The cost of pediatric specialization

I suspect that very few of you chose to go into pediatrics as part of a get-rich-quick scheme. But, like me, you may have assumed that by going into medicine you would always have a job buffered from the erratic winds of the economy, an assumption that it turns out did not take into account the risk of a global pandemic.

I also bet that if you chose to subspecialize it was not because you felt you might make more money. I and most of the lay public have always naively assumed that specialists generally make more money because … well, because they spent more time training. You, on the other hand, may have discovered belatedly that becoming a pediatric subspecialist isn’t as lucrative as you thought it might be.

It turns out that, when subjected to some standard money-crunching exercises, the lifetime earning potential of most pediatric subspecialists falls significantly behind that of general pediatricians. In a paper published in the April 2021 issue of Pediatrics, investigators from the departments of neurology and pediatric neurology at Johns Hopkins University have reported that, with the exception of three hospital-based, procedure-oriented specialties (cardiology, critical care, and neonatology) the earning time lost during training is usually not recouped over the course of a subspecialist’s career. This observation may be explained in many cases by the fact that the income generated by most subspecialists is similar to and not greater than that of general pediatricians. Even when the income of a subspecialist is greater, it is generally not enough to allow for catch up for the earning power lost during training. The researchers observed this effect both in academic and nonacademic settings.

It is possible that, as the results of this study become more widely distributed, more pediatricians in training will begin to think a bit more about the bottom line when they are considering fellowship training. I suspect that drift is already underway, and if it continues, we will find more subspecialties experiencing shortages. And the importance of this lack of subspecialists on both a local and national level is not something to ignore.

The authors discuss several possible solutions. One option might be to shorten the subspecialty training period. Obviously, this would raise some concerns about quality. Another might be for the government to begin a program in which student loans were selectively forgiven based on a physician’s decision to pursue a subspecialty that is experiencing a shortage.

Another option might be to subsidize the income of some subspecialists. Although this might have a similar effect as loan forgiveness, as a physician with a longstanding pride in being a generalist I would hate to see subspecialists guaranteed a higher income merely because of the narrower mix of patients they have chosen to see. I have always felt that the challenge faced by a primary care generalist who must be prepared to deal with the breadth of complaints that present themselves at the door is at least as great and in many cases greater than that of a specialist whose patients to a large extent have been presorted.

Another solution that comes to mind is that, instead of shortening fellowship programs, one could restructure basic pediatric training programs to allow physicians who have already chosen to become subspecialists to enter a fellowship program after 2 years of house officer training. Restructuring of this magnitude would not be as simple as lopping off the last year of house officer training. It would require tailoring each physician’s shortened prefellowship learning experience to maximize his or her exposure to clinical situations that will be most relevant to the anticipated subspecialty they have chosen. A plan like this also assumes that a significant number of recent medical school graduates will be ready to make choices during their internship that will channel them into careers that will span decades.

Becoming a generalist was an easy decision for me. Any of the subspecialties I was considering would have meant I would have had to live and work in or near a high-density population. I am and always have been a small town kind of guy.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

I suspect that very few of you chose to go into pediatrics as part of a get-rich-quick scheme. But, like me, you may have assumed that by going into medicine you would always have a job buffered from the erratic winds of the economy, an assumption that it turns out did not take into account the risk of a global pandemic.

I also bet that if you chose to subspecialize it was not because you felt you might make more money. I and most of the lay public have always naively assumed that specialists generally make more money because … well, because they spent more time training. You, on the other hand, may have discovered belatedly that becoming a pediatric subspecialist isn’t as lucrative as you thought it might be.

It turns out that, when subjected to some standard money-crunching exercises, the lifetime earning potential of most pediatric subspecialists falls significantly behind that of general pediatricians. In a paper published in the April 2021 issue of Pediatrics, investigators from the departments of neurology and pediatric neurology at Johns Hopkins University have reported that, with the exception of three hospital-based, procedure-oriented specialties (cardiology, critical care, and neonatology) the earning time lost during training is usually not recouped over the course of a subspecialist’s career. This observation may be explained in many cases by the fact that the income generated by most subspecialists is similar to and not greater than that of general pediatricians. Even when the income of a subspecialist is greater, it is generally not enough to allow for catch up for the earning power lost during training. The researchers observed this effect both in academic and nonacademic settings.

It is possible that, as the results of this study become more widely distributed, more pediatricians in training will begin to think a bit more about the bottom line when they are considering fellowship training. I suspect that drift is already underway, and if it continues, we will find more subspecialties experiencing shortages. And the importance of this lack of subspecialists on both a local and national level is not something to ignore.

The authors discuss several possible solutions. One option might be to shorten the subspecialty training period. Obviously, this would raise some concerns about quality. Another might be for the government to begin a program in which student loans were selectively forgiven based on a physician’s decision to pursue a subspecialty that is experiencing a shortage.

Another option might be to subsidize the income of some subspecialists. Although this might have a similar effect as loan forgiveness, as a physician with a longstanding pride in being a generalist I would hate to see subspecialists guaranteed a higher income merely because of the narrower mix of patients they have chosen to see. I have always felt that the challenge faced by a primary care generalist who must be prepared to deal with the breadth of complaints that present themselves at the door is at least as great and in many cases greater than that of a specialist whose patients to a large extent have been presorted.

Another solution that comes to mind is that, instead of shortening fellowship programs, one could restructure basic pediatric training programs to allow physicians who have already chosen to become subspecialists to enter a fellowship program after 2 years of house officer training. Restructuring of this magnitude would not be as simple as lopping off the last year of house officer training. It would require tailoring each physician’s shortened prefellowship learning experience to maximize his or her exposure to clinical situations that will be most relevant to the anticipated subspecialty they have chosen. A plan like this also assumes that a significant number of recent medical school graduates will be ready to make choices during their internship that will channel them into careers that will span decades.

Becoming a generalist was an easy decision for me. Any of the subspecialties I was considering would have meant I would have had to live and work in or near a high-density population. I am and always have been a small town kind of guy.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

I suspect that very few of you chose to go into pediatrics as part of a get-rich-quick scheme. But, like me, you may have assumed that by going into medicine you would always have a job buffered from the erratic winds of the economy, an assumption that it turns out did not take into account the risk of a global pandemic.

I also bet that if you chose to subspecialize it was not because you felt you might make more money. I and most of the lay public have always naively assumed that specialists generally make more money because … well, because they spent more time training. You, on the other hand, may have discovered belatedly that becoming a pediatric subspecialist isn’t as lucrative as you thought it might be.

It turns out that, when subjected to some standard money-crunching exercises, the lifetime earning potential of most pediatric subspecialists falls significantly behind that of general pediatricians. In a paper published in the April 2021 issue of Pediatrics, investigators from the departments of neurology and pediatric neurology at Johns Hopkins University have reported that, with the exception of three hospital-based, procedure-oriented specialties (cardiology, critical care, and neonatology) the earning time lost during training is usually not recouped over the course of a subspecialist’s career. This observation may be explained in many cases by the fact that the income generated by most subspecialists is similar to and not greater than that of general pediatricians. Even when the income of a subspecialist is greater, it is generally not enough to allow for catch up for the earning power lost during training. The researchers observed this effect both in academic and nonacademic settings.

It is possible that, as the results of this study become more widely distributed, more pediatricians in training will begin to think a bit more about the bottom line when they are considering fellowship training. I suspect that drift is already underway, and if it continues, we will find more subspecialties experiencing shortages. And the importance of this lack of subspecialists on both a local and national level is not something to ignore.

The authors discuss several possible solutions. One option might be to shorten the subspecialty training period. Obviously, this would raise some concerns about quality. Another might be for the government to begin a program in which student loans were selectively forgiven based on a physician’s decision to pursue a subspecialty that is experiencing a shortage.

Another option might be to subsidize the income of some subspecialists. Although this might have a similar effect as loan forgiveness, as a physician with a longstanding pride in being a generalist I would hate to see subspecialists guaranteed a higher income merely because of the narrower mix of patients they have chosen to see. I have always felt that the challenge faced by a primary care generalist who must be prepared to deal with the breadth of complaints that present themselves at the door is at least as great and in many cases greater than that of a specialist whose patients to a large extent have been presorted.

Another solution that comes to mind is that, instead of shortening fellowship programs, one could restructure basic pediatric training programs to allow physicians who have already chosen to become subspecialists to enter a fellowship program after 2 years of house officer training. Restructuring of this magnitude would not be as simple as lopping off the last year of house officer training. It would require tailoring each physician’s shortened prefellowship learning experience to maximize his or her exposure to clinical situations that will be most relevant to the anticipated subspecialty they have chosen. A plan like this also assumes that a significant number of recent medical school graduates will be ready to make choices during their internship that will channel them into careers that will span decades.

Becoming a generalist was an easy decision for me. Any of the subspecialties I was considering would have meant I would have had to live and work in or near a high-density population. I am and always have been a small town kind of guy.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.