Using multiple metrics, the diversity of the pediatric population in the United States is increasing. However, recent data suggest significant disparities in both the prevalence and management of child health conditions cared for by pediatric subspecialists. These inequities occur across multiple dimensions of diversity, including race and ethnicity, country of origin, socioeconomic status, sex and gender, and disability. Research also suggests that attending to diversity, equity, and inclusion in the medical workforce may positively affect health outcomes. High-quality pediatric subspecialty care thus requires knowledge of these data, attention to the effects of social drivers, including racism and discrimination, on health and wellbeing, and interventions to improve pediatric health equity through educational, practice, policy, and research innovations. In this article, we review data on the diversity of the pediatric population and pediatric subspecialty workforce, suggest potential strengths, weaknesses, opportunities, and threats of current diversity, equity, and inclusion initiatives in academic pediatrics, and provide recommendations across 4 domains: education and training, practice, policy, and future research. The ultimate goal of pediatrics is to improve health equity for all infants, children, adolescents, and young adults cared for in the United States by pediatric subspecialists.

Pediatricians and pediatric health care organizations are increasingly affirming diversity, equity, and inclusion (DEI) as a core value across clinical practice, education and training, policy, and research, with the ultimate goal of eliminating longstanding pediatric health inequities.15  The American Academy of Pediatrics (AAP) conceptualizes DEI as “celebrating the diversity of children and families and promoting nurturing, inclusive environments…actively opposing intolerance, bigotry, bias, and discrimination.”6  In addition to this focus on patients and families, pediatric organizations have also highlighted the importance of enhancing workforce diversity as part of efforts to improve pediatric health equity.7 

This article is part of a Pediatrics supplement focused on the pediatric subspecialty workforce’s ability to meet the needs of infants, children, adolescents, and young adults (hereafter, “children”) in the United States.8  It focuses specifically on decreasing health inequities experienced by children and families with acute and chronic conditions requiring pediatric subspecialty care for whom their varied dimensions of diversity may result in worse health due to lack of access to high-quality care. Decreasing health inequities requires understanding the ever-increasing diversity of the US pediatric population, as well as researching and acknowledging the detrimental impact on child health of the myriad social drivers of health (SDoH), including poverty, racism, and discrimination, and mitigating adverse effects through education and training, practice improvement, policy changes, and research.9  Additionally, understanding the current diversity of the workforce, the status of current DEI efforts, and how a diverse pediatric subspecialty workforce can positively impact child health is essential. Pediatric subspecialists who manage many chronic conditions for children are often involved in subspecialty education and training for general pediatric and subspecialty trainees, serve as volunteers or consultants to inform policy decisions, and conduct child health research. We posit that attention to both the diversity of the pediatric population and the pediatric subspecialty workforce will positively impact the health of the nation’s children.10 

Diversity, as defined in this article, is dynamic; it includes race and ethnicity, country of origin, socioeconomic status, sex, sexuality, gender, and disability categorizations. Because of heightened attention to the ongoing adverse effects of racism and discrimination and limited data regarding some dimensions of diversity, we focus substantively on racial and ethnic diversity in this article.

Regarding the race and ethnicity minority (minoritized) population, 26% of children 0 to 17 years of age in 2021 identified as of Hispanic, Latino, or Spanish origin (Latino), 14% as Black or African American (Black), 5% as Asian, 1% as American Indian or Alaska Native (AI/AN), and 5% as multiracial.11  Moreover, 1 in 4 children live in an immigrant family, defined as children with at least 1 parent born outside the United States.12  Currently, 50% of immigrants are from Latin America and 25% are from Asia.13  The US Census Bureau estimates that, by 2060, 2 in 3 children in the United States will identify as Latino, Black, Asian, AI/AN, Native Hawaiian or Other Pacific Islander, or multiracial in origin and 1 in 3 will live in an immigrant family.14  These sociodemographic variations are reflected in the diversity of languages spoken by US children.15 

Data from 2019 to 2022 suggest that ∼20% of US children have special health care needs.16  Approximately 10% of US adolescents self-identify as sexual- and gender-diverse (SGD).17  Nearly 12 million children grow up in rural areas.18  Data from 2021 indicate that 16.9% of children live in poverty.19  Children from Black, Latino, or AI/AN communities are more likely to live in poverty compared with an aggregate of all US children, revealing how different dimensions of diversity may potentiate one another.20 

Inequities in the frequency and outcomes of pediatric conditions cared for by pediatric subspecialists have been identified on the basis of race and ethnicity,21  socioeconomic status,2224  rural geography,18,25  SGD self-identification,26  community resources,27  and disability.28  For example, statistically, Black infants in the NICU have an increased risk of morbidity and mortality relative to all other racial or ethnic groups,29  children living in poverty have increased asthma morbidity and mortality,30  and children from the SGD community experience stigmatization and often face significant mental health obstacles.31 Table 1 provides further data regarding inequities in the occurrence and treatment of several conditions cared for by pediatric subspecialists. These health inequities may begin in early childhood, be amplified by adverse childhood experiences, including racism and discrimination, and contribute to poor health outcomes in adulthood.32,33 

TABLE 1

Examples of Pediatric Health Inequities Related to SDoH or Racism

DomainDescription
Pediatric structures and processes  
 Inaccurate pulse oximetry measurement Falsely elevated pulse oximetry readings in Black children are an example of structural racism, which led them to not have been eligible for therapies like remdesivir or corticosteroids (which required a certain oxygen threshold or receipt of supplemental oxygen).93  
 Closure of pediatric units Between 2008 and 2018, the number of pediatric inpatient units declined by 19.1%.94  Rural environments had more than twice the decline in inpatient units relative to urban settings. More than one-quarter of children seeking inpatient care experienced an increase in their driving distance.94  Closure of pediatric units can decrease access to pediatric expertise in rural communities. 
Pediatric health outcomes  
 COVID-19 In the early stages of the pandemic, when testing was routinely recommended, children identifying as Black, Hispanic, or Asian were less likely to be tested for COVID-19 compared with children identifying as white95  but were more likely to be infected with COVID-19. In addition, Black patients had nearly 3 times the frequency of occult hypoxemia, low levels of oxygen in the blood, when compared with white patients, despite normal pulse oximetry readings.93  The false readings result in the ineligibility to receive supplemental oxygen and more intensive treatments for Black patients. These findings suggest the ongoing need to correct racial bias in pulse oximetry technology, given its original development in nonracially diverse populations. Overall, children identifying as Black or AI/AN had 3.5 and 2.7 higher rates of death compared with children identifying as white.96  These differences are attributed to poverty, differential access to health care, lack of trust in the health care system, and other negative SDoH, primarily due to structural racism.97  
 Cystic fibrosis CFTR modulators are an innovative, genomic-specific therapy that targets CFTR gene mutations to treat many CF patients. However, racial and ethnic minorities lack access to this revolutionary treatment of CF, despite comprising 15% of all people listed in the CF Foundation patient registry98  because they are less likely to have the specific CFTR mutations that are targeted by CFTR modulators.99  This lack of access to an inclusive CF treatment is largely a result of disparities in SDoH and could potentially increase already existing health disparities.100  
 Maternal mortality rate Recent data from 2021 reveals significant racial disparities in maternal mortality rates in the United States. Although the rate of maternal deaths per 100 000 live births increased across Black, Hispanic, and non-Hispanic white women, maternal mortality rates for Black women were more than double the national average, with a rate of 69.9 deaths per 100 000 live births.101  Black mothers die in childbirth at 2.6 times the rate of white mothers.101  
 Mental health Discriminatory policing,102  racism,9  microaggressions, police violence,103  anti-Asian and antisemitic rhetoric,104  rural domiciles,105  and higher prevalence of feeling hopeless, considering suicide, and attempting suicide among members of the SGD community,17  all contribute to mental health inequities. 
 Obesity Overall, 19.7% of children 2 to 19 years of age have obesity.106  The prevalence of obesity is lowest among individuals from the highest socioeconomic classification and highest among children identifying as Black, Hispanic, or AI/AN (24.2%,106  25.6%106  and 29.7%,17  respectively, compared with non-Hispanic white children, 16.1%).106  There are also important inequities in obesity by geography, in which children from rural communities are at increased risk.108  Understanding the various community and societal factors that differentially impact communities, such as food insecurity which has a higher prevalence in Black, Hispanic, and AI/AN communities, and the role of food deserts, which are closely linked to poverty.109111  Additionally, evidence suggests that sugar-sweetened beverages are intentionally marketed to children from racial and ethnic minority communities. Pediatric obesity contributes to type 2 diabetes among other cardiovascular risk factors that affect the life course.112  
 Pain management When presenting to the emergency pediatric with appendicitis, Black children are less likely to have pain treated compared with white children.113  There is also long history of children with sickle cell disease encountering barriers to adequate pain management of their vaso-occlusive crises.114  
DomainDescription
Pediatric structures and processes  
 Inaccurate pulse oximetry measurement Falsely elevated pulse oximetry readings in Black children are an example of structural racism, which led them to not have been eligible for therapies like remdesivir or corticosteroids (which required a certain oxygen threshold or receipt of supplemental oxygen).93  
 Closure of pediatric units Between 2008 and 2018, the number of pediatric inpatient units declined by 19.1%.94  Rural environments had more than twice the decline in inpatient units relative to urban settings. More than one-quarter of children seeking inpatient care experienced an increase in their driving distance.94  Closure of pediatric units can decrease access to pediatric expertise in rural communities. 
Pediatric health outcomes  
 COVID-19 In the early stages of the pandemic, when testing was routinely recommended, children identifying as Black, Hispanic, or Asian were less likely to be tested for COVID-19 compared with children identifying as white95  but were more likely to be infected with COVID-19. In addition, Black patients had nearly 3 times the frequency of occult hypoxemia, low levels of oxygen in the blood, when compared with white patients, despite normal pulse oximetry readings.93  The false readings result in the ineligibility to receive supplemental oxygen and more intensive treatments for Black patients. These findings suggest the ongoing need to correct racial bias in pulse oximetry technology, given its original development in nonracially diverse populations. Overall, children identifying as Black or AI/AN had 3.5 and 2.7 higher rates of death compared with children identifying as white.96  These differences are attributed to poverty, differential access to health care, lack of trust in the health care system, and other negative SDoH, primarily due to structural racism.97  
 Cystic fibrosis CFTR modulators are an innovative, genomic-specific therapy that targets CFTR gene mutations to treat many CF patients. However, racial and ethnic minorities lack access to this revolutionary treatment of CF, despite comprising 15% of all people listed in the CF Foundation patient registry98  because they are less likely to have the specific CFTR mutations that are targeted by CFTR modulators.99  This lack of access to an inclusive CF treatment is largely a result of disparities in SDoH and could potentially increase already existing health disparities.100  
 Maternal mortality rate Recent data from 2021 reveals significant racial disparities in maternal mortality rates in the United States. Although the rate of maternal deaths per 100 000 live births increased across Black, Hispanic, and non-Hispanic white women, maternal mortality rates for Black women were more than double the national average, with a rate of 69.9 deaths per 100 000 live births.101  Black mothers die in childbirth at 2.6 times the rate of white mothers.101  
 Mental health Discriminatory policing,102  racism,9  microaggressions, police violence,103  anti-Asian and antisemitic rhetoric,104  rural domiciles,105  and higher prevalence of feeling hopeless, considering suicide, and attempting suicide among members of the SGD community,17  all contribute to mental health inequities. 
 Obesity Overall, 19.7% of children 2 to 19 years of age have obesity.106  The prevalence of obesity is lowest among individuals from the highest socioeconomic classification and highest among children identifying as Black, Hispanic, or AI/AN (24.2%,106  25.6%106  and 29.7%,17  respectively, compared with non-Hispanic white children, 16.1%).106  There are also important inequities in obesity by geography, in which children from rural communities are at increased risk.108  Understanding the various community and societal factors that differentially impact communities, such as food insecurity which has a higher prevalence in Black, Hispanic, and AI/AN communities, and the role of food deserts, which are closely linked to poverty.109111  Additionally, evidence suggests that sugar-sweetened beverages are intentionally marketed to children from racial and ethnic minority communities. Pediatric obesity contributes to type 2 diabetes among other cardiovascular risk factors that affect the life course.112  
 Pain management When presenting to the emergency pediatric with appendicitis, Black children are less likely to have pain treated compared with white children.113  There is also long history of children with sickle cell disease encountering barriers to adequate pain management of their vaso-occlusive crises.114  

CF, cystic fibrosis; CFTR, cystic fibrosis conductance regulator.

The social–ecological model of health is frequently used in health promotion to acknowledge the complexity of patients’ and their families’ lived experiences and their impact on health.34  This model conceptualizes health as the complex interaction of individual characteristics, interpersonal interactions, and community and societal factors. Although medicine can influence ∼16% of overall health, drivers outside of medicine have a more significant influence on the health of the children it serves.35  Recent focus on health over the lifespan highlights how health risks and conditions in childhood often influence adult health32,3638  and serves as a reminder that the long-term health of our nation depends on how we care for its children. The model acknowledges that our society, as a result of our nation’s history, continues to perpetuate racial and ethnic, cultural, geographic, disability, sex and gender, and socioeconomic discriminations, leading to health inequities. Considering the social–ecological model in clinical care can help us move beyond “race-based medicine”39  and other forms of discrimination by attending to the system and societal structures that can preferentially benefit and disenfranchise individuals from certain communities.

Greater diversity in the medical workforce has been linked to higher quality of care.40  Physician–patient racial concordance is associated with decreased morbidity among Black newborns, improved patient–provider communication, and increased medication adherence in adult populations.4143  However, actualizing this goal of greater diversity requires understanding the current status of the career pathway into the pediatric subspecialties from medical school through fellowship, pediatric subspecialist retention, and leadership development, as discussed below.

A diverse pediatric subspecialty workforce begins well before medical school. However, many barriers exist for individuals from populations experiencing discrimination to pursue a career as a pediatric subspecialist. The pathway to medical school is long and requires significant support at each stage of the journey. Unfortunately, not all children have equal access to the social and financial resources, educational, volunteer, work opportunities, or mentorship necessary to dream of becoming a pediatrician, let alone realize their dream by attending college and medical school.

Given the substantial financial barrier that entering medical education represents, it is critical to consider the socioeconomic diversity of medical school applicants and matriculants. The representation of medical student applicants from households with an annual income of ≥$200 000 increased from 2014 to 2019, whereas individuals from households with <$75 000 income have decreased.44  Individuals from households in the highest income bracket had twice the odds of acceptance to medical school relative to individuals from households in the lowest bracket.44  Socioeconomic diversity can intersect with other dimensions of diversity, including race and ethnicity. Individuals identifying as Black or Latino have the most educational debt45,46  and frequently have less generational wealth.47  This has the potential to deter such individuals from pursuing these careers due to financial obstacles.48 

Additional data reveal that for racial and ethnic minority students, multiple barriers exist in pursuing a career in medicine beyond the cost of education, including lack of exposure to medicine, limited mentorship, inadequate education preparation, and “stereotype threat,” defined as an internalized feeling of not being able to succeed.49  These barriers have led to a situation in which gains in racial and ethnic diversity within medicine have largely stalled. In the past 4 decades, medical school matriculant gains from racial and ethnic minority groups have been incremental, at best, and have, in the worst case, decreased. Over a 4-decade period, women identifying as Black or Latino experienced increased matriculation into medical schools from 3.6% to 4.4% and 0.7% to 3.2%, respectively. Among men, there was a slight decrease among individuals identifying as Black (3.2% to 2.9%), whereas the representation of individuals identifying as Latino remained stagnant.50  For AI/AN students, although medical school matriculants increased from 1996 to 2017, the number of medical school graduates did not.51  These matriculation and graduation statistics further reinforce the current state in which the overall physician workforce does not represent the racial and ethnic diversity of our nation or its children.50  Additionally, they do not capture the negative experiences of racism and discrimination students who identify as Black, Latino, or Asian may experience throughout their training, career, and personal lives.52,53 

Challenges also exist across other dimensions of diversity, as experienced by international medical graduates (IMG), women, SGD individuals, and individuals living with disabilities. For IMGs, additional barriers include a lower probability of being selected for residency interviews despite higher US Medical Licensing Examination scores, restrictive immigration policies, the availability of residency training positions for IMGs, and antiimmigrant racism.54  Of note, despite being US citizens, Puerto Rican applicants to residency programs face the same biases as IMGs, despite the national need for more Latino physicians, including subspecialists and faculty.55  Women have made tremendous strides at earlier stages of the pediatric subspecialty pathway. According to 2019 Association of American Medical Colleges (AAMC) data, women represent more than one-half of medical school matriculants, as well as the majority of pediatric residents, and have an increasing representation in the pediatric subspecialty workforce.56,57  However, inequities emerge at more distal points along the career pathway. Women face discrimination and bias, are less likely to have leadership positions, and encounter barriers to academic productivity.58,59  Individuals from the SGD community also face obstacles in identifying mentors, fear of sharing identity with peers and colleagues, poor visibility of SGD faculty during medical school, and concerns about discrimination and bias;60  however, robust data are lacking for medical school applicants and matriculants who self-identify as SGD. This underscores the need to understand SGD applicants’ experiences better and support them through the medical school admission process.61  An additional dimension with little available information is individuals with disabilities.58  Anecdotally, this community faces barriers in identifying and accessing reasonable accommodations during medical training.

According to data from the American Board of Pediatrics (ABP) from academic year 2022 to 2023 for all fellows across the 15 pediatric subspecialties certified by the ABP (n = 4728, Table 2), gender composition was 27.9% male and 71.9% female. A total of 4 individuals did not disclose their gender and 2 self-identified as nonbinary. Only 16.8% of fellows across the 15 subspecialties identified as underrepresented in medicine (URiM).62  Of the URiM categories, 5.2% identified as Black, 8.9% identified as Latino, and ∼0.1% identified as AI/AN or Native Hawaiian or other Pacific Islander.62  Those identifying as Asian comprised 22.0%; a little more than one-half (52.5%) of all fellows identified as white.

TABLE 2

Percentages of Race and Ethnicity, Gender, and Medical School Location/Degree Among Fellows in Standard Pathways, Levels 1 to 3, Academic Year 2022 to 2023

Pediatric Subspecialty (n = No. of Fellows, Levels 1–3)Race and Ethnicity,a %Gender, %Medical School Location/Degree, %
AsianBlack or African AmericanHispanic, Latino, or Spanish OriginWhiteAll Other SelectionsbMaleFemaleI Prefer Not to AnswerNonbinaryAMG/MDAMG/DOIMG/MDIMG/InternationalUnknown Degree
Adolescent medicine (93) 12.8 18.6 3.5 54.7 10.5 19.4 79.6 1.1 0.0 74.2 12.9 6.5 0.0 2.2 
Cardiology (489) 23.2 2.7 6.1 57.7 10.3 46.6 53.4 0.0 0.0 66.7 10.2 12.7 9.4 0.6 
Child abuse pediatrics (58) 27.3 5.5 5.5 47.3 14.5 22.4 77.6 0.0 0.0 65.5 19.0 12.1 1.7 0.0 
Critical care medicine (617) 18.8 3.7 6.2 61.8 9.5 34.7 65.2 0.2 0.0 67.9 12.8 11.5 6.8 0.2 
Developmental–behavioral pediatrics (107) 25.7 4.0 9.9 50.5 9.9 10.3 89.7 0.0 0.0 48.6 18.7 27.1 3.7 1.9 
Emergency medicine (600) 19.8 7.2 8.0 55.6 9.5 32.7 67.3 0.0 0.0 62.5 15.8 12.0 2.8 0.8 
Endocrinology (243) 23.6 3.2 13.4 47.7 12.1 19.8 80.2 0.0 0.0 45.7 12.8 19.8 11.1 9.9 
Gastroenterology (341) 28.5 5.6 11.9 44.0 9.9 29.9 69.8 0.3 0.0 61.3 10.6 13.8 12.9 0.3 
Hematology–oncology (466) 22.0 3.1 7.0 56.3 11.6 31.3 68.7 0.0 0.0 57.7 13.5 15.2 8.6 1.5 
Hospital medicine (193) 17.6 7.1 4.4 58.8 12.0 26.9 73.1 0.0 0.0 77.7 14.0 5.7 2.1 0.0 
Infectious diseases (183) 20.0 2.6 12.3 53.5 11.6 31.1 68.9 0.0 0.0 53.0 9.3 17.5 7.1 12.0 
Neonatal–perinatal medicine (839) 23.1 7.0 9.9 49.6 10.3 27.7 72.2 0.0 0.1 57.3 13.6 15.4 11.7 1.4 
Nephrology (144) 26.0 4.1 8.9 48.8 12.2 29.9 70.1 0.0 0.0 56.3 11.1 6.3 9.0 11.8 
Pulmonary (197) 24.4 2.4 12.2 46.3 14.6 34.0 65.5 0.5 0.0 54.3 12.2 16.2 9.6 7.6 
Rheumatology (104) 16.5 1.1 14.3 54.9 13.2 22.1 76.9 0.0 1.0 73.1 5.8 13.5 5.8 1.0 
All 15 pediatric subspecialties 22.0 5.2 8.9 52.5 11.4 27.9 71.9 0.1 0.1 61.5 12.8 13.7 6.8 3.4 
Pediatric Subspecialty (n = No. of Fellows, Levels 1–3)Race and Ethnicity,a %Gender, %Medical School Location/Degree, %
AsianBlack or African AmericanHispanic, Latino, or Spanish OriginWhiteAll Other SelectionsbMaleFemaleI Prefer Not to AnswerNonbinaryAMG/MDAMG/DOIMG/MDIMG/InternationalUnknown Degree
Adolescent medicine (93) 12.8 18.6 3.5 54.7 10.5 19.4 79.6 1.1 0.0 74.2 12.9 6.5 0.0 2.2 
Cardiology (489) 23.2 2.7 6.1 57.7 10.3 46.6 53.4 0.0 0.0 66.7 10.2 12.7 9.4 0.6 
Child abuse pediatrics (58) 27.3 5.5 5.5 47.3 14.5 22.4 77.6 0.0 0.0 65.5 19.0 12.1 1.7 0.0 
Critical care medicine (617) 18.8 3.7 6.2 61.8 9.5 34.7 65.2 0.2 0.0 67.9 12.8 11.5 6.8 0.2 
Developmental–behavioral pediatrics (107) 25.7 4.0 9.9 50.5 9.9 10.3 89.7 0.0 0.0 48.6 18.7 27.1 3.7 1.9 
Emergency medicine (600) 19.8 7.2 8.0 55.6 9.5 32.7 67.3 0.0 0.0 62.5 15.8 12.0 2.8 0.8 
Endocrinology (243) 23.6 3.2 13.4 47.7 12.1 19.8 80.2 0.0 0.0 45.7 12.8 19.8 11.1 9.9 
Gastroenterology (341) 28.5 5.6 11.9 44.0 9.9 29.9 69.8 0.3 0.0 61.3 10.6 13.8 12.9 0.3 
Hematology–oncology (466) 22.0 3.1 7.0 56.3 11.6 31.3 68.7 0.0 0.0 57.7 13.5 15.2 8.6 1.5 
Hospital medicine (193) 17.6 7.1 4.4 58.8 12.0 26.9 73.1 0.0 0.0 77.7 14.0 5.7 2.1 0.0 
Infectious diseases (183) 20.0 2.6 12.3 53.5 11.6 31.1 68.9 0.0 0.0 53.0 9.3 17.5 7.1 12.0 
Neonatal–perinatal medicine (839) 23.1 7.0 9.9 49.6 10.3 27.7 72.2 0.0 0.1 57.3 13.6 15.4 11.7 1.4 
Nephrology (144) 26.0 4.1 8.9 48.8 12.2 29.9 70.1 0.0 0.0 56.3 11.1 6.3 9.0 11.8 
Pulmonary (197) 24.4 2.4 12.2 46.3 14.6 34.0 65.5 0.5 0.0 54.3 12.2 16.2 9.6 7.6 
Rheumatology (104) 16.5 1.1 14.3 54.9 13.2 22.1 76.9 0.0 1.0 73.1 5.8 13.5 5.8 1.0 
All 15 pediatric subspecialties 22.0 5.2 8.9 52.5 11.4 27.9 71.9 0.1 0.1 61.5 12.8 13.7 6.8 3.4 
a

Those stating “I prefer not to answer” were excluded from the analysis.

b

The “All other selections” include those selecting 2 or more categories, “American Indian or Alaska Native,” “Middle Eastern or North African,” “Native Hawaiian or Other Pacific Islander,” and those stating, “Some other race or ethnicity.”

The ABP also collects data on medical school location and degree type. Most (61.5%) were American medical school graduates (AMGs) with a Doctor of Medicine (MD) degree, 12.8% were AMG graduates with a Doctor of Osteopathy (DO) degree, 13.7% were IMGs with an MD degree, and 6.8% were IMGs with an international degree, such as Bachelor of Medicine, Bachelor of Surgery. The remaining 3.4% had an unknown degree. No data were available with respect to disability status.

Table 2 reveals these variables for each pediatric subspecialty. Most displayed similar proportions by gender, reflecting the increasing numbers of women entering pediatrics. Adolescent medicine had the highest representation of individuals who identify as URiM. Several subspecialties included higher proportions of IMGs than others.

Among certified pediatric subspecialists (n = 28 280, Table 3) in 2023, 63% identified as female, slightly less than the current fellowship cohort. Although women represent more than one-half of the pediatric subspecialty workforce, this representation does not translate into more women in leadership roles.58,59  Survey data from pediatric department chairs published in 2015 revealed that women held only 33.6% of division head, 37.7% of vice chair, and 26.2% of chair positions.58  Women may face parenting and household management pressures not expected of their male partners, which can impede professional growth, as highlighted during the coronavirus disease 2019 (COVID-19) pandemic.63 

TABLE 3

Percentages of Race and Ethnicity, Gender, and Medical School Location/Degree Among Those Currently Certified (≤70 y)

Pediatric Subspecialty (n = No. of Currently Certified Pediatricians ≤70 Years of Age in 2023)Race and Ethnicity,a %Gender, %Medical School Location/Degree, %
AsianBlack or African AmericanHispanic, Latino, or Spanish OriginWhiteAll Other SelectionsbMaleFemaleI Prefer Not to AnswerNonbinaryAMG/MDAMG/DOIMG/MDIMG/International
Adolescent medicine (555) 9.3 16.5 5.8 60.2 8.3 23.1 76.8 0.0 0.2 81.8 5.9 9.2 3.1 
Cardiology (3045) 23.9 2.4 4.8 60.2 8.7 59.4 40.6 0.0 0.0 73.2 3.3 10.3 13.1 
Child abuse pediatrics (342) 10.2 6.9 4.0 71.9 7.1 17.0 83.0 0.0 0.0 88.3 5.3 5.3 1.2 
Critical care medicine (3076) 18.2 3.5 5.9 63.9 8.3 51.4 48.6 0.0 0.0 68.9 5.5 14.1 11.5 
Developmental–behavioral pediatrics (755) 17.7 4.5 4.6 64.0 9.3 23.4 76.6 0.0 0.0 73.5 7.9 13.4 5.2 
Emergency medicine (2972) 17.2 4.9 5.3 66.2 6.4 39.2 60.8 0.0 0.0 75.7 7.3 11.2 5.8 
Endocrinology (1494) 25.3 3.9 6.4 55.2 9.2 26.3 73.6 0.0 0.1 63.0 3.8 18.2 15.0 
Gastroenterology (1796) 26.1 3.2 8.6 51.6 10.5 47.6 52.3 0.1 0.0 61.0 5.2 18.0 15.9 
Hematology–oncology (2898) 20.9 3.0 5.0 64.1 6.9 39.7 60.3 0.0 0.0 71.3 5.5 11.7 11.5 
Hospital medicine (2533) 18.0 3.7 4.3 67.0 7.1 26.6 73.4 0.0 0.0 80.2 7.4 6.9 5.5 
Infectious diseases (1290) 17.0 4.2 9.4 60.0 9.5 41.1 58.8 0.1 0.0 69.5 3.1 16.6 10.9 
Neonatal–perinatal medicine (5152) 26.0 6.1 5.9 54.4 7.5 41.7 58.3 0.0 0.0 57.2 5.8 17.0 20.0 
Nephrology (709) 26.7 6.2 5.1 50.7 11.4 37.5 62.5 0.0 0.0 60.2 2.7 16.6 20.5 
Pulmonary (1172) 20.4 2.3 7.8 60.0 9.5 50.8 49.2 0.0 0.0 62.6 4.7 20.4 12.3 
Rheumatology (491) 19.1 2.4 6.7 62.9 8.9 29.1 70.7 0.0 0.2 72.7 6.3 16.1 4.9 
All 15 pediatric subspecialties 19.7 4.9 6.0 60.8 8.6 36.9 63.0 0.0 0.0 70.6 5.3 13.7 10.4 
Pediatric Subspecialty (n = No. of Currently Certified Pediatricians ≤70 Years of Age in 2023)Race and Ethnicity,a %Gender, %Medical School Location/Degree, %
AsianBlack or African AmericanHispanic, Latino, or Spanish OriginWhiteAll Other SelectionsbMaleFemaleI Prefer Not to AnswerNonbinaryAMG/MDAMG/DOIMG/MDIMG/International
Adolescent medicine (555) 9.3 16.5 5.8 60.2 8.3 23.1 76.8 0.0 0.2 81.8 5.9 9.2 3.1 
Cardiology (3045) 23.9 2.4 4.8 60.2 8.7 59.4 40.6 0.0 0.0 73.2 3.3 10.3 13.1 
Child abuse pediatrics (342) 10.2 6.9 4.0 71.9 7.1 17.0 83.0 0.0 0.0 88.3 5.3 5.3 1.2 
Critical care medicine (3076) 18.2 3.5 5.9 63.9 8.3 51.4 48.6 0.0 0.0 68.9 5.5 14.1 11.5 
Developmental–behavioral pediatrics (755) 17.7 4.5 4.6 64.0 9.3 23.4 76.6 0.0 0.0 73.5 7.9 13.4 5.2 
Emergency medicine (2972) 17.2 4.9 5.3 66.2 6.4 39.2 60.8 0.0 0.0 75.7 7.3 11.2 5.8 
Endocrinology (1494) 25.3 3.9 6.4 55.2 9.2 26.3 73.6 0.0 0.1 63.0 3.8 18.2 15.0 
Gastroenterology (1796) 26.1 3.2 8.6 51.6 10.5 47.6 52.3 0.1 0.0 61.0 5.2 18.0 15.9 
Hematology–oncology (2898) 20.9 3.0 5.0 64.1 6.9 39.7 60.3 0.0 0.0 71.3 5.5 11.7 11.5 
Hospital medicine (2533) 18.0 3.7 4.3 67.0 7.1 26.6 73.4 0.0 0.0 80.2 7.4 6.9 5.5 
Infectious diseases (1290) 17.0 4.2 9.4 60.0 9.5 41.1 58.8 0.1 0.0 69.5 3.1 16.6 10.9 
Neonatal–perinatal medicine (5152) 26.0 6.1 5.9 54.4 7.5 41.7 58.3 0.0 0.0 57.2 5.8 17.0 20.0 
Nephrology (709) 26.7 6.2 5.1 50.7 11.4 37.5 62.5 0.0 0.0 60.2 2.7 16.6 20.5 
Pulmonary (1172) 20.4 2.3 7.8 60.0 9.5 50.8 49.2 0.0 0.0 62.6 4.7 20.4 12.3 
Rheumatology (491) 19.1 2.4 6.7 62.9 8.9 29.1 70.7 0.0 0.2 72.7 6.3 16.1 4.9 
All 15 pediatric subspecialties 19.7 4.9 6.0 60.8 8.6 36.9 63.0 0.0 0.0 70.6 5.3 13.7 10.4 
a

Those stating “I prefer not to answer” were excluded from the analysis.

b

The “All other selections” include those selecting 2 or more categories, “American Indian or Alaska Native,” “Middle Eastern or North African,” “Native Hawaiian or Other Pacific Islander,” and those stating, “Some other race or ethnicity.”

ABP data from 2018 to 2023 reveals that, among the current subspecialty workforce, 4.9% identify as Black, 6.0% identify as Latino, 0.1% identify as AI/AN, 60.8% identify as white, and 19.7% identify as Asian. The proportion of individuals from URiM backgrounds among the current workforce is lower compared with the recent fellowship cohort, suggesting growing URiM representation in future pediatric subspecialists.

ABP data from June 2023 reveal that 70.6% of pediatric subspecialists are AMGs with an MD degree, 5.3% are AMGs with a DO degree, 13.7% are IMGs with an MD degree, and 10.40% are IMGs with an international degree, suggesting there are more DOs and fewer IMGs with international degrees entering pediatric subspecialty fellowships. DOs are increasing in numbers across pediatrics, including the pediatric subspecialties.64  IMGs contribute significantly to the pediatric subspecialty workforce, comprising 25.4% of pediatric subspecialties overall65  and a substantial proportion of the gastroenterology, nephrology, endocrinology, and hematology–oncology pediatric subspecialty workforce.6669  Despite the role of IMGs in providing subspecialty care, IMGs who are not US citizens face numerous policy barriers, including work and length of stay limitations and administrative delays.70 

Data from the pediatric department chairs survey in 2015 revealed that <1% of residents, fellows, and faculty self-identified as SGD, including 1% of division heads, 2.0% of vice chairs, and no department chairs. This same data set revealed little representation of individuals with physical disabilities in Departments of Pediatrics.58 

The 2003 National Academies of Medicine report, Unequal Treatment, recommended increasing the racial and ethnic diversity of the health workforce.71  Two decades later, little progress has been made.72  The murder of George Floyd in 2020, the negative health impact on Black and Latino communities of the COVID-19 pandemic, and anti-Asian rhetoric53  cumulatively prompted a heightened awareness of the impact of racism and discrimination on children and their families and the medical workforce. Yet, 2 recent US Supreme Court cases, “Students for Fair Admission Inc v President and Fellows of Harvard College” and “Students for Fair Admission, Inc v The University of North Carolina,” underscored a wavering national commitment to addressing racial injustices, at least at the governmental level. Recent legislation at the state level has further challenged a commitment to an evidence-based approach toward children who may be exploring their sexual and gender identity. These actions stall progress toward health equity and diversity in the workforce.

In preparation for this article, the authors applied the Strength, Weaknesses, Opportunities, and Threats framework to organize our view of DEI in pediatrics, analyze the current situation, and inform future directions (Table 4). In our analysis, a major strength of current DEI efforts among the pediatric subspecialty workforce is the intentional focus on and support of multiple pediatric-focused institutions and entities. Many pediatric departments have developed programs to increase diversity among trainees, educators, researchers, and general and subspecialty clinicians. The ABP, AAP, Academic Pediatric Association (APA), American Pediatric Society (APS), Association of Pediatric Program Directors, Society for Pediatric Research, and Association of Medical School Pediatric Department Chairs have all affirmed their commitment to DEI.2,5,7375  Weaknesses continue to include a lack of awareness of the extent of racism and discrimination across several dimensions of diversity and complacency with the status quo. Potential external opportunities build on established efforts among national organizations to diversify the pediatric subspecialty workforce and address pediatric health inequities. Potential external threats to current DEI efforts stem from rising political opposition, insufficient acknowledgment of the history of racism and discrimination in the United States, and antiimmigration and SGD policies, all resulting in inaction and regression from previous advances in health care for all children.

TABLE 4

Summary of DEI in Pediatrics Strengths, Weaknesses, Opportunities, and Threats Analysis

DomainExample
Strengths 
 Advocacy by the FOPO in DEI Multiple FOPO organizations are collaborating in the Pediatrics 2025: Association of Medical School Pediatric Department Chairs Workforce Initiative with the stated goal: “to increase the number and diversity of high-quality students who enter training in categorical Pediatrics, Internal Medicine-Pediatric, and Combined Pediatric Subspecialties’ training programs, as well as improve the supply and distribution of pediatric subspecialists with the ultimate goal of meeting the health and wellness needs of the wide diversity of US children, adolescents, and young adults.”73  Pediatric specialty organizations include the AAP, the APA, the Society for Pediatric Research, and the APS. These organizations promote the wellbeing of all infants, children, adolescents, and young adults by supporting the pediatric workforce and their efforts to enhance diversity and inclusion. 
 National Academic Medical Societies and the NIH Support DEI The AAMC and NIH, over the past decades, have intensified DEI efforts through their Group on Diversity and Inclusion and NIH Office of Equity, Diversity, and Inclusion. This group brings medical schools and research training and funding into DEI activities at the national level that can support pediatric DEI efforts in departments. 
 National Minority Medical and Student Associations National minority medical associations play an important role in supporting pediatricians from URiM backgrounds, such as the National Medical Association, National Hispanic Medical Association, Association of American Indian Physicians, Student National Medical Association, Latino Medical Student Association, and Association of Native American Students. These organizations have deep linkages with minority students and the health professional population that can enhance outreach and recruitment to improve the pediatric subspecialty workforce diversity. 
 National efforts on social justice for racial and ethnic minority communities, particularly for children Communities have focused on problems of childhood inequity, particularly experiences due to structural racism. These inequities provide an opportunity to collaborate with local, regional, and national groups with similar goals with respect to providing health and educational equity for diverse children. 
Weaknesses 
 Relying on status quo activities A weakness limiting success is leaders who have a “status quo” approach. As revealed in Mendoza et al, despite evidence of a lack of DEI efforts in pediatric departments, a majority of department chairs were content with their DEI efforts.58  It is concerning that leaders may accept the current state of DEI instead of being driven to identify and implement dynamic programs to drastically change the status quo. 
 Lack of preparation in the pediatric workforce for diversity of languages with inconsistent use of interpreters for clinical encounters81  The diversity of languages spoken by the nation’s children is increasing. Effective communication is essential for equitable, patient-focused care. 
 Seeing DEI efforts as optional rather than necessary for high-quality health care With the demographic change of the US child population, DEI efforts need to be seen as quality improvement in health care. Doing so requires all health care sectors to work together to address DEI concerns, including physicians, nurses, staff, and academic center leaders.7  
 Leaking pathway from undergraduate to faculty for URiM individuals Exposure to bias and lack of mentorship have led not only to a lack of increases in URiM medical school graduates but also a higher proportion of URiM faculty attrition. Outside of pediatrics, numerous upstream factors hinder DEI efforts. The cost of a career in medicine is a significant obstacle. Individuals identifying as Black or Hispanic frequently have less generational wealth, making this level of educational debt and, subsequently, a career in medicine unobtainable.46  
 Inadequate funding for DEI programs and the support of medical careers for URiM individuals Black, Hispanic, and American Indian or Alaskan Native origin individuals account for 34% of the US population. Yet, they only comprise 7% of medical school faculty in the United States.115  Those URiM individuals who become medical school faculty face substantial challenges in retention and leadership development in academic medicine, including coping with isolation as an URiM faculty member, significantly lower probability of receiving NIH research funding,116  and receiving inadequate mentorship.117  
 The burden of the “minority tax” The work of advancing DEI should be done in an equitable way that does not unfairly burden those from diverse backgrounds. DEI is everyone’s responsibility and requires a coordinated effort to further progress.118,119  
 Lack of career mentorship and sponsorship Once on faculty, URiM individuals can encounter an uninviting or hostile work environment, including exposure to discrimination and microaggressions, leading to burnout and attrition. 
Opportunities 
 Growing opportunities to work in partnership among DEI programs Examples include Research in Academic Pediatric Initiative on Diversity120  (an APA-initiated DEI program for junior faculty, now in partnership with the APS, the ABP, the Pediatrics Infectious Disease Society), and the New Century Scholars Resident Mentoring Program78  (sponsored by the ABP, APA, APS, and the Society for Behavioral and Developmental Pediatrics). 
 Efforts to include DEI training into pediatric residency curricula This effort includes acknowledging bias and racism in medicine that impacts patients and the bias experienced by URiM residents from patients, staff, and peers.77  
 Mentorship and sponsorship of junior faculty Growing commitment among senior faculty to mentor and sponsor junior faculty and trainees.118  
 Prioritization of social justice in health care National emphasis on social justice in health care and the workforce that is affecting academic centers, governmental agencies, foundations, accrediting entities, and community organizations, thereby increasing the ability to develop a more significant collective impact on DEI. 
 Holistic approach to health Including SDoH for all children and recognition that factors outside the clinic or hospital influence the majority of health.35  
Threats 
 Lack of commitment to DEI Concern that leadership does not prioritize DEI. 
 Political environment Introduction of legislation at the local and state level to reduce or censor DEI initiatives and programs at public universities that may further exacerbate issues of addressing and educating trainees and faculty on the impacts of health inequities in medicine. 
 Legal environment US Supreme Court decisions that may increase the challenges URiM individuals face to pursue medicine. This will limit the ability to diversify the workforce and potentially address health inequities.121  
 Barriers to providing standard of care Introduction of legislation against the provision of gender-affirming care. 
 Continued barriers to obtaining a career in pediatrics Persistence of challenges faced by individuals that identify as URiM to enter careers in health care because of bias, a lack of role-modeling, financial stress, and lack of encouragement throughout the educational and training pathway to senior faculty.122  
 Barriers of IMGs Discrimination and immigration policies that negatively affect IMGs’ ability to train and practice in the United States.54,123  
DomainExample
Strengths 
 Advocacy by the FOPO in DEI Multiple FOPO organizations are collaborating in the Pediatrics 2025: Association of Medical School Pediatric Department Chairs Workforce Initiative with the stated goal: “to increase the number and diversity of high-quality students who enter training in categorical Pediatrics, Internal Medicine-Pediatric, and Combined Pediatric Subspecialties’ training programs, as well as improve the supply and distribution of pediatric subspecialists with the ultimate goal of meeting the health and wellness needs of the wide diversity of US children, adolescents, and young adults.”73  Pediatric specialty organizations include the AAP, the APA, the Society for Pediatric Research, and the APS. These organizations promote the wellbeing of all infants, children, adolescents, and young adults by supporting the pediatric workforce and their efforts to enhance diversity and inclusion. 
 National Academic Medical Societies and the NIH Support DEI The AAMC and NIH, over the past decades, have intensified DEI efforts through their Group on Diversity and Inclusion and NIH Office of Equity, Diversity, and Inclusion. This group brings medical schools and research training and funding into DEI activities at the national level that can support pediatric DEI efforts in departments. 
 National Minority Medical and Student Associations National minority medical associations play an important role in supporting pediatricians from URiM backgrounds, such as the National Medical Association, National Hispanic Medical Association, Association of American Indian Physicians, Student National Medical Association, Latino Medical Student Association, and Association of Native American Students. These organizations have deep linkages with minority students and the health professional population that can enhance outreach and recruitment to improve the pediatric subspecialty workforce diversity. 
 National efforts on social justice for racial and ethnic minority communities, particularly for children Communities have focused on problems of childhood inequity, particularly experiences due to structural racism. These inequities provide an opportunity to collaborate with local, regional, and national groups with similar goals with respect to providing health and educational equity for diverse children. 
Weaknesses 
 Relying on status quo activities A weakness limiting success is leaders who have a “status quo” approach. As revealed in Mendoza et al, despite evidence of a lack of DEI efforts in pediatric departments, a majority of department chairs were content with their DEI efforts.58  It is concerning that leaders may accept the current state of DEI instead of being driven to identify and implement dynamic programs to drastically change the status quo. 
 Lack of preparation in the pediatric workforce for diversity of languages with inconsistent use of interpreters for clinical encounters81  The diversity of languages spoken by the nation’s children is increasing. Effective communication is essential for equitable, patient-focused care. 
 Seeing DEI efforts as optional rather than necessary for high-quality health care With the demographic change of the US child population, DEI efforts need to be seen as quality improvement in health care. Doing so requires all health care sectors to work together to address DEI concerns, including physicians, nurses, staff, and academic center leaders.7  
 Leaking pathway from undergraduate to faculty for URiM individuals Exposure to bias and lack of mentorship have led not only to a lack of increases in URiM medical school graduates but also a higher proportion of URiM faculty attrition. Outside of pediatrics, numerous upstream factors hinder DEI efforts. The cost of a career in medicine is a significant obstacle. Individuals identifying as Black or Hispanic frequently have less generational wealth, making this level of educational debt and, subsequently, a career in medicine unobtainable.46  
 Inadequate funding for DEI programs and the support of medical careers for URiM individuals Black, Hispanic, and American Indian or Alaskan Native origin individuals account for 34% of the US population. Yet, they only comprise 7% of medical school faculty in the United States.115  Those URiM individuals who become medical school faculty face substantial challenges in retention and leadership development in academic medicine, including coping with isolation as an URiM faculty member, significantly lower probability of receiving NIH research funding,116  and receiving inadequate mentorship.117  
 The burden of the “minority tax” The work of advancing DEI should be done in an equitable way that does not unfairly burden those from diverse backgrounds. DEI is everyone’s responsibility and requires a coordinated effort to further progress.118,119  
 Lack of career mentorship and sponsorship Once on faculty, URiM individuals can encounter an uninviting or hostile work environment, including exposure to discrimination and microaggressions, leading to burnout and attrition. 
Opportunities 
 Growing opportunities to work in partnership among DEI programs Examples include Research in Academic Pediatric Initiative on Diversity120  (an APA-initiated DEI program for junior faculty, now in partnership with the APS, the ABP, the Pediatrics Infectious Disease Society), and the New Century Scholars Resident Mentoring Program78  (sponsored by the ABP, APA, APS, and the Society for Behavioral and Developmental Pediatrics). 
 Efforts to include DEI training into pediatric residency curricula This effort includes acknowledging bias and racism in medicine that impacts patients and the bias experienced by URiM residents from patients, staff, and peers.77  
 Mentorship and sponsorship of junior faculty Growing commitment among senior faculty to mentor and sponsor junior faculty and trainees.118  
 Prioritization of social justice in health care National emphasis on social justice in health care and the workforce that is affecting academic centers, governmental agencies, foundations, accrediting entities, and community organizations, thereby increasing the ability to develop a more significant collective impact on DEI. 
 Holistic approach to health Including SDoH for all children and recognition that factors outside the clinic or hospital influence the majority of health.35  
Threats 
 Lack of commitment to DEI Concern that leadership does not prioritize DEI. 
 Political environment Introduction of legislation at the local and state level to reduce or censor DEI initiatives and programs at public universities that may further exacerbate issues of addressing and educating trainees and faculty on the impacts of health inequities in medicine. 
 Legal environment US Supreme Court decisions that may increase the challenges URiM individuals face to pursue medicine. This will limit the ability to diversify the workforce and potentially address health inequities.121  
 Barriers to providing standard of care Introduction of legislation against the provision of gender-affirming care. 
 Continued barriers to obtaining a career in pediatrics Persistence of challenges faced by individuals that identify as URiM to enter careers in health care because of bias, a lack of role-modeling, financial stress, and lack of encouragement throughout the educational and training pathway to senior faculty.122  
 Barriers of IMGs Discrimination and immigration policies that negatively affect IMGs’ ability to train and practice in the United States.54,123  

FOPO, Federation of Pediatric Organizations; NIH, National Institutes of Health.

The diversity of the nation’s children is increasingly recognized as is the need for a pediatric subspecialty workforce highly attuned to their evolving health needs. Although this workforce is small compared with the adult subspecialty workforce, it remains an integral part of efforts to improve pediatric health equity now and adult health equity in the future. Supporting this workforce will require dedicated attention, given that market forces and current social movements in the United States may not support enhancing DEI.8  The recommendations below address specific changes in training and education, practice, policy, and workforce research to improve child health equity.

The future pediatric subspecialty workforce will only partially represent the diverse and varied experiences of the patients and families it serves. To address this reality, it is important to ensure that educational opportunities regarding health equity and culturally appropriate care are offered across the career pathway of medical students, residents, fellows, and pediatric subspecialists.40  A single-site study of clinical experiences in underserved communities revealed that (1) residents who participated were more comfortable using interpreters and discussing cultural issues, (2) attending physicians were more likely to believe cultural bias affects care, and (3) both residents and attending physicians felt that didactic training in cultural competency was inadequate to preparation for work in underserved communities.76  Training in cultural humility and health equity could begin in medical school and continue during training and through continuing education and lifelong learning activities for pediatric subspecialists, such as maintenance of certification.2,10,77  Available resources and experiential learning opportunities could be better leveraged and made available to individuals, residency programs, and institutions to foster lifelong learning regarding DEI and its implications for pediatric health equity.

In addition to educational innovations, other tools could be employed.40  Mentorship programs specifically designed for residents could be used to introduce trainees to the numerous career trajectories within the pediatric subspecialty workforce and provide faculty and peer mentorship.78,79  Intentional, data-informed steps could be taken to recruit, retain, and support junior faculty who are underrepresented in academic medical centers and more midcareer subspecialities in achieving leadership positions.80 

Steps should be taken to ensure that children and families seeking pediatric subspecialty expertise receive care that promotes health equity. This involves actively studying barriers to care experienced by patients and families from diverse backgrounds. Although cultural- and linguistic-appropriate services are required for programs receiving federal funding, a study examining interpreter use in the pediatric emergency department for families whose preferred language is not English revealed that a little more than one-third of encounters involved professional interpreters and only 11% of encounters for procedures involved professional interpreters.81,82  Efforts are needed to both document disparities and employ quality improvement methodologies to intervene to address these inequities. Such efforts could incorporate published guidelines and expectations regarding the care of patients from diverse backgrounds along diversity dimensions of race and ethnicity, SGD, and immigration status.13,83,84  Increased awareness and implementation of these tools into current practice could move pediatric subspecialty care a step closer toward health equity.

Policy interventions at multiple levels and involving invested entities should be considered. Although the COVID-19 pandemic put children’s health at risk, a robust federal response to increase and maintain enrollment in Medicaid improved access to health care, including subspecialists. The gains in coverage among children, especially in states that had not expanded Medicaid, are currently at risk.85  Vigorous advocacy for Medicaid expansion should continue, given the importance of insurance coverage in children’s access to subspecialty care.86  In addition to ensuring insurance for children, policies encouraging health systems to screen for and address SDoh will be important, given the influence of factors outside of the clinic or hospital on child health.87,88 

Policy efforts that address barriers to pediatric subspecialty training and practice would aid in addressing the diversification of the pediatric subspecialty workforce. Data revealing that annual household income is positively associated with medical school acceptance44  suggest the need for a holistic medical school admission process and access to opportunities well before application to medical school. This process would allow selection committees to better understand the individual context of the applicant and account for differential access to experiences and opportunities due to differences in financial circumstances. Efforts to reduce the cost of medical school through tuition-free medical schools or the reduced duration of medical school could also be considered. The pediatric specialty loan repayment program from the US Department of Health and Human Services is a step toward decreasing the debt burden for those who undertake pediatric subspecialty training. However, the limited number of awardees (150 in fiscal year 2023) is unlikely to change the financial calculation for many individuals; some of the work requirements may limit applicability to pediatric subspecialists who see patients and also engage in education, quality improvement, administration, and research.89  Additionally, Medicaid payment parity90  with Medicare could substantially improve pediatric subspecialty compensation relative to adult subspecialty and reduce the negative lifetime earning potential that most pediatric subspecialty training represents.91  Policy interventions that recognize and support the contributions of IMGs in the pediatric subspecialties6669  include expanding work locations and length of stay and processing time of visas.70  Finally, as medical entities invest and promote DEI in the workforce at large, it will be important to revisit the AAMC’s definition of “underrepresented in medicine” and consider including individuals who self-identify as SGD in that definition.61 

The need for robust data on child health inequities continues and for interventions to address them. Up-to-date data on child demographics and characteristics, geography, health needs, access, and outcomes will be necessary to guide the implementation of care and community prevention models to improve health and mitigate disparities and efforts to enhance training. Reliable and uniform collection of SDoH data would help these efforts further. As interventions in response to data are developed, quality improvement and implementation science methods can be applied to test interventions, monitor progress, and ensure that interventions are not inadvertently worsening existing inequities.92 

National surveys to understand the composition and experiences of the current pediatric subspecialty workforce should continue. An important variable to monitor is the educational debt faced by recent fellow graduates due to the asymmetric burden placed on minoritized individuals. Future research should also evaluate the Pediatric Specialty Loan Repayment program. Data on the representation of providers from the SGD and IMG communities should continue to be collected in a non-stigmatizing and confidential manner. A better understanding of the representation of individuals with disabilities and neurodivergence should begin. Together, this information will provide a better understanding of the demographics of the pediatric subspecialty workforce, barriers faced, and opportunities to support the pediatricians who make up this workforce. Interventions concerning recruitment, training, education, and workplace environment improvements should be studied to determine what works. These interventions should not just target the pediatric subspecialist members of the care team but the myriad of other health care providers interacting with these children to provide their care.

As the US child population evolves and becomes more diverse, pediatric subspecialty training, care, policy, and research must adjust to meet the needs of all the children pediatricians aim to serve. Success in doing so will require a multipronged approach across all pediatric subspecialties, including (1) addressing the needs of our increasingly diverse child population through clinical care and research, (2) providing career development for the next generation of diverse pediatric subspecialty clinicians, researchers, and leaders, and (3) offering effective professional development on DEI topics. Medical history is replete with examples of systems and policies that created or reinforced racism, discrimination, and inequity on the basis of race and ethnicity, sexual and gender identities, immigration status, and disabilities. We have a tremendous opportunity and obligation to reconcile history and reverse its trends. Together, we can work to create an equitable workforce with diverse, culturally competent, family-focused pediatric subspecialists working with teams, including families, to eliminate inequities and provide experiences of respect and dignity, resulting in the highest quality of pediatric subspecialty health care.

The authors thank Virginia A. Moyer and Patience Leino for their editorial support. We also thank the pediatricians who shared their information with the American Board of Pediatrics Foundation and made this supplement possible.

Drs Orr and Leslie conceptualized and designed the study, drafted the initial manuscript, and critically reviewed and revised the manuscript; Dr Mendoza conceptualized and designed the study, critically reviewed, and revised the manuscript for important intellectual content; Drs Schaechter, Williams, Montez, Evans, Deen, and Russell, Mr Webb, and Ms Gaona critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: This manuscript was funded by the American Board of Pediatrics (ABP) Foundation. The ABP Foundation, the Carolina Health Workforce Research Center at the University Of North Carolina at Chapel Hill’s Sheps Center for Health Services Research, and the Strategic Modelling Analytics & Planning Ltd partnered in the design and conduct of this study. Research reported in this publication was supported by the National Institute Of Diabetes And Digestive And Kidney Diseases of the National Institutes of Health under Award Number K23DK132513 (Orr). The content is solely the authors’ responsibility and does not necessarily represent the official views of the National Institutes of Health or ABP or the ABP Foundation.

CONFLICT OF INTEREST DISCLOSURES: Dr Leslie is an employee of the ABP. Mr Webb is on the Board of Directors for the ABP Foundation. Dr Orr receives grant funding from the ABP Foundation. The other authors have indicated they have no potential conflicts of interest relevant to this article to disclose.

AAMC

Association of American Medical Colleges

AAP

American Academy of Pediatrics

ABP

American Board of Pediatrics

AI/AN

American Indian or Alaska Native

AMG

American medical school graduate

APA

Academic Pediatric Association

APS

American Pediatric Society

COVID-19

coronavirus disease 2019

DEI

diversity, equity, and inclusion

DO

Doctor of Osteopathy

IMG

international medical graduate

MD

Doctor of Medicine

SDoH

social drivers of health

SGD

sexual- and gender-diverse

URiM

underrepresented in medicine

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