Editor’s note: The opinions expressed by the author do not necessarily reflect the opinions of the AAMC or its members.
In 1994, the year I started my pediatrics internship at Children’s Hospital Los Angeles, the fertility rate in the United States was two children per woman. Thirty years later, that number had dropped to fewer than 1.6 children per woman, the lowest rate on record.
Throughout my career as a pediatrician, I’ve seen my patient population and practice change, in part because of the declining fertility rate but also because of a complex combination of factors that includes a decline in acute infectious disease among children, advancements in medicine that have resulted in some children requiring significant medical care for conditions they might not have survived in the past, and lower compensation for pediatricians compared with earnings for physicians who treat adults.
Many young doctors have perceived these changes and worry that they have no sustainable path to a practice caring for children. In 2024, the National Resident Matching Program® statistics showed that the pediatrics match in the United States was the lowest recorded in 30 years. According to the American Academy of Pediatrics (AAP), 67 pediatric residencies did not fill their residency slots, leaving 251 positions empty. While 2025 Match® data were much improved — 95% of positions were filled, up from 91% in 2024 — only 78% of pediatric specialty fellowships were filled last year, with some subspecialties, including pediatric endocrinology, filling fewer than 50% of their fellowship slots.
As the world has changed, the field of pediatrics — and, in particular, the way we train pediatricians — needs to adapt and change. I believe the time has come to reexamine the current model of pediatric residency, fellowship training, and practice, and propose a new approach to attract recent medical graduates and ensure a sustained pipeline of pediatricians well prepared to care for future generations of children.
Barriers to becoming a pediatrician
The challenges for today’s pediatricians are multifaceted.
It should be no surprise that, as people have fewer babies, there are fewer patients and less demand for pediatric services, particularly for children covered by private insurance.
One 2004 study made projections regarding the general pediatric workforce supply and demand in the period between 2000 and 2020; the authors forecast an increase in the number of pediatricians by 64% (from the baseline year of 2000), compared with an increase in the pediatric population by a paltry 9% over that same period. Similar concerns about the pediatric workforce were raised, in the context of declining birth rates, by another paper published back in 1975!
Additionally, the profile of pediatric patients has changed in the 21st century. There has been a decline in acute infectious diseases and an increase in the burden of chronic diseases. This change has largely been achieved through (1) public health measures, including the availability and use of vaccines developed within the past 30 to 40 years (e.g., Hib, pneumococcal conjugate, varicella, and rotavirus vaccines), despite current challenges, and (2) advanced medical care helping children to survive previously deadly conditions.
As a result, the pediatric workforce has now dichotomized into community-based general pediatricians focused largely on preventive care and hospital-based pediatricians focused on inpatient medical care.
On top of declining demand for pediatricians, new medical graduates interested in pediatrics may be deterred by the relatively low pay scale for pediatricians, while considering their own debt burden. One 2021 study found that the lifetime earning potential for pediatricians and pediatric subspecialists was, on average, 25% lower than that of physicians in comparable positions in adult practices. An AAP report published in December 2025 found that pediatricians remained the lowest paid of all primary care physicians. Pediatricians made an average salary of $265,230 in 2024, compared with family medicine physicians, who made $318,959, on average. The median education debt for physicians graduating in 2025 was $215,000, regardless of chosen specialty, according to the AAMC.
Part of the reason for this disparity is the fact that about half of all children in the United States are covered by Medicaid, compared with 17% of adults. Medicaid reimbursements are set at a significantly lower rate than those paid by most private insurance. The AAP has long called for parity in pay between adult and pediatric physicians. Many pediatricians do an exceptional job of preventing illness among their patients, setting them up for a healthier future. Yet, paradoxically, reimbursement models are more generous for procedures than for preventing the need for them.
Rethinking pediatric training programs
One solution to this problem could be to train pediatricians as subspecialists. This model isn’t novel. In other high-income countries, such as Canada, the United Kingdom, the Netherlands, Germany, France, and Australia, general practitioners serve as the frontline providers for children as well as adults and refer complex childhood cases to pediatricians who are regarded as subspecialists in their respective health systems.
In the United States this transformation of the field would result in fewer independent pediatricians, thus addressing the reduced demand for pediatric services. While it would place more pressure on family practices, the restructuring could also channel more medical graduates interested in working with children into family medicine or other primary care specialties.
Pediatric residency training programs would need to adapt to this paradigm shift. Current pediatric residency training lasts three years regardless of whether the trainee would like to be a community pediatrician or a pediatric hospitalist or subspecialist in the future. This training model could be revised to be tailored to the career goals of the trainee.
The residency track could be decided by the trainees by the middle of their second year. Those intending to be community pediatricians could have two years of clinical training followed by a final year of specialized education and training in public health, leading to a Master of Public Health (MPH) degree in fields such as health policy and management, community health, and global health. Those graduates willing to complete an MPH in the fourth year would be on track to do so. The path to an MPH would provide these graduates with additional skill sets for administration and advocacy in the United States and an understanding of the burden of pediatric diseases in low- and middle-income countries.
The training path for pediatric hospitalists or pediatric subspecialists could be incorporated into pediatric residency training. The pediatric hospital medicine fellowship could start after two years of clinical training in pediatrics. This would allow the prospective pediatric subspecialty trainee to join the workforce a year sooner than in the current model.
Measures to strengthen general pediatric care in the community could include:
- incorporating a year of pediatric training in family practice residencies instead of the current requirement of nine months;
- strengthening the four-year combined internal medicine and pediatric program for better pediatric care in the outpatient primary care setting by changing training requirements for those who want to focus on general pediatrics — i.e., create a pathway to include a year of training in public health pertinent to pediatric health policy and advocacy, in lieu of a year of internal medicine.
Making these changes to pediatric residency could have the combined benefits of tailoring skill sets of trainees to the needs of the current pediatric population while also allowing trainees a fast track to pursue their interests and career goals.
My own career in pediatrics has meandered through a premier children’s hospital (as a pediatric infectious diseases subspecialist) to ambulatory general pediatrics at a private multispecialty medical group, with a short stint at community clinics in between. In 2013, after 11 years of practicing as a general pediatrician, my full-time practice at the private medical group was relegated to a part-time practice by my employer.
I decided to pursue a Master of Public Health (in Health Policy and Management) at the University of California, Los Angeles, and graduated in 2015. This allowed me to find my place in teaching and scholarly activities in public health at the University of Southern California’s Keck School of Medicine. The MPH experience has expanded the horizons of my career to include an interest in advocating for policy changes.
As pediatricians, we are proud to have improved the lives of children through the generations. Now we need to adapt to the advancements in medical science and carry forward the efforts of former and current pediatricians in promoting child health. Despite the structural disparities in reimbursement for pediatric care, it is incumbent on us to find ways to create value in pediatric training in order to attract the best medical graduates to become quality pediatricians and pediatric subspecialists of the future.
