted their career (career choice [10.4%], employment search [15.6%], or employment offers [19.0%]); applicants to general pediatrics (GP) (52.9%) or pediatric hospitalist (PH) positions (49.3%) were most affected. Multivariate logistic regression modeling found those applying to GP (odds ratio [OR]: 3.83, 95% confidence interval [CI]: 2.22-6.60), PH (OR: 9.02, 95% CI: 5.60-14.52), and International Medical Graduates (IMGs) (OR: 1.90; 95% CI: 1.39-2.59) most likely to experience any career impact. CONCLUSIONS: Almost one third of pediatricians registering for the initial general pediatrics certifying examination reported their careers were impacted by the COVID-19 pandemic, with 10% of respondents reporting the pandemic impacted their career choice. Half of new pediatricians seeking employment reported being impacted by the pandemic, particularly IMGs. As the pandemic evolves, career advising will continue to be critical to support trainees in their career choices and employment.

Pursuing a Career in Pediatrics: Intersection of Educational Debt and Race/Ethnicity.

OBJECTIVES: To examine the associations among pediatric trainees' self-reported race/ethnicity, educational debt, and other factors for pursuing a pediatrics career. STUDY DESIGN: Cross-sectional study using data from the American Board of Pediatrics In-training Examination Post-examination Survey years 2018-2020 of categorical pediatric interns. Independent variable of interest was race/ethnicity. Classifications used were White, Hispanic/Latinx, Black/African American, Asian, and other/multiracial. The primary dependent variable was educational debt; secondary dependent variables included the importance of personal, professional, and financial factors in selecting a pediatric career. Means with 95% CIs were computed to summarize scores regarding a factor's importance. Chi-square tests of homogeneity and one-way ANOVA F tests were used to compare proportions and means of dependent variables across levels of self-reported race/ethnicity. RESULTS: A total of 11 150 (91.5%) completed the survey. Of the final analytical sample (7 943), approximately 6.3% self-identified as Black/African American, 8.2% as Hispanic/Latinx, 22% as Asian, and 55% as White; 44% reported >$200 000 of debt. Overall, 33% of those identifying as Black/African American had >$300 000 in educational debt. The highest ranked career factor was interest in a specific disease/patient population. The importance of educational debt in career choices was highest among those identifying as Black/African American, followed by Asians and Hispanic/Latinx. Among all races/ethnicities, the importance of mentorship decreased with higher educational debt. CONCLUSION: Among individuals pursuing pediatrics, the intersection of race/ethnicity and debt may influence trainees' pursuit of pediatric careers. Educational debt negatively impacts the importance of mentorship.

Exploring paediatricians' experiences with performance improvement modules and quality improvement.

OBJECTIVE: The American Board of Pediatrics' (ABP) maintenance of certification (MOC) programme seeks to continue educating paediatricians throughout their careers by encouraging lifelong learning and continued improvement. The programme includes four parts, each centring on a different aspect of medical practice. Part 4 MOC centres on quality improvement (QI). Surveys by the ABP suggest that paediatricians are dissatisfied with aspects of part 4, but their reasons are unclear. This study sought to explore factors contributing to dissatisfaction with part 4 by focusing on performance improvement modules (PIMs), a popular means of achieving part 4 credit. METHODS: The study used cross-sectional purposive sampling drawing from US physicians working in a range of practice settings: private outpatient, hospital, academic and low-income clinics. The sampling frame was divided by practice characteristics and satisfaction level, derived from a five-point Likert item asking about physician satisfaction regarding a recent PIM. In-depth interviews were conducted with 21 physicians, and the interview data were coded, categorised into themes and analysed using a framework analysis approach. RESULTS: Paediatricians expressed nuanced views of PIMs and remain globally dissatisfied with part 4, although reasons for dissatisfaction varied. Concerns with PIMs included: (1) excessive time and effort; (2) limited improvement and (3) lack of clinically relevant topics. While most agreed that QI is important, participants felt persistently dissatisfied with the mechanics of doing PIMs, especially when QI tasks fell outside of their typical work regimen. CONCLUSIONS: Paediatricians agreed that part 4, PIMs, and QI efforts in general still lack clinical relevance and need to be more easily incorporated into practice workflow. Clinicians specifically felt that PIMs must be directly integrated with physicians' practice settings in terms of topic, data quality and metrics, and must address practice differences in time and monetary resources for completing large or complex projects.

Competency of Future Pediatricians Caring for Children With Behavioral and Mental Health Problems.

BACKGROUND AND OBJECTIVES: There is an urgent need to prepare pediatricians to care for children with behavioral and mental health (B/MH) conditions. In this study, we evaluate the perceived competence of pediatric residents and recent graduates in the assessment and treatment of B/MH conditions, characterize variation in competence across residency programs, and identify program characteristics associated with high competence. METHODS: Cross-sectional survey of applicants for the initial certifying examination in pediatrics. Questions were focused on (1) who should be competent in B/MH skills, (2) institutional support around B/MH training, and (3) perceived competence in 7 B/MH assessment skills and 9 treatment skills. Competence was rated on a 5-point scale, and high levels of assessment and treatment competence were defined as scores of ≥4. Composite measures for B/MH assessment and treatment were calculated as mean scores for each domain. We examined variation in residents' self-reported competence across programs and used linear regression to identify factors associated with high levels of competence at the program level. RESULTS: Of applicants, 62.3% responded to the survey (n = 2086). Of these, 32.8% (n = 595) reported high competence in assessment skills and 18.9% (n = 337) in treatment skills. There were large variations in reported competence across programs. Respondents from smaller programs (<30 trainees) reported higher competence in assessment and treatment than those from large programs (P < .001). CONCLUSIONS: Current and recent pediatric trainees do not report high levels of perceived competence in the assessment and treatment of children with B/MH conditions. The substantial variation across programs indicates that the pediatric community should create standards for B/MH training.

International Experience of US Pediatricians and Level of Comfort Caring for Immigrant Children and Children Traveling Internationally.

OBJECTIVE: To determine whether international experience is associated with greater comfort in providing care to US children who are immigrants, refugees, and traveling internationally. STUDY DESIGN: Following enrollment into the 2018 American Board of Pediatrics Maintenance of Certification program, general pediatricians and subspecialists received a voluntary, online survey with questions about their experience and self-reported comfort caring for immigrant, refugee, and internationally traveling children and previous international experiences. Using multivariable logistic regression, we examined how previous international experiences, and other personal characteristics, were associated with self-reported comfort. RESULTS: A total of 5461 eligible participants completed the survey; 76.3%, (n = 4168) reported caring for immigrant children, 35.8% (n = 1957) cared for refugee children, and 79.8% (n = 4358) cared for children traveling internationally. High levels of comfort caring for immigrant children were reported by 68.5% (n = 3739), for refugee children by 50.1% (n = 2738), and for children traveling internationally by 72.7% (n = 3968). One-third of respondents (34.1%, n = 1866) reported past international experiences. In multivariable analysis, respondents with previous international experience and of Hispanic origin were significantly more likely to report high levels of comfort caring for all 3 populations. CONCLUSIONS: The majority of pediatricians report caring for children in the US who are immigrants, refugees, and traveling internationally, and previous international experience was associated with greater comfort with care. Training programs and professional organizations should consider ways to encourage a more diverse workforce and to support all pediatricians in achieving the skills and confidence required to care for children in our highly mobilized society.

Pediatrician Perspectives on Feasibility and Acceptability of the MOCA-Peds 2017 Pilot.

BACKGROUND AND OBJECTIVES: The American Board of Pediatrics (ABP) certifies that general and subspecialty pediatricians meet standards of excellence established by their peers, immediately after training and over the course of their careers (ie, Maintenance of Certification [MOC]). In 2015-2016, the ABP developed the Maintenance of Certification Assessment for Pediatrics (MOCA-Peds) as an alternative assessment to the current proctored, closed-book general pediatrics (GP) MOC examination. This article is 1 of a 2-part series examining results from the MOCA-Peds pilot in 2017. METHODS: We conducted quantitative and qualitative analyses with 5081 eligible pediatricians who registered to participate in the 2017 pilot; 81.4% (n = 4016) completed a quarter 4 survey and/or end-of-year survey (January 2018) and comprise the analytic sample. RESULTS: The majority of pediatricians considered the MOCA-Peds to be feasible and acceptable as an alternative to the proctored MOC GP examination. More than 90% of respondents indicated they would participate in the proposed MOCA-Peds model instead of the examination. Participants also offered recommendations to improve the MOCA-Peds (eg, enhanced focus of questions on outpatient GP, references provided before taking questions); the ABP is carefully considering these as the MOCA-Peds is further refined. CONCLUSIONS: Pilot participant feedback in 2017 suggested that the MOCA-Peds could be implemented for GP starting in January 2019, with all 15 subspecialties launched by 2022. Current and future evaluations will continue to explore feasibility, acceptability, and learning and practice change as well as sustainability of participation.

Pediatrician Perspectives on Learning and Practice Change in the MOCA-Peds 2017 Pilot.

BACKGROUND AND OBJECTIVES: This article is the second of a 2-part series examining results regarding self-reported learning and practice change from the American Board of Pediatrics 2017 pilot of an alternative to the proctored, continuing certification examination, termed the Maintenance of Certification Assessment for Pediatrics (MOCA-Peds). Because of its design, MOCA-Peds has several learning advantages compared with the proctored examination. METHODS: Quantitative and qualitative analyses with 5081 eligible pediatricians who registered to participate in the 2017 pilot; 81.4% (n = 4016) completed a quarter 4 survey and/or the end-of-year survey (January 2018) and compose the analytic sample. RESULTS: Nearly all (97.6%) participating pediatricians said they had learned, refreshed, or enhanced their medical knowledge, and of those, 62.0% had made a practice change related to pilot participation. Differences were noted on the basis of subspecialty status, with 68.9% of general pediatricians having made a practice change compared with 41.4% of subspecialists. Within the 1456 open-ended responses about participants' most significant practice change, responses ranged widely, including both medical care content (eg, "care for corneal abrasions altered," "better inform patients about. . .flu vaccine") and nonspecific content (eg, providing better patient education, using evidence-based medicine, increased use of resources in regular practice). CONCLUSIONS: As a proctored examination alternative, MOCA-Peds positively influenced self-reported learning and practice change. In future evaluation of MOCA-Peds and other medical longitudinal assessments, researchers should study ways to further encourage learning and practice change and sustainability.