As many as 20% of children and youth have special health care needs (CYSHCN), many with complex medical conditions who require pediatric subspecialty care in the first two decades of life.1 Shortages of physicians in many pediatric subspecialties have been reported by families of CYSHCN, pediatric primary care providers, and academic department chairs, although verifying and quantifying the extent of subspecialty-specific shortages is fraught with methodologic challenges.2,3,4 Some families report long waits for initial appointments, particularly in developmental behavioral pediatrics and child psychiatry.5 A number of pediatric primary care providers have expanded their scope of practice in those areas to help reduce the need for referral.6 Public and private payers struggle to ensure network adequacy, especially when families of CYSHCN with complex clinical conditions live far from the urban academic health centers where pediatric subspecialists tend to practice congregate.7 Pediatric department chairs have often reported significant difficulty recruiting for many pediatric subspecialties, including endocrinologists, developmentalists, and neurologists.3,8 Pediatric surgical specialties report similar challenges.9 Studying pediatric workforce using quantitative methods has been challenging and somewhat controversial, yet the problem remains: how do we assure that all have timely access to the care they need for the unique health problems of children and youth?10,11

The increasing demand for pediatric subspecialty care has occurred concurrently with a marked increase in supply of pediatric subspecialists. While 35–40% of graduates of pediatric residency programs in the United States choose primary care careers, the absolute number of pediatric residents entering fellowship training has steadily increased year over year since the turn of the century.12 This is especially true in neonatology, critical care, cardiology, hematology–oncology and emergency medicine. Of note, the proportion of pediatric residency graduates whose future clinical practice goal is hospital-based medicine has increased from about 3% in 2003 (when first measured) to almost 10% in 2018.12 If the overall subspecialty workforce is increasing in size, why is access still perceived to be a problem? The answer may lie in the distribution of our workforce and the way in which subspecialists work.13 Except in neonatology, most of the newly graduated fellows find positions in academic medical centers that, particularly when associated with large children’s hospitals, are generally located in large urban centers. Private pediatric subspecialty practices share this geography as well.10 Children from the suburbs, small towns, and rural areas, particularly those with limited resources, may have difficulty in receiving care easily from a distance. Perhaps more importantly, the culture of academia, with its emphasis on teaching, research, and service, may implicitly or explicitly discourage time spent in clinical care as faculty members often strive to reduce clinical time in order to fulfill other aspects of the academic mission.14 Moreover, incentives for success in academia are rarely, if ever, associated with clinical care.

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