Is Pediatric Subspecialty Training Financially Worth It?

Jaleesa Baulkman

March 09, 2021

Pursuing fellowship training is often financially costly in terms of lifetime earnings compared with starting a career as a general pediatrician immediately after residency, a new report suggests.

Researchers found that most pediatric subspecialists — including those practicing neurology, pulmonology, and adolescent medicine ― do not see a financial return from additional training because of the delays in receiving increased compensation and the repayment of educational debt.

"Most pediatric subspecialists don't experience a relative increase in compensation after training compared to a general pediatrician, so there isn't a financial benefit to additional training," lead author Eva Catenaccio, MD, from the Division of Pediatric Neurology, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, told Medscape Medical News.

The findings, published online March 8 in Pediatrics, contribute to the ongoing debate about the length of pediatric fellowship training programs. The data also provide evidence for the potential effect of a pediatric subspecialty loan repayment program.

Pediatric Subspecialty Training Rarely Pays Off

However, not all practitioners in pediatric subspecialties would find themselves in the red relative to their generalist peers. Three subspecialties had a positive financial return: cardiology, critical care, and neonatology. Catenaccio explained that this may be because these subspecialties tend to be "inpatient procedure-oriented, which are often more [lucrative] than outpatient cognitive-oriented subspecialties, such as pediatric infectious diseases, endocrinology, or adolescent medicine."

Enrolling in a pediatric fellowship program resulted in lifetime financial returns that ranged from an increase of $852,129 for cardiology, relative to general pediatrics, to a loss of $1,594,366 for adolescent medicine, researchers found.

For the study, researchers calculated the financial returns of 15 pediatric subspecialties — emergency medicine, neurology, cardiology, critical care, neonatology, hematology and oncology, pulmonology, hospitalist medicine, allergy and immunology, gastroenterology, rheumatology, nephrology, adolescent medicine, infectious diseases, and endocrinology — in comparison with returns of private practice general pediatrics on the basis of 2018–2019 data on fellowship stipends, compensation, and educational debt.

They obtained most of the data from the Association of American Medical Colleges (AAMC) Survey of Resident/Fellow Stipends and Benefits, AAMC's annual Medical School Faculty Salary Report, and the AAMC Medical School Graduation Questionnaire.

Richard Mink, MD, Department of Pediatrics, Harbor–University of California, Los Angeles, Medical Center, Torrance, California, noted that it would have been helpful to have also compared the lifetime earnings of practitioners in pediatric subspecialties to academic general pediatricians and not just those in private practice.

The Financial Gap Has Worsened

To better understand which aspects of fellowship training have the greatest effect on lifetime compensation, Catenaccio and colleagues evaluated the potential effects of shortening fellowship length, eliminating school debt, and implementing a federal loan repayment plan. These changes enhanced the returns of cardiology, critical care, and neonatology — subspecialties that had already seen financial returns before these changes — and resulted in a positive financial return for emergency medicine.

The changes also narrowed the financial gap between subspecialties and general pediatrics. However, the remaining subspecialties still earned less than private practice pediatrics.

The new study is an update to a 2011 report, which reflected 2007–2008 data for 11 subspecialties. This time around, the researchers included the subspecialties of hospitalist medicine, which was approved as a board certified subspecialty by the American Board of Pediatrics in 2014, as well as neurology, allergy and immunology, and adolescent medicine.

"I was most surprised that the additional pediatric subspecialties we included since the 2011 report followed the same general trend, with pediatric subspecialty training having a lower lifetime earning potential than general pediatrics," Catenaccio said.

Comparing results from the two study periods showed that the financial gap between general pediatrics and subspecialty pediatrics worsened over time. For example, the financial return for pediatric endocrinology decreased an additional $500,000 between 2007 and 2018.

The researchers believe a combination of increased educational debt burden, slow growth in compensation, and changing interest rates over time have caused the financial differences between general pediatrics and subspecialty pediatrics to become more pronounced.

"Pediatric Subspecialty Training Is Worth It!"

Despite the financial gaps, Catenaccio and colleagues say pediatric subspecialty training is still worthwhile but that policymakers should address these financial differences to help guide workforce distribution in a way that meets the needs of patients.

"I think pediatric subspecialty training is worth it," said Catenaccio, who's pursuing pediatric subspecialty training. "There are so many factors that go into choosing a specialty or subspecialty in medicine, including the desire to care for a particular patient population, interest in certain diseases or organ systems, lifestyle considerations, and research opportunities."

But it's also important for trainees to be aware of economic considerations in their decision making.

Mink, who wrote an accompanying commentary, agrees that young clinicians should not make career decisions on the basis of metrics such as lifetime earning measures.

"I think people who go into pediatrics have decided that money is not the driving force," said Mink. He noted that pediatricians are usually not paid well compared with other specialists. "To me the important thing is you have to like what you're doing."

A 2020 study found that trainees who chose a career in pediatric pulmonology, a subspecialty, said that financial considerations were not the driving factor in their decision making. Nevertheless, Mink also believes young clinicians should take into account their educational debt.

The further widening of the financial gap between general pediatrics and pediatric subspecialties could lead to shortages in the pediatric subspecialty workforce.

The authors and Mink have disclosed no relevant financial relationships.

Pediatrics. Published online March 8, 2021. Full text, Commentary

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