More pediatric subspecialists entering private practice could mean fewer at academic centers

An increasing number of pediatric subspecialists are entering private practice, a trend that could mean a smaller proportion working at academic centers, conducting research, teaching or advancing specialty care, a University of Michigan study finds.  This trend could also result in greater availability of some subspecialists to provide clinical care to children.

The process unfolding will have ripple effects across pediatrics.  The numbers need to be watched to ensure that the pipeline of doctors entering jobs at academic centers does not diminish significantly, says Gary L. Freed, M.D., M.P.H., chief of the division of general pediatrics and director of the Child Health Evaluation and Research (CHEAR) Unit at U-M C.S. Mott Children's Hospital.

"In contrast to adult medicine, in pediatrics, there is an overall shortage of subspecialists, both to provide clinical care and to conduct research," Freed says. "If more leave academics without commensurate increase in the total overall, it could severely impact new discoveries for the care of children."

The results of this study are available today in the journal Pediatrics.

University of Michigan researchers surveyed a random national sample of 1,696 pediatricians from five subspecialties and assessed the ownership of their current clinical practice setting.

The study found that there are significant proportions of pediatric subspecialists in private practice across most of the five subspecialties studied. Differences also exist among these specialties in the proportion of physicians in private practice.

Neonatology is the largest pediatric subspecialty and had the highest proportion of its providers in non-academic settings (51 percent). Hematology-oncology is the subspecialty with the highest proportion practicing in academic settings (77 percent). This is likely, at least in part, due to the relative rarity of childhood cancers and the need for highly sophisticated treatment environments usually only available in academic centers. A larger proportion of cardiologists (27 percent) and gastroenterologists (24 percent), reported that they work in private outpatient practice.

Respondents from procedure-based subspecialties, such as gastroenterology, had the highest proportion of providers in private outpatient practice. Such procedures provide significant opportunities for income generation in private practice.

"Ensuring the ability of children to have access to pediatric subspecialists will likely require a robust workforce in both the academic and private clinical arenas," Freed says. "Ongoing studies of the career trajectories of pediatric subspecialists with regard to their venues of practice will be essential to future workforce planning."

Another just-published workforce study from Dr. Freed and the CHEAR Unit found that more nurse practitioners and physicians assistants are needed in the pipeline to keep up with care demands. In this study, published Sept. 5 in the journal Pediatrics, generalist pediatricians and subspecialist pediatricians were polled on their current experiences and future plans for working with these health professionals.

The study found that more than 40 percent of subspecialty pediatrician respondents overall plan to increase the number of nurse practitioners in their practices in the next five years, and 25 percent will further expand the scope of nurse practitioners' work. The subspecialties most likely to report plans for increased hiring of nurse practitioners are intensive care unit-based, critical care and neonatology.

Some pediatric subspecialty respondents reported that increased restrictions in duty hours for residents will have a significant impact on their ability to provide patient care unless they are able to expand the number and scope of care providers, including nurse practitioners. These trends are expected to result in even greater demand on the pediatric nurse practitioner and physician assistant workforce.  The dilemma is that there has been no increase in the number of students entering pediatric nurse practitioner training in the last 10 years.  This is in stark contrast to the near doubling of nurse practitioners training in the care of adults and the elderly.  

"Despite the strong focus of policymakers on addressing the health care needs of the growing elderly population, attention also needs to be focused on addressing the needs of our nation's children," Freed says.