The subspeciality of pediatric neurosurgery is well established in North America, with a training pathway through the American Board of Pediatric Neurological Surgery (ABPNS) and the Accreditation Council for Pediatric Neurosurgical Fellowships (ACPNF). Integral steps in the pathway to specialized practice in pediatric neurosurgery are completion of an ACPNF-accredited fellowship and obtaining American Board of Neurological Surgery (ABNS) certification focused on pediatrics. The latter requires submission of surgical logs in which at least 75% of cases involve a patient younger than 21 years of age or at least 125 cases in which the patient is 12 years or younger in the year preceding application.
Despite these strenuous requirements for pediatric neurosurgery board certification, a growing concern within pediatric neurosurgery as a subspecialty is the finite number of employment opportunities available for those who want to pursue a predominantly pediatric practice. Currently, there are 33 pediatric neurosurgery fellowship training programs in North America, with enough positions that nearly everyone who might desire a dedicated pediatric neurosurgery practice is successfully matched into a fellowship program after residency. These fellowship programs have all been vetted and approved by the ACPNF to ensure equal training for candidates such that each is competent in all facets of pediatric neurosurgery upon completion of fellowship. However, with limited numbers of dedicated pediatric positions in the market, the question becomes “Are we training too many pediatric neurosurgeons?” Dr. Susan Durham, division chief of pediatric neurosurgery at Los Angeles Children’s Hospital and professor of neurosurgery at the University of Southern California Keck School of Medicine, has spent significant time studying this subject.
A 2009 article defining the pediatric neurosurgical workforce by Durham et al. revealed that fewer than 200 pediatric neurosurgeons (defined as >75% of their operative volume was pediatric) were practicing in the United States. At that time, fewer than 10 pediatric neurosurgery fellows were being trained each year, and only about two-thirds of these went into a US pediatric neurosurgical practice. The conclusions from this 2009 study indicated that the pediatric neurosurgery workforce would be insufficient to meet the demand in coming years; however, this conclusion was based on the five or six fellowship-trained pediatric neurosurgeons joining the workforce on an annual basis.
Since that time, as noted, the number of pediatric neurosurgery fellowship positions has tripled in the past year in North America. Clearly, the pendulum has swung in the other direction. The concern is oversaturation of the workforce without adequate study of the epidemiological need for children with surgical diseases of the nervous system.
When examining why the pendulum has swung, several facts become apparent. Data from the American Medical Association have demonstrated that surgeons have more recently tended to work past the previous age of retirement of 65 years. This overall trend is mirrored in pediatric neurosurgery, leading to a reduction in positions available. The cause is multifactorial and may include increased cost of living, inflation, effects of the COVID-19 pandemic, later age of Social Security eligibility, family/social scenarios requiring prolonged financial support and job satisfaction and identity maintenance. This phenomenon has been observed outside of medicine as well.
Another factor in the potential oversupply is that there is currently no cap on the number of pediatric neurosurgery fellowships available. The ACPNF criteria for fellowship training programs includes a minimum of three pediatric neurosurgeons at the fellowship training facility, a minimum caseload of 400 cases per year and affiliation with an approved neurosurgical residency training program. With these criteria, many children’s hospitals seek fellowship accreditation, which indirectly may act as a marker for status and renown. However, with the annual fellowship match, there is no forecast for potential positions that are available, thus many candidates may be left without a desired job in pediatric neurosurgery. Furthermore, there are numerous neurosurgeons that care for children without having completed a pediatric fellowship and/or obtaining certification by the ABPNS; thus, training surgeons for these roles is an important aspect of fellowship training.
Historically, some of the pressure on the North American job market was alleviated because pediatric neurosurgery training programs trained numerous international fellows, which allowed a training experience that would eventually have global impact. With a recent increase in North American chief residents seeking pediatric subspecialty training, this pipeline has decreased for international applicants. Dewan et al. found that in low- and middle-income countries there is grossly insufficient presence of pediatric neurosurgery providers, thus supporting the need for training opportunities for individuals wanting to serve these areas.
Overall, pediatric neurosurgery as an entity should evaluate the fellowship training paradigm, ensure each fellowship program is able to adequately train incoming fellows and critically study the workforce to identify gaps and help forecast future need.
AUTHOR DISCLAIMER
“The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government.”
COPYRIGHT STATEMENT
“I am a military Service member. This work was prepared as part of my official duties. Title 17, U.S.C., §105 provides that copyright protection under this title is not available for any work of the U.S. Government. Title 17, U.S.C., §101 defines a U.S. Government work as a work prepared by a military Service member or employee of the U.S. Government as part of that person’s official duties.”
