High unfilled numbers this year in pediatrics

[oldbearprofessor]

Okay folks, why let Reddit have all the fun with this topic! Why was there an approximate tripling of the number of unmatched positions in the pedi match this year to about 250? What can be done about this in the future?

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[GoSpursGo]

Okay folks, why let Reddit have all the fun with this topic! Why was there an approximate tripling of the number of unmatched positions in the pedi match this year to about 250? What can be done about this in the future?

Well I hate to say it, but I think it has to do with the last sentence in my signature 🙂

Of course this question of compensation is nothing new (that quote from you must be 15 years old now), but I think it is being compounded by problems we have been discussing over the last several years without any sign of meaningful improvement. We know that the job market for non-NICU/PEM subspecialists is tight, with many fellowship-trained pediatricians winding up either going back to practice as a general pediatrician or as a subspecialist "hospitalist" workhorse. If you even want to be a gen peds hospitalist, well you have to spend 3 years doing a PHM fellowship. Additionally, across subspecialties and even in primary care settings many pediatricians are being replaced with APPs. And you could make your way through all of that and still wind up needing to take the boards 2-3 times because somehow we're failing 20% of our residency and fellowship grads on their boards.

I think we all know that we sacrifice a lot monetarily for the privilege (and joy!) of taking care of children. But there is a lot of additional baggage that comes with it just beyond the money. The more these problems continue to fester and the word continues to get out about the problems we face as pediatricians, I think more and more students who might otherwise be willing to accept a paycut to go into peds are being turned off by all of the other issues and are finding reasons to suck it up and go into IM or FM instead.

In many ways I sort of feel like 10+ years of momentum on these issues is making it increasingly difficult to reverse course, so honestly whenever I talk to students who ask about these problems I just say that these are real problems but that I'm still happier in peds than I would be doing anything else. I'm not sure what else I can do as a lowly assistant professor. I would like to believe that the number of unfilled spots has to eventually be a wake up call to the AAP and ABP.

What do you think, @oldbearprofessor ?

 

[HemeOncHopeful19]

Low pay

3 year fellowships with even lower pay, even the “high paying” fellowships typically make about what an adult PCP makes

Hospitalist fellowship

And for all of that you are rewarded with a 80% board pass rate

 

[oldbearprofessor]

Well I hate to say it, but I think it has to do with the last sentence in my signature 🙂

Of course this question of compensation is nothing new (that quote from you must be 15 years old now), but I think it is being compounded by problems we have been discussing over the last several years without any sign of meaningful improvement. We know that the job market for non-NICU/PEM subspecialists is tight, with many fellowship-trained pediatricians winding up either going back to practice as a general pediatrician or as a subspecialist "hospitalist" workhorse. If you even want to be a gen peds hospitalist, well you have to spend 3 years doing a PHM fellowship. Additionally, across subspecialties and even in primary care settings many pediatricians are being replaced with APPs. And you could make your way through all of that and still wind up needing to take the boards 2-3 times because somehow we're failing 20% of our residency and fellowship grads on their boards.

I think we all know that we sacrifice a lot monetarily for the privilege (and joy!) of taking care of children. But there is a lot of additional baggage that comes with it just beyond the money. The more these problems continue to fester and the word continues to get out about the problems we face as pediatricians, I think more and more students who might otherwise be willing to accept a paycut to go into peds are being turned off by all of the other issues and are finding reasons to suck it up and go into IM or FM instead.

In many ways I sort of feel like 10+ years of momentum on these issues is making it increasingly difficult to reverse course, so honestly whenever I talk to students who ask about these problems I just say that these are real problems but that I'm still happier in peds than I would be doing anything else. I'm not sure what else I can do as a lowly assistant professor. I would like to believe that the number of unfilled spots has to eventually be a wake up call to the AAP and ABP.

What do you think, @oldbearprofessor ?

Certainly the standard answers of low pay/low board pass rate are true, but they aren't new this year so why the huge spike this year? I think there is a lot more communication in a variety of forums and ways in which medical students are becoming aware of the issues in a field and respond to them with career choices. People who want to care for children have a variety of specialty options (e.g. peds anesthesia) which may be appealing in this background.

Fixing the low pay will be a challenge, but some things can be fixed fairly readily. First, all fellowships must have 2 year, limited research options/pathways. Second, the board pass rate problem needs to be changed. There is no rational reason for a failure rate > 5%. I suspect the test itself is a large part of the problem. Finally, we need to improve the understanding by medical students of opportunities for advocacy, education and other forms of practice enhancements that exist within pediatrics. The AAP needs to work on this.

 

[GoSpursGo]

Certainly the standard answers of low pay/low board pass rate are true, but they aren't new this year so why the huge spike this year? I think there is a lot more communication in a variety of forums and ways in which medical students are becoming aware of the issues in a field and respond to them with career choices. People who want to care for children have a variety of specialty options (e.g. peds anesthesia) which may be appealing in this background.

Fixing the low pay will be a challenge, but some things can be fixed fairly readily. First, all fellowships must have 2 year, limited research options/pathways. Second, the board pass rate problem needs to be changed. There is no rational reason for a failure rate > 5%. I suspect the test itself is a large part of the problem. Finally, we need to improve the understanding by medical students of opportunities for advocacy, education and other forms of practice enhancements that exist within pediatrics. The AAP needs to work on this.

Of course some of these things "can" be fixed readily, but they have been problems for 10+ years and they haven't been fixed. And even if you make fellowships 2 years with limited research, that isn't going to fix the underlying problems that you're going to be paid less than gen peds and that there may not be a job for you in your desired location.

I think this year is a snowball effect. Yes, there's a massive tripling of unfilled spots this year, but between 2013-2023 the number of unfilled spots increased by 8x (86 in 2023 compared to 10 in 2013). It also doubled from 41 in 2021 to 81 in 2022. To me it is an increasing recognition that "oh crap, they're not going to do anything about these problems and if I go into peds then this is actually what my career is going to look like." And yes, that message is increasingly being disseminated through various forums and as pediatricians become increasingly dissatisfied.

 

[oldbearprofessor]

Of course some of these things "can" be fixed readily, but they have been problems for 10+ years and they haven't been fixed. And even if you make fellowships 2 years with limited research, that isn't going to fix the underlying problems that you're going to be paid less than gen peds and that there may not be a job for you in your desired location.

I think this year is a snowball effect. Yes, there's a massive tripling of unfilled spots this year, but between 2013-2023 the number of unfilled spots increased by 8x (86 in 2023 compared to 10 in 2013). It also doubled from 41 in 2021 to 81 in 2022. To me it is an increasing recognition that "oh crap, they're not going to do anything about these problems and if I go into peds then this is actually what my career is going to look like." And yes, that message is increasingly being disseminated through various forums and as pediatricians become increasingly dissatisfied.

The likely most powerful change force related to fellowships and board pass rates would be the programs themselves/department chairs, etc putting pressure on ABP. This seems more likely to occur if more high profile places don't fill. Will be very interesting to see the unfilled program lists this year, I expect some well known names to be on it.

 

[HemeOncHopeful19]

The likely most powerful change force related to fellowships and board pass rates would be the programs themselves/department chairs, etc putting pressure on ABP. This seems more likely to occur if more high profile places don't fill. Will be very interesting to see the unfilled program lists this year, I expect some well known names to be on it.

I don’t see why this would be any different from Rad Onc or EM, the world will come down from above to start interviewing more IMGs/FMGs to maintain the cheap labor pool for the hospital. Numbers will look better next year.

 

[GoSpursGo]

I don’t see why this would be any different from Rad Onc or EM, the world will come down from above to start interviewing more IMGs/FMGs to maintain the cheap labor pool for the hospital. Numbers will look better next year.

Idunno, unlike EM and rad onc which once were pretty competitive specialties, peds has always been noncompetitive and somewhat attainable to IMG/FMGs. I'm not sure you can just waive a magic wand and create a pool of candidates that doesn't exist.

To me the real question is going to be does anyone care that their peds programs aren't filling, or are they just going to make the attendings work harder and/or hire more APPs? Cuz if I got told, "welp, our peds program didn't fill this year so there's going to be one less resident on the weekend and the attendings are going to have to see 5 patients on their own on the weekend" or "we didn't get a fellow this year, so the attendings are taking home call by themselves"... I sort of just have to suck it up. Yes eventually maybe I try to find my way to another program, but based on what I'm reading about my specialty I don't get the sense that anywhere else is really doing much better.

 

[calvinhobbes]

Answers are easy. Peds is losing the battle to incompetent NPs who get paid less (but similar) to gen peds, thus cheap labor for hospitals); the fellowships that pay even less than gen peds, and that stupid hospitalist fellowship which makes zero sense financially and skills-wise. Oh, and the fact that the ABP exam is horrendous and has the lowest pass rate amongst any other medical specialty, yet is the most expensive. So why would anyone subject themselves to becoming a pediatrician when clinics and hospitals are looking to cut costs and hire NPs with a cheap online degree? Don’t believe me? Ask the peds folks working out there today in the real world. They are overworked, underpaid, and legit being passed on over for jobs that go to NPs with no training. Until salaries significantly go up and the hospitalist fellowship is abolished, there will be zero incentive to subject oneself to the rigors of pediatric training but still come out making less money than an FM or IM doc (usually about ~100k less in starting salary!) Hell, many med students I mentor who had an interest in peds ended up matching psych because it’s a more flexible field with starting salaries around 350k-400k, with child psych paying even more. Med school is getting more expensive and interest rates for loans are out of control. Med students are realizing they want a lifestyle speciality that pays well, with the option to see adults, too. So, since peds is very limiting, why not choose FM and do pain management all day making bank? That’s what I hear from friends of mine anyways. People want options, and in peds you’re stuck forever. Peds used to be a wonderful speciality but now its own leadership is treating it like crap—so why would med students respect it?

 

[oldbearprofessor]

I don’t see why this would be any different from Rad Onc or EM, the world will come down from above to start interviewing more IMGs/FMGs to maintain the cheap labor pool for the hospital. Numbers will look better next year.

I expect top 20-30 programs to readily fill in the SOAP this and most any year. When these programs do not fill in the primary match it will be embarrassing and MAY lead to some introspection. Whether that will turn into action is less clear.

 

[HemeOncHopeful19]

I expect top 20-30 programs to readily fill in the SOAP this and most any year. When these programs do not fill in the primary match it will be embarrassing and MAY lead to some introspection. Whether that will turn into action is less clear.

These are the programs that I think still have room to interview more IMGs though which is what I think will happen. We’ll see

 

[Fpg1245]

This seems to be a great opportunity for
Programs to interview international grads who have likely already done pediatric training in their home countries. No need to
Really “train” them. And they’re basically operating as attendings already at a fraction of the cost. Even MLPs might have a tough time competing with that

 

[vikingforever]

Also, the changing ACGME requirements for pediatric residency is probably another blow to our desirability as a specialty, especially with the significantly decreased emphasis on acute care and procedures. We complained that the hospitalist fellowship was unnecessary due to residency training, so the response was to make residency training now inadequate for a true practicing hospitalist.

 

[SurfingDoctor]

Okay folks, why let Reddit have all the fun with this topic! Why was there an approximate tripling of the number of unmatched positions in the pedi match this year to about 250? What can be done about this in the future?

Nothing. Additionally, we are overtraining subspecialists, so that’s neat. In my own field, I’ve come to realize the 2 year fellowship wouldn’t fix anything, as the market would be continued to be flooded with non-cognitive operators with even less unique skills who are essentially just expensive APRNs. But a number reduction in spots is heresy… so flood away I guess.

This all seems like the natural consequence of having pediatricians (and doctors in general) be leaders in training who have no concept of market forces and instead, as the boss used to say, “enjoy sitting under the trees and drinking Diet Pepsi with medical students and talking about how they should go into pediatrics”.

I as a more senior person in my own program, I tried to bring this up and be thoughtful about how to promote our own recruits/graduates in the labor force. I was shot down by the younger generation attendings who prefer the Diet Pepsi route and who would rather tilt at windmills.

At this point, I’m okay letting things just rot and watching it crumble from the sidelines.

 

[GoSpursGo]

Nothing. Additionally, we are overtraining subspecialists, so that’s neat. In my own field, I’ve come to realize the 2 year fellowship wouldn’t fix anything, as the market would be continued to be flooded with non-cognitive operators with even less unique skills who are essentially just expensive APRNs. But a number reduction in spots is heresy… so flood away I guess.

This is also true. In my own field, fellowship programs with funding for an optional 4th year are seen as attractive, because we know if we don’t have a first author pub at the end of training we can’t get a decent job.

 

[SurfingDoctor]

This is also true. In my own field, fellowship programs with funding for an optional 4th year are seen as attractive, because we know if we don’t have a first author pub at the end of training we can’t get a decent job.

Certainly and this is becoming a problem of stupid proportions. In ICU, we have had CVICU and Research Fellowships for a long time, at least over a decade for both. The research fellowships have always been unpopular and the CVICU fellowships also tend to be unpopular, albeit for different reasons. But both fellowship self-select a lot of trainees out so the spots remain sparse. But instead of doing the right thing and trimming global spots, not allowing programs with 1 fellow per year open up, we (as a collective) decided the opposite and not only should be let crap programs open up because they meet the minimal standard, we should invent a whole bunch of useless non-ACGME fellowship that do nothing but waste time. ECMO fellowship, stimulation fellowship and the newest pile o garbage, point-of-care ultrasound fellowship.

No one has any vision in leadership positions beyond 1) what allows them to pretend they are useful (all those people who so enjoy smelling their own farts) and 2) what cheap labor can be employed via that mechanism. But then again, I wholeheartedly think that on the whole, physicians make very poor leaders so whatever...

 

[GoSpursGo]

Certainly and this is becoming a problem of stupid proportions. In ICU, we have had CVICU and Research Fellowships for a long time, at least over a decade for both. The research fellowships have always been unpopular and the CVICU fellowships also tend to be unpopular, albeit for different reasons. But both fellowship self-select a lot of trainees out so the spots remain sparse. But instead of doing the right thing and trimming global spots, not allowing programs with 1 fellow per year open up, we (as a collective) decided the opposite and not only should be let crap programs open up because they meet the minimal standard, we should invent a whole bunch of useless non-ACGME fellowship that do nothing but waste time. ECMO fellowship, stimulation fellowship and the newest pile o garbage, point-of-care ultrasound fellowship.

No one has any vision in leadership positions beyond 1) what allows them to pretend they are useful (all those people who so enjoy smelling their own farts) and 2) what cheap labor can be employed via that mechanism. But then again, I wholeheartedly think that on the whole, physicians make very poor leaders so whatever...

For us neuro-onc fellowships make some sense there is an actual neuro-onc boards. BMT also makes sense since it really is so specialized. Other than that, there are a bunch of programs that can theoretically make you more marketable, but also leave you fairly pigeonholed. And it’s all still more or less in the name of giving you time to get a paper out

 

[SurfingDoctor]

For us neuro-onc fellowships make some sense there is an actual neuro-onc boards. BMT also makes sense since it really is so specialized. Other than that, there are a bunch of programs that can theoretically make you more marketable, but also leave you fairly pigeonholed. And it’s all still more or less in the name of giving you time to get a paper out

Well, at least they get a paper. No one, no one gets a paper on point-of-care ultrasound or simulation.

 

[oldbearprofessor]

Some relevant numbers in this article, we'll perhaps see official numbers tomorrow. In any case, according to this, up to 66 unfilled programs from 30 last year representing about 1/4 of all programs.

Pediatrics Taxed in This Year's Match With 249 Unfilled Positions

Unfilled positions were spread across more than 60 pediatric residency programs

www.medpagetoday.com

 

[SurfingDoctor]

Some relevant numbers in this article, we'll perhaps see official numbers tomorrow. In any case, according to this, up to 66 unfilled programs from 30 last year representing about 1/4 of all programs.

Pediatrics Taxed in This Year's Match With 249 Unfilled Positions

Unfilled positions were spread across more than 60 pediatric residency programs

www.medpagetoday.com

I always love how out of touch (or just deceptive) people.

"What is so alarming about this is that pediatric workforce needs are increasing," she said.

She pointed to a recent reportopens in a new tab or window from the National Academies of Science, Engineering, and Medicine that addresses

Yeah, we need general pediatrics, but those jobs are in Wyoming, Idaho, Kansas. Actually they usually pay pretty well because they are desperately understaffed. But that competes against trainees expectations, because trainees feel like deserve to be a 1% national income earner in NYC or LA. This is all a pure reflection of data being used improperly combined with people who are kinda FOS. Oh well.

 

[SurfingDoctor]

I always love how out of touch (or just deceptive) people.



Yeah, we need general pediatrics, but those jobs are in Wyoming, Idaho, Kansas. Actually they usually pay pretty well because they are desperately understaffed. But that competes against trainees expectations, because trainees feel like deserve to be a 1% national income earner in NYC or LA. This is all a pure reflection of data being used improperly combined with people who are kinda FOS. Oh well.

I will say, college costs in this country are way too high. This isn’t a pediatric, nor medicine, issues, it’s a societal issue. I suppose it trickles down into pediatrics and medicine, but it’s impact is far more global.

Of course, there is no real catalyst to change that either and the federal government is happy to give out crippling loans and the universities are happy to accept them so one can major in “German Fairytales”… but we’ll, there it is.

 

[oldbearprofessor]

I always love how out of touch (or just deceptive) people.



Yeah, we need general pediatrics, but those jobs are in Wyoming, Idaho, Kansas. Actually they usually pay pretty well because they are desperately understaffed. But that competes against trainees expectations, because trainees feel like deserve to be a 1% national income earner in NYC or LA. This is all a pure reflection of data being used improperly combined with people who are kinda FOS. Oh well.

Also of relevance is that the number of unfilled spots before the SOAP process does not relate very much to a lack of people who will be trained in a field. Ultimately, the SOAP will fill all or virtually all available slots in categorical peds residency programs except a handful that perhaps shouldn't be filled. The driver of the number of pediatric residency graduates is the number of available positions, not the number of SOAP spots. What the failure to fill in the primary match indicates is concern among US medical school graduates primarily that the field is not what they want it to be, for all the reasons being discussed.

This is of course a much different dynamic than pedi fellowship matches, where unfilled slots in things like child abuse, developmental and other less-popular fellowships (also less well paid) in pediatrics will not get filled and in many cases there is a broad shortage of specialists, albeit largely localized to places that have the volume to support these faculty. This problem is why creating a 2 year fellowship in these fields especially would be of importance.

 

[SurfingDoctor]

Also of relevance is that the number of unfilled spots does not relate very much to a lack of people who will be trained in a field. Ultimately, the SOAP will fill all or virtually all available slots in categorical peds residency programs except a handful that perhaps shouldn't be filled. The driver of the number of pediatric residency graduates is the number of available positions, not the number of SOAP spots. What the failure to fill in the primary match indicates is concern among US medical school graduates primarily that the field is not want they want, for all the reasons being discussed.

This is of course a much different dynamic than pedi fellowship matches, where unfilled slots in things like child abuse, developmental and other less-popular fellowships (also less well paid) in pediatrics will not get filled and in many cases there is a broad shortage of specialists, albeit largely localized to places that have the volume to support these faculty. This problem is why creating a 2 year fellowship in these fields especially would be of importance.

Of course. No program is gonna sit around and idle about when there are plenty of IMGs willing to fill the cheap labor pool. I mean, frankly, they would be dumb not to take the closest warm body.

As for the latter, sure. Probably could create a fast track pathway for those really interested in fields with true deficits. I’m still not convinced though that graduates are gonna to take that path it doesn’t get them to their desired location. We can take about money all we want, but it my experience geographic location >>> salary.

 

[calvnandhobbs68]

As for the latter, sure. Probably could create a fast track pathway for those really interested in fields with true deficits. I’m still not convinced though that graduates are gonna to take that path it doesn’t get them to their desired location. We can take about money all we want, but it my experience geographic location >>> salary.

Maybe but you also can't discount the impact of losing 100K+/year of salary when you're in your late 20s/early 30s for most people, especially when you're going into a fellowship where you may not make much more than gen peds so each year you're not making attending salary you're essentially running a deficit.

I mean you take even half of that and invest it for 30 years at a 6% return and you have an extra almost 300K when you're in your 60s (and 6% is a pretty conservative number). Even short term, that's easily the difference between being able to buy a new car or not or have extra money for a down payment when you finish fellowship. It's not peanuts.

 

[SurfingDoctor]

Maybe but you also can't discount the impact of losing 100K+/year of salary when you're in your late 20s/early 30s for most people, especially when you're going into a fellowship where you may not make much more than gen peds so each year you're not making attending salary you're essentially running a deficit.

I mean you take even half of that and invest it for 30 years at a 6% return and you have an extra almost 300K when you're in your 60s (and 6% is a pretty conservative number). Even short term, that's easily the difference between being able to buy a new car or not or have extra money for a down payment when you finish fellowship. It's not peanuts.

Hmm. I still don’t think most people, pediatricians included, really think about this. I remember asking a fellow about her retirement and her answer was “I don’t know, I don’t think about it. I don’t even know if I have a retirement account.” This answer is far more common than not.

She ended up in private practice, probably making more than academics and still having no idea how to manage money. The job she got was close enough to home however, so ultimately, that was the deciding factor.

Heck most of the faculty I know invest in garbage Vanguard retirement accounts. My wife, who is has business masters, doesn’t manage her retirement portfolio. I do. She doesn’t even know how much money is in her account.

I think globally, you are giving people way too much credit.

 

[calvnandhobbs68]

Hmm. I still don’t think most people, pediatricians included, really think about this. I remember asking a fellow about her retirement and her answer was “I don’t know, I don’t think about it. I don’t even know if I have a retirement account.” This answer is far more common than not.

She ended up in private practice, probably making more than academics and still having no idea how to manage money. The job she got was close enough to home however, so ultimately, that was the deciding factor.

Heck most of the faculty I know invest in garbage Vanguard retirement accounts. My wife, who is has business masters, doesn’t manage her retirement portfolio. I do. She doesn’t even know how much money is in her account.

I think globally, you are giving people way too much credit.

This is an aside but target date Vanguard retirement accounts are generally perfectly fine for people who just want to fire and forget their retirement accounts. You shouldn't need to "manage" retirement accounts too much for about 20+ years.

Anyway throw the retirement thing aside, most people can understand what $100,000 means, no matter if they think about it in retirement terms or not. Again, these are not specialities that are paying any more than gen peds and so every year you're in fellowship you are losing that amount of money in absolute terms, you'll never make it back. I'll tell you that I knew plenty of residents who were very aware of this fact. So anecdotes are anecdotes but it's not clear why pediatrics is keeping all these fellowships 3 years when they have NPs working in all these fields who switched from an outpatient peds clinic last month.

 

[SurfingDoctor]

This is an aside but target date Vanguard retirement accounts are generally perfectly fine for people who just want to fire and forget their retirement accounts. You shouldn't need to "manage" retirement accounts too much for about 20+ years.

Anyway throw the retirement thing aside, most people can understand what $100,000 means, no matter if they think about it in retirement terms or not. Again, these are not specialities that are paying any more than gen peds and so every year you're in fellowship you are losing that amount of money in absolute terms, you'll never make it back. I'll tell you that I knew plenty of residents who were very aware of this fact. So anecdotes are anecdotes but it's not clear why pediatrics is keeping all these fellowships 3 years when they have NPs working in all these fields who switched from an outpatient peds clinic last month.

I guess. Even so, tell me how these salaries are comparable to US percentiles as well as percentiles to other western nations.

 

[calvnandhobbs68]

I guess. Even so, tell me how these salaries are comparable to US percentiles as well as percentiles to other western nations.

I'm not sure of your point? Med students aren't looking at US percentiles when they're looking at a specialty, they're looking at relative pay between different physician specialities. Residents are looking at relative cost between specializing and not specializing. They're not choosing between being a doctor and an electrician. I think they all realize they aren't going to be homeless on any physician salary but certainly continued deferment of an immediate six figure income boost is painful for anyone.

Now I think this is very different for different fellowships, as you've alluded to above. Fellowships like DB peds, endo, ID, nephrology, pulm, rheum that are only filling like 50% of their slots should be taking a hard look as specialities overall at whether the issue is they're oversaturing their national job markets (doesn't seem like it, but if they are, they should be cutting down positions) vs need to make their fields more attractive to residents somehow (one way would be 2 year fellowship programs).

 

[SurfingDoctor]

I'm not sure of your point? Med students aren't looking at US percentiles when they're looking at a specialty, they're looking at relative pay between different physician specialities. Residents are looking at relative cost between specializing and not specializing. They're not choosing between being a doctor and an electrician. I think they all realize they aren't going to be homeless on any physician salary but certainly continued deferment of an immediate six figure income boost is painful for anyone.

Now I think this is very different for different fellowships, as you've alluded to above. Fellowships like DB peds, endo, ID, nephrology, pulm, rheum that are only filling like 50% of their slots should be taking a hard look as specialities overall at whether the issue is they're oversaturing their national job markets (doesn't seem like it, but if they are, they should be cutting down positions) vs need to make their fields more attractive to residents somehow (one way would be 2 year fellowship programs).

They are looking at ROI. Yet most don’t know what that acronym means.

I also globally think, if you are a top 5% earner in this country, but are worried about your financial future… you’re probably doing it all wrong. I have yet to see otherwise. But as I said, physicians may be smart from a biology standpoint, but that doesn’t make them smart financially.

Honestly, the only lecture I received in residency that I remember was on retirement and finance. In my residency class nearly 20 years ago, it was one of the least attended lectures.

As an aside, what do doctors have against electricians? That sounds like elitism. Most physicians couldn’t replace a light socket.

 

[DO2015CA]

Of course. No program is gonna sit around and idle about when there are plenty of IMGs willing to fill the cheap labor pool. I mean, frankly, they would be dumb not to take the closest warm body.

As for the latter, sure. Probably could create a fast track pathway for those really interested in fields with true deficits. I’m still not convinced though that graduates are gonna to take that path it doesn’t get them to their desired location. We can take about money all we want, but it my experience geographic location >>> salary.

Ya but there are needs in some of those cities for those specialist. My endo colleague had job offers on both coasts pretty readily (albeit worse pay). But even mine, pulm, there is an open job in most major cities. I have residents that are interested but say that 3 years isn’t worth it. With 2, we could grab those few extra people per year potentially that would find 2 yrs worth the opportunity cost vs 3 when it no longer is.

 

[calvnandhobbs68]

They are looking at ROI. Yet most don’t know what that acronym means.

I also globally think, if you are a top 5% earner in this country, but are worried about your financial future… your probably doing it all wrong. But as I said, physicians may be smart from a biology standpoint, but that doesn’t make them smart financially.

Honestly, the only lecture I received in residency that I remember was on retirement and finance. In my residency class nearly 20 years ago, it was one of the least attended lectures.

As an aside, what do doctors have against electricians? That sounds like elitism. Most physicians couldn’t replace a light socket.

I think you're really having a hard time differentiating between "worried about your financial future" and "wow an extra 100K+ for a down payment on my house when I'm just starting out my career would be really nice to have, what am I getting for forgoing that?". I also don't think you have to be "worried about your financial future" to realize that 200K/year and 350K/year are two different numbers and equal several million dollars over your career when you're looking at different specialties as a med student.

I was a resident much more recently than you. They care. They're also all part of things like physician/medical specific facebook groups where they get to blatently hear about other specialities making double or triple what they make. Not stuff you usually hear around the water cooler in the hospital.

The only thing I have against electricians is that they charge me too much so I rewired my basement myself. What's your point with these weird asides? Pick any other random occupation that you're no longer looking at when you're already in medical school.

 

[SurfingDoctor]

I think you're really having a hard time differentiating between "worried about your financial future" and "wow an extra 100K+ for a down payment on my house when I'm just starting out my career would be really nice to have, what am I getting for forgoing that?". I also don't think you have to be "worried about your financial future" to realize that 200K/year and 350K/year are two different numbers and equal several million dollars over your career when you're looking at different specialties as a med student.

I was a resident much more recently than you. They care. They're also all part of things like physician/medical specific facebook groups where they get to blatently hear about other specialities making double or triple what they make. Not stuff you usually hear around the water cooler in the hospital.

The only thing I have against electricians is that they charge me too much so I rewired my basement myself. What's your point with these weird asides? Pick any other random occupation that you're no longer looking at when you're already in medical school.

You’re tying in the housing market to pediatrics? Those are separate markets you must realize.

Interestingly and not surprisingly, the housing market is whole different issues…

There was a whole recent Marketplace on this very subject.

And no, I’m not convinced people are good a planning for the future now than they have been prior. In fact, my direct observations are they aren’t. But if your observations say otherwise, then so be it.

 

[SurfingDoctor]

Ya but there are needs in some of those cities for those specialist. My endo colleague had job offers on both coasts pretty readily (albeit worse pay). But even mine, pulm, there is an open job in most major cities. I have residents that are interested but say that 3 years isn’t worth it. With 2, we could grab those few extra people per year potentially that would find 2 yrs worth the opportunity cost vs 3 when it no longer is.

But there are. And for most subspecialties, there are plenty already.

But I have no problem flooding the market with 2 year fellowships in open labor markets. In fact, one could probably learn the clinical skills in 1 year. I mean, APRNs do it in less than 2 years, why would physicians need more time? My question is more about when those markets get tight, then what? Historically, the trend has been to open more programs.

My point is all of this lacks a strategic vision. But then again, I’m getting older so let whatever happens in the short term happen I guess and you younger folks can have this argument again in a decade. Maybe it’ll be different then.

 

[calvnandhobbs68]

You’re tying in the housing market to pediatrics? Those are separate markets you must realize.

Interestingly and not surprisingly, the housing market is whole different issues…

There was a whole recent Marketplace on this very subject.

This stuff is just whooshing over your head unless you’re just intentionally being obtuse. It’s like the focusing on the electrician thing instead of the actual point.

I can make it very simple here.
($200,000 x 1 year) > ($70,000 x 1 year)

 

[SurfingDoctor]

This stuff is just whooshing over your head unless you’re just intentionally being obtuse. It’s like the focusing on the electrician thing instead of the actual point.

I can make it very simple here.
($200,000 x 1 year) > ($70,000 x 1 year)

You are making $70K/year. Then you need to find a new employer. Unfortunately, Harvard does pay at those rates.

Otherwise, you are saying that a one-time $130K in lost earnings over a lifetime (2 year versus 3 year fellowship is what you are getting at?) is putting you in the poor house? I guess, but I've never personally seen it outside of people who are terrible at managing money and I would suggest anyone who does find a financial advisor.

Incidentally, this all reminds me of my division chief who makes nearly double of all of us in the group, but 1) has been divorced and pays lots of alimony, 2) has a lot of kids, 3) goes on expensive vacations and 4) complains they have no retirement because of the former. Yeah...

Anyway, I'm not here to convince you that physicians are bad money managers (there's enough articles on this already), nor am I going to try to convince you that throwing more money at people who can't manage money is going to fix the problem (which also has a lot of articles), so we can move on from this point and get back to the real topic at hand... too many programs and slots despite a lack of reasonable demand.

 

[DarkBluMage]

They are looking at ROI. Yet most don’t know what that acronym means.

I also globally think, if you are a top 5% earner in this country, but are worried about your financial future… you’re probably doing it all wrong. I have yet to see otherwise. But as I said, physicians may be smart from a biology standpoint, but that doesn’t make them smart financially.

Honestly, the only lecture I received in residency that I remember was on retirement and finance. In my residency class nearly 20 years ago, it was one of the least attended lectures.

As an aside, what do doctors have against electricians? That sounds like elitism. Most physicians couldn’t replace a light socket.

Trust me, us med students know what ROI means. Keep in mind that medical school is far more expensive now than it was 20 years ago. Students are graduating with 6 figure debt. Compare that to possibly “low salary” for physicians comparatively, extended time in fellowships, and ROI isn’t looking good regardless of being a top 5% earner especially if you’re a non-trad student already in your late 20s-30s before even starting residency. Anyone with 6 figure debt should definitely be concerned for their financial future…

 

[SurfingDoctor]

Trust me, us med students know what ROI means. Keep in mind that medical school is far more expensive now than it was 20 years ago. Students are graduating with 6 figure debt. Compare that to possibly “low salary” for physicians comparatively, extended time in fellowships, and ROI isn’t looking good regardless of being a top 5% earner especially if you’re a non-trad student already in your late 20s-30s before even starting residency. Anyone with 6 figure debt should definitely be concerned for their financial future…

I definitely agree, education globally in this country is way too expensive. Not just for doctors, for everyone.

 

[DO2015CA]

But there are. And for most subspecialties, there are plenty already.

But I have no problem flooding the market with 2 year fellowships in open labor markets. In fact, one could probably learn the clinical skills in 1 year. I mean, APRNs do it in less than 2 years, why would physicians need more time? My question is more about when those markets get tight, then what? Historically, the trend has been to open more programs.

My point is all of this lacks a strategic vision. But then again, I’m getting older so let whatever happens in the short term happen I guess and you younger folks can have this argument again in a decade. Maybe it’ll be different then.

Oh I agree about that point in the second paragraph. I don’t see us attracting enough candidates in these opportunity cost specialties to be filling every year and needing expansion. It just tips the balance a little in the favor of those that are on the fence. For picu, I think you are right.

 

[SurfingDoctor]

Oh I agree about that point in the second paragraph. I don’t see us attracting enough candidates in these opportunity cost specialties to be filling every year and needing expansion. It just tips the balance a little in the favor of those that are on the fence. For picu, I think you are right.

I would be an interesting hypothesis to test. I just worry about the lack of an off ramp.

 

[DO2015CA]

You are making $70K/year. Then you need to find a new employer. Unfortunately, Harvard does pay at those rates.

Otherwise, you are saying that a one-time $130K in lost earnings over a lifetime (2 year versus 3 year fellowship is what you are getting at?) is putting you in the poor house? I guess, but I've never personally seen it outside of people who are terrible at managing money and I would suggest anyone who does find a financial advisor.

Incidentally, this all reminds me of my division chief who makes nearly double of all of us in the group, but 1) has been divorced and pays lots of alimony, 2) has a lot of kids, 3) goes on expensive vacations and 4) complains they have no retirement because of the former. Yeah...

Anyway, I'm not here to convince you that physicians are bad money managers (there's enough articles on this already), nor am I going to try to convince you that throwing more money at people who can't manage money is going to fix the problem (which also has a lot of articles), so we can move on from this point and get back to the real topic at hand... too many programs and slots despite a lack of reasonable demand.

Now that we can agree on! Most doctors are bad with money lol

 

[DO2015CA]

I would be an interesting hypothesis to test. I just worry about the lack of an off ramp.

Yes that is reasonable. A lot of things get implemented short term that then become permanent. It makes sense to be worrying about an exit strategy if the scales were tip the other way.

I think what drives me to at least try is having done residency in the middle of the country seeing the complete void of some specialties. We had no pediatric rheumatology in the state. Many more examples of lack of service but rheum was particularly an important missed specialty

 

[calvnandhobbs68]

Otherwise, you are saying that a one-time $130K in lost earnings over a lifetime (2 year versus 3 year fellowship is what you are getting at?) is putting you in the poor house? I guess, but I've never personally seen it outside of people who are terrible at managing money and I would suggest anyone who does find a financial advisor.

Who's said anything about the poor house other than you?

But correct, that is what I'm saying and everyone who is advocating for 2 year fellowships esp for subspecialities with high unfilled slots is saying. I guess if you're so rich that 130K is chump change to you, then sure might not matter much. For the rest of us plebes, 130K at the beginning of your career is a significant chunk of change, esp when you're only gonna be maybe making in the low 200s at best in a lot of these specialities anyway.

 

[SurfingDoctor]

Who's said anything about the poor house other than you?

But correct, that is what I'm saying and everyone who is advocating for 2 year fellowships esp for subspecialities with high unfilled slots is saying. I guess if you're so rich that 130K is chump change to you, then sure might not matter much. For the rest of us plebes, 130K at the beginning of your career is a significant chunk of change, esp when you're only gonna be maybe making in the low 200s at best in a lot of these specialities anyway.

I don’t know. I’m still not convinced it would make any longterm impact in the field, other than appear as a carrot whose longterm impact is negligible, but if someone cares to figure out a way to change it and make that carrot all the same, sounds good.

To me, getting at the cost of education seems like a more impactful goal (and the only real place for cost reductions), but still think that is unlikely until people stop going to college for nonsense degrees forcing colleges to actually become monetarily competitive. And medical schools keep popping up and are willing to charge whatever because everyone would give a kidney to be a doctor.

Anyway, the system is buggered, but there are 1) too many people the poor system benefits and 2) too many incompetent people helping drive it. Those systems tend to just meander on until all the wheels come off, which tend to be never because there’s also a lot of people in the system whose job is just to patch the indefinitely.

 

[mvenus929]

There is lots of chatter happening amongst PDs right now. The general thoughts are:

1) There has been a lot of growth of peds programs in the past several years, likely at least partially driven from workload related concerns (my program rivaled the surgery program in terms of hours per week at the job).

2) There has been a decrease in US MD and DO applicants over the past several years; this year, IMG applicants have also gone down, creating the surge in open positions.

3) A lot of people are applying to peds as a secondary specialty

4) The lack of autonomy and perceived competency compared to adult specialties is terrible--IM and FM interns run codes frequently, but Peds has a three year fellowship to do hospital medicine.

5) Multiple subspecialties get paid less, on average, than gen peds but still require a three year fellowship. There are at least some efforts to decrease fellowship length to 2 years, but the scholarly project will remain in those cases as it is an ABP requirement.

6) There's likely a regional component to this, though I haven't looked too far into the data, suggesting that people aren't applying to certain areas based on political ideas. Gender affirming care has been banned in several states, as has abortion. In a field that is mostly women, the idea of not having reproductive freedoms during training likely pushes some people away from applying in those areas. Similarly, having restrictions on what discussions you can have with your patients by state law may push some people away from certain areas. Obviously this is not the biggest contributor, but may support why some programs are filling compared to others of the same 'quality' (whatever that is).

 

[DO2015CA]

There is lots of chatter happening amongst PDs right now. The general thoughts are:

1) There has been a lot of growth of peds programs in the past several years, likely at least partially driven from workload related concerns (my program rivaled the surgery program in terms of hours per week at the job).

2) There has been a decrease in US MD and DO applicants over the past several years; this year, IMG applicants have also gone down, creating the surge in open positions.

3) A lot of people are applying to peds as a secondary specialty

4) The lack of autonomy and perceived competency compared to adult specialties is terrible--IM and FM interns run codes frequently, but Peds has a three year fellowship to do hospital medicine.

5) Multiple subspecialties get paid less, on average, than gen peds but still require a three year fellowship. There are at least some efforts to decrease fellowship length to 2 years, but the scholarly project will remain in those cases as it is an ABP requirement.

6) There's likely a regional component to this, though I haven't looked too far into the data, suggesting that people aren't applying to certain areas based on political ideas. Gender affirming care has been banned in several states, as has abortion. In a field that is mostly women, the idea of not having reproductive freedoms during training likely pushes some people away from applying in those areas. Similarly, having restrictions on what discussions you can have with your patients by state law may push some people away from certain areas. Obviously this is not the biggest contributor, but may support why some programs are filling compared to others of the same 'quality' (whatever that is).

How quick can we roll out this 2 year requirement for fellowships lol

 

[calvnandhobbs68]

There is lots of chatter happening amongst PDs right now. The general thoughts are:

1) There has been a lot of growth of peds programs in the past several years, likely at least partially driven from workload related concerns (my program rivaled the surgery program in terms of hours per week at the job).

2) There has been a decrease in US MD and DO applicants over the past several years; this year, IMG applicants have also gone down, creating the surge in open positions.

3) A lot of people are applying to peds as a secondary specialty

4) The lack of autonomy and perceived competency compared to adult specialties is terrible--IM and FM interns run codes frequently, but Peds has a three year fellowship to do hospital medicine.

5) Multiple subspecialties get paid less, on average, than gen peds but still require a three year fellowship. There are at least some efforts to decrease fellowship length to 2 years, but the scholarly project will remain in those cases as it is an ABP requirement.

6) There's likely a regional component to this, though I haven't looked too far into the data, suggesting that people aren't applying to certain areas based on political ideas. Gender affirming care has been banned in several states, as has abortion. In a field that is mostly women, the idea of not having reproductive freedoms during training likely pushes some people away from applying in those areas. Similarly, having restrictions on what discussions you can have with your patients by state law may push some people away from certain areas. Obviously this is not the biggest contributor, but may support why some programs are filling compared to others of the same 'quality' (whatever that is).

I think those are all good thoughts (and I honestly hadn't even thought of the gender affirming care/reproductive aspect of things...although if that was truly a huge impact you should see this reflected in stuff like the OB/GYN match too).

However, what I don't see there is again the financial aspect of peds at this point. This is something that no applicant is ever going to say is a problem. This isn't something PDs can do anything about but something they really really need to start recognizing they're working AGAINST. Seemingly moreso than in the past, I wonder if some of this is driven by how high COL/inflation overall has been over the last 4-5 years.

The overall decrease in applicants overall is very telling. 200+ less MD seniors than last year applied which is huge. Peds is going to start feeling the way IM/FM has felt for a long time....overall peds was relatively insulated from becoming terribly uncompetitive previously likely because a large portion of people applying for peds historically were relatively decent US grad applicants who really wanted to work with kids and a not insignificant number of MD/PhDs who wanted to do pediatric specific research. I'm wondering if that's starting to fizzle out as the cons you've noted above along with financial aspects are starting to overwhelm the pros.

I also agree that it must be pretty disheartening to work with NPs during residency/fellowship knowing you'll barely make more than them even as an attending for a lot of cognitive subspecialities/hospitalists/gen peds. Much less of a "light at the end of the tunnel" from that standpoint. Again, not something PDs can do much about but just recognizing as a vibe med students might get during rotations.

 

[mvenus929]

I think those are all good thoughts (and I honestly hadn't even thought of the gender affirming care/reproductive aspect of things...although if that was truly a huge impact you should see this reflected in stuff like the OB/GYN match too).

Like this? 🙂 Obstetrics and Gynecology Residency Applications After Abortion Access Changes

However, what I don't see there is again the financial aspect of peds at this point. This is something that no applicant is ever going to say is a problem. This isn't something PDs can do anything about but something they really really need to start recognizing they're working AGAINST. Seemingly moreso than in the past, I wonder if some of this is driven by how high COL/inflation overall has been over the last 4-5 years.

Yes, I figured I wouldn't beat a dead horse and emphasize the financial aspect, though clearly this is a concern especially as medical school costs are rising. There was also discussion from more junior people discussing the shift in attitude from medicine as a calling to medicine as a job and 'work/life balance', for which financials play a large role, as does the uncompensated work we do (including advocacy, prior auths, etc).

 

[SurfingDoctor]

Like this? 🙂 Obstetrics and Gynecology Residency Applications After Abortion Access Changes



Yes, I figured I wouldn't beat a dead horse and emphasize the financial aspect, though clearly this is a concern especially as medical school costs are rising. There was also discussion from more junior people discussing the shift in attitude from medicine as a calling to medicine as a job and 'work/life balance', for which financials play a large role, as does the uncompensated work we do (including advocacy, prior auths, etc).

Pediatrics has always been a calling. There are just less people interested in that anymore.

Twitter and social media in general have given rise to competition in consumerism and materialism. People have constant and easy access to see what others have and compare it to themselves and that leads to very different life expectations.

 

[SurfingDoctor]

I’m not enough in the know to know if our peds residency program did or didn’t fill. But several of the matches were from medical schools I’ve never heard of and had to Google.

Pediatric critical care is very clinically oriented these days and not much research or scholarship. But there’s also only like 5 things in an intensivists tool box and one of those things are CPR. I already lament how non-cognitive our field has become but if clinically mediocre applicants are all we are going to be able to muster for the foreseeable future, our field is screwed. And since peds CCM still remains somewhat competitive for now, I can’t imagine what other subspecialties are going to go through.

 

[Oso]

There was also discussion from more junior people discussing the shift in attitude from medicine as a calling to medicine as a job and 'work/life balance', for which financials play a large role, as does the uncompensated work we do (including advocacy, prior auths, etc).

Agreed. As an example, if someone is interested in oncology, why do peds heme onc, make less than a general pediatrician, and have to meet all demands of an academic job (if you can even find one)if you could alternatively do adult heme inc and have more job options, make a lot more, and have more say in the type of lifestyle you have?

The people who love working with children (or the people who hate working with adults) will go into peds, but for anyone on the fence, it makes a lot of sense to go into something else (esp. if there’s an option to subspecialize in peds later on - ex. Anesthesia, psych, etc)