Attrition in Pediatric Pulmonology Fellowship

Pediatric Pulmonology is an established pediatric subspecialty in the United States with physicians certified through the American Board of Pediatrics (ABP) after completion of a fellowship program accredited by the Accreditation Council on Graduate Medical Education (ACGME). In addition to clinical training, fellows are required to become knowledgeable in research and proficient in teaching. Like other pediatric subspecialties, there are growing concerns regarding the future workforce in Pediatric Pulmonology not only in the Unites States, but internationally. ¹ The most recent results of the National Resident Match Program (NRMP) match for Pediatric Pulmonology found only 50% (22/44) of fellowship programs being completely filled, with 35% (23/65) of positions going unfilled for the 2013 academic year. ² With a small number of individuals entering the Pediatric Pulmonology fellowship training, retention of fellows should be the priority to assist in the increase of the physician workforce caring for children with pulmonary disorders.

We completed an analysis of the ABP Workforce Data ³ Pediatric subspecialty fellowship training programs to determine if there is a specific time period where attrition is significantly higher for trainees in Pediatric Pulmonology, so that interventions could be considered to assist in retention of fellows. A total of 34% (373/1091) of the current ABP diplomates in Pediatric Pulmonology completed their certification examination on or before 1992. Since 1995, the mean (±SD) number of residents entering Pediatric Pulmonology fellowship training was 123±36 (range 31–178). To perform a contemporary analysis, we limited our analysis to the years 2001 to 2011 and found a mean graduation rate of 85% (range 78%–95%) with a steady attrition rate across this time period. The only year that the graduation rate was >90% was in 2003 at 95%, while the nadir was in 2008 with a graduation rate of 78%. Using a Mann–Whitney test for analysis, there was a statistically significant higher rate of attrition for year 2 compared with year 1, median 10.2 (confidence interval [CI] 5.6, 15.7) versus 5.3 (CI 2.4, 7.5), p=0.047 (Fig. 1), respectively.

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FIG. 1.

Attrition rate (% of class that left the fellowship program), overall and for year 1 vs. 2. *P=0.047.

Published reports have identified important factors as to why residents pursue pediatric subspecialty training, including physician and patient demographics, trainee debt and lifestyle considerations, competition among subspecialty providers, equitable reimbursement for subspecialty care and services, and policies related to physician supply. ⁴ Entering pediatric subspecialty fellowship training is unlike adult subspecialty training with a higher variability on financial return for 3 more years of postgraduate training. ⁵

Although this small study is limited due to retrospective collection of data and the lack of granularity of the ABP data, we identified that the Pediatric Pulmonology workforce is aging in the United States and, more importantly, found a specific time period during which, Pediatric Pulmonology fellows seem to be more vulnerable to attrition. A retrospective study cannot identify causal relationships, so further research is needed to identify the factors involved leading to fellows departing Pediatric Pulmonology training. Identification and amelioration of these factors may potentially impact physician shortage of Pediatric Pulmonologists.