Dr. John Barnard: Trends in Pediatric Workforce — A Growing Concern

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John Barnard MD gave a great talk today as part of the yearly Donald Schaffner lecture. This lecture also honored Larry Saripkin (see blog post: Thank You Larry) as a master clinician. My notes below may contain errors in transcription and in omission. Along with my notes, I have included many of his slides.

Key Points:

  • Since 2015, there is less interest in U.S.-trained physicians to pursue a career in pediatrics.
  • The pediatric gastroenterology workforce continues to grow. Other pediatric subspecialties are understaffed and not attracting enough younger pediatric trainees
  • The percentage of women and international medical graduates has been increasing; currently 67% of board-certified pediatricians are women and 22% are non-US international medical graduates
  • Women through all medical fields and even in pediatrics segregate to less well-paying positions. For example, pediatric cardiology has a lower percentage of women and has a higher median income compared to many other pediatric subspecialty areas
  • While relatively lower pay is thought to be a driving force in choosing a career in pediatrics/pediatric subspecialty, several surveys of medical students indicate that this is not the only factor; other factors may be more important
When workforce changes are noted in the mainstream press, there is often a clear worrisome trend
This slide does not include pediatricians who are not board-certified (~10% of workforce)
Pediatric physicians’ race/ethnicity is varied but does not match general population
There are a lot of counties without any board-certified pediatricians
68 counties in Georgia without a board-certified pediatrician
Driving distance to see a pediatric gastroenterologist
There is expected to be a substantial increase in pediatric GIs by 2040 (about 1700 now). Even with some adjusting of the number of trainees, this will not make a big change in the projections
In contrast to pediatric GI, the general pediatric workforce is likely to decline modestly.
There is an expected/projected drop in the pediatric population of 6.6 million by 2040
Since 2015, there has been a lower interest (7.9% of U.S. medical students) in U.S. pediatric match positions. From 1990–2015, it had been stable around 10%.
2024 is the first year with an absolute drop in the number of trainees as the number of residency positions have been increasing and open positions after the match can be filled with DO and non-US international medical graduates.
Medical students cite other non-monetary factors as important in their career choices

Physicians are in the top 5% of compensation, though pediatric physicians receive less
compensation than their peers. According to 2024 Doximity survey
(https://press.doximity.com/reports/doximity-physician-compensation-report-2023.pdf)
average physician salary exceeds $350,000 in most metro areas.

The growth of the medical-industrial complex/management may
be a factor affecting physician job satisfaction
Pediatricians are a small fraction of all U.S. physicians.
We need to make sure that our interests and the interests of children are heard.

My take: Dr. Barnard noted that “medicine has never been more exciting than it is today.” Yet, the decreased interest of medical students for a career in pediatrics/pediatric subspecialties needs to be addressed.

Dr. Barnard modified the material and presented the William Balistreri lecture at this year’s NASPGHAN meeting. Here are some additional slides from this talk which focused more on Pediatric Gastroenterology:

Distribution of Pediatric Gastroenterologists

Related blog post: “Why It’s So Hard to Find a Pediatrician These Days”

Age of Loper Bright –Forget Chevron Doctrine

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  • RE Sachs, EC Fuse Brown. NEJM 2024: 391: 777-779. Supreme Power — The Loss of Judicial Deference to Health Agencies
  • YouTube: NEJM Interview Erin Fuse Brown (12 minutes)

Excerpts from this commentary:

  • “On June 28, 2024, the U.S. Supreme Court issued its decision in the companion cases of Loper Bright Enterprises v. Raimondo and Relentless, Inc. v. Department of Commerce, overturning the 40-year-old Chevron doctrine. Under Chevron, courts would defer to reasonable agency interpretations of ambiguous statutes.”
  • “Loper Bright will touch every aspect of society, but the potential consequences of putting generalist judges at the center of power are especially troubling for scientific and technical agencies within the Department of Health and Human Services. These implications could include increased litigation and regulatory uncertainty for the health care industry as well as diminished expert authority over the regulation of health care products and services — with heightened risks to patient safety and public health.”
  • For Centers for Medicare and Medicaid Services (CMS): “Well-funded industry actors will now have an incentive to challenge every unfavorable payment rule, hoping to convince a court to adopt their preferred interpretation of a particular statute. The result is likely to be greater uncertainty, more litigation, and generalist judges making consequential and often technical determinations about Medicare payment policies…Well-funded industry actors will now have an incentive to challenge every unfavorable payment rule, hoping to convince a court to adopt their preferred interpretation of a particular statute. The result is likely to be greater uncertainty, more litigation, and generalist judges making consequential and often technical determinations about Medicare payment policies.”
  • For the FDA: “The FDA has had the authority to regulate devices, which are defined by statute to include various types of instruments or other articles, including those that are “intended for use in the diagnosis of disease or other conditions…decision by a court to adopt the industry’s interpretation would hamstring the FDA’s ability to regulate the accuracy of tests that are intended to, for example, detect cancers, enable noninvasive prenatal screening, or identify the presence of a new pandemic pathogen.”
  • “Whereas Chevron favored the government experts charged with administering public programs, Loper Bright favors well-funded industry insiders with the resources to litigate rules that threaten to curb waste, fraud, or abuse. For example, industry-driven litigation has hampered government implementation of the No Surprises Act, which has resulted in far less savings and weaker protections for patients from surprise out-of-network bills than anticipated.”
  • “The net effect of Loper Bright will be to move regulatory policy in an industry-friendly — and in many cases deregulatory — direction, to the detriment of patient welfare, public health, and safety…Disavowing any deference to agency expertise, the Supreme Court has claimed greater authority for generalist judges like themselves to decide whether to allow efforts aimed at “keeping air and water clean, food and drugs safe, and financial markets honest.” In this regard, Loper Bright continues the Court’s assault on administrative authority and scientific expertise.”

My take: By overturning the Chevron doctrine, in the event of legislative ambiguity, technical decisions will be in the hands of judges rather than in those with expertise in the federal agencies. This is going to lead to all sorts of ill-informed policy changes.

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Isle of Palms, SC

Home Parenteral Nutrition in Children with Severe Neurological Impairment

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D D’Arienzo et al. JPGN 2024; 79:1031–1039. Open Access! Characteristics and outcomes of home parenteral nutrition among children with severe neurological impairment

Background:  “A subset of patients with SNI may not tolerate enteral feeding due to gastrointestinal (GI) issues, resulting in pain, feeding intolerance, and malnutrition, despite the absence of primary digestive disorders.3–5 In these cases, home parenteral nutrition (HPN) can be considered…The decision to initiate HPN in children with SNI is challenging. The lack of evidence, absence of definitive etiologies for GI symptoms, known complications, and psychosocial burden of HPN create ethical hurdles for clinicians when partnering with caregivers in this decision.12, 18, 20“

Methods: This was a retrospective review from Canada’s largest tertiary care pediatric hospital of all children with severe neurologic impairment (SNI, n=18) and primary digestive disorders (n=187), where home parenteral nutrition (HPN) was initiated between January 2010 and September 2023.

Key findings:

  • Compared with the primary digestive disorders group, children with SNI with non-primary digestive disorders were less likely to achieve enteral autonomy (p < 0.0001).
  • There was a higher mortality rate were observed in the SNI cohort, though this did not reach statistical significance (22% in SNI group vs. 8% those primary digestive disorders; p = 0.09). Only one death in the SNI group was attributed to HPN-related complications.
  • “CRBSI rate of 1.7 per 1000 catheter days among the SNI and non-primary digestive disorder population on HPN indicates no increased risk in this population. Similarly, our observed rate for catheter-related mechanical problems (occlusion, leakage, dislodgement) of 4.3 per 1000 catheter days is similar to the report of 3.4 per 1000 catheter-days in children with intestinal failure on HPN.28 “

In the discussion, the authors note that “HPN initiation was found to not influence utilization acute care hospital resources, with no difference in ED visits, hospitalizations, ICU admissions or days in hospital in the year before initiating HPN, compared to the following year…the high usage of acute care that is characteristic of this population persisted, suggesting that HPN also did not meaningfully decrease health care use for these children.”

My take: HPN may improve symptoms and nutrition in some children with SNI. This comes with a substantial burden. Prior to starting PN, careful exploration of long-term goals is essential. The decision to use of PN is fraught with ethical issues in children with SNI and could be considered a ‘heroic’ measure; some families will opt for palliative care.

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Fields in the Month of June by Charles-Francois Daubigny at National Gallery of Art (Washington, D.C.)

Frequency of Erythema Nodosum and Pyoderma Gangrenosum in 32,497 Pediatric Patients with Inflammatory Bowel Disease

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MY Yousif et al. JPGN 2024; 79:1009–1016. Open Access! The association between erythema nodosum and pyoderma gangrenosum and pediatric inflammatory bowel disease

Using the ImproveCareNow prospective registry, the authors analyzed a total of 285,913 visits from 32,497 patients aged ≤ 21 years.

Key findings:

  • The occurrence of erythema nodousm (EN) was 1.57% and the occurrence of pyoderma gangrenosum (PG) was 0.90%. Co-occurrence of EN and PG was reported in 0.30% patients.
  • Both EN and PG were associated (p < 0.0001) with worse intestinal disease, lower remission, higher inflammatory markers, and extraintestinal manifestations (EIMs) arthritis and uveitis. 
  • Limitations: “imperfect and incomplete data entry that may introduce bias. However, due to the extensive longitudinal data, we expect any bias to be minimal.”

My take: This study clarifies how common these dermatologic findings occur in pediatric patients with IBD. Prompt recognition of these disorders is important. Recently, our group cared for a 20 yo patient with inadequately-treated PG by multiple internal medicine physicians; this led to prolonged hospitalization.

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The Dancer by Auguste Renoir, National Gallery of Art

Is There a Residual Impact of a Tethered Cord on Colonic Motility

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JM van der Zande et al. JPGN 2024; 79:976–982. Open Access! Anorectal physiology and colonic motility in children with a history of tethered cord syndrome

This retrospective review of 24 children with tethered cord syndrome (TCS) (50% female) who had ARM testing (median age at ARM 6.0 years). 19 children had prior TCS repair.

Key findings:

  •  No significant differences in ARM parameters were found between children who had detethering surgery before ARM and children with functional constipation (FC). The children with TCS did have lower resting pressures though this was attributed to most having their ARM while under GA for concurrent procedures. The resting pressures were still normal.
  • Among the 14 children who also had a colonic manometry (CM) performed (13/14 after detethering surgery), there were no significant differences in colonic motility were found between children with a history of TCS and children with FC.

My take: The vast majority of children with a history of TCS (following detethering) should be treated akin to children with functional constipation.

Impression, Sunrise by Claude Monet at National Gallery of Art (Washington, D.C.)

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Impact of “Healthy Low-Carb Diet” and Time-Restricted Eating on Weight Loss

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Li, Lin et al. Cell Reports Medicine, Volume 0, Issue 0, 101801. Effects of healthy low-carbohydrate diet and time-restricted eating on weight and gut microbiome in adults with overweight or obesity: Feeding RCT

    Methods: The participants (n=96 adults) in the combination of Healthy Low Carbohydrate Diet (HLCD) and Time Restricted Eating (TRE group were provided with HLCD and instructed to follow the 10-h TRE. The HLCD … consisted of approximately 30% of total energy from carbohydrates, 50% from fats, and 20% from proteins. Moreover, compared to a traditional low-carbohydrate diet that only focused on carbohydrate restriction, HLCD also emphasized healthy food sources and high-quality macronutrients such as unsaturated fatty acids, plant proteins, and high-quality carbohydrates, including whole grains, fresh vegetables, and fruits. Additionally, 25–35 g of mixed nuts were provided along with HLCD per day, which mainly included walnuts, peanuts, cashews, pistachios, pecans, almonds, and hazelnuts. 10-h TRE required participants to consume the provided meals within 10 h each day. Outside the eating window, only water, and noncaloric beverages were allowed.64 

    Key findings:

    • Each of the patient groups lost between 2.57 to 4.11 kg
    • HLCD was more effective in reducing fat mass
    • Both dietary interventions resulted in changes in the microbiome

    My take: It is still to work on improving diet quality and improving exercise –only a small percentage of patients will be receiving GLP-1 drugs or bariatric surgery. The Mediterranean diet likely has the most data supporting its use for obesity.

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    Rock Creek Park, Washington D.C.

    Environmental Toxins/Forever Chemicals and Steatotic Liver Disease

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    AK Jain et al. JPGN 2024; 79:943–953. Open access: Environmental toxicants modulate disease severity in pediatric metabolic dysfunction-associated steatohepatitis

    This study correlated environmental toxins and steatotic liver disease. Four hundred and thirty-five children distributed across MASH (n = 293) and MASLD (n = 142), with 304 (69.9%) males. Toxins analyzed: PFAS chemicals included perfluorohexane-1-sulphonic acid (PFHXS), perfluorononanoic acid, perfluorooctanoic acid, and perfluorooctanesulfonic acid and PBDE included 2,2′,4,4′-tetrabromodiphenyl ether (BDE47), 2,2′,4,4′,5-pentabromodiphenyl ether (BDE99), and 2,2′,4,4′,6-pentabromodiphenyl ether (BDE100).

    Key findings:

    • There was an inverse association between PFAS/PBDE mixture and MASH versus MASLD, lobular inflammation (p = 0.026), NAS (p = 0.009, FDR p = 0.04), and log-transformed ALT (p = 0.005, FDR p = 0.025) driven by perfluorohexane sulfonate (PFHXS). 
    • PFASs were detected in 290 (67%) samples, showing the pervasive nature of this chemical exposure in children

    My take: Not surprisingly, our environmental exposures influence the severity of steatotic liver disease. There is widespread exposure to pollutants and the full toll on our health is not clear.

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    Case Study: Elevated Liver Enzymes in Diabetic Ketoacidosis

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    Å Sjöholm et al. N Engl J Med 2024;391:1528. Glycogenic Hepatopathy

    Case report: “An 18-year-old man with type 1 diabetes mellitus who had been admitted to the hospital with diabetic ketoacidosis had unexpected elevations in aminotransferase levels. Laboratory studies showed a peak alanine aminotransferase level of 972 U per liter.”

    “Computed tomography of the abdomen showed hepatomegaly without parenchymal changes (Panel A). A liver biopsy showed swollen hepatocytes with abundant deposition of glycogen in the cytoplasm, as evidenced by positive staining with periodic acid–Schiff (Panel B) and digestion of the deposits after treatment with diastase (Panel C).”

    “At follow-up 3 weeks after discharge from the hospital, the patient had been adherent to insulin therapy, and his aminotransferase levels had normalized.”

    My take: The potential etiologies for elevated liver enzymes in the setting of diabetic ketoacidosis include glycogenic hepatopathy, ischemic hepatitis, infectious etiologies, autoimmune hepatitis, celiac disease, and steatotic liver disease. This recent case report describes glycogenic hepatopathy. There was not a discussion as to why a CT scan and a liver biopsy were deemed necessary.

    Related blog post: Mauriac Syndrome (Glycogenic Hepatopathy)

    Ten-Year Outcomes of Adolescent Bariatric Surgery

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    JR Ryder et al. N Engl J Med 2024;391:1656-1658. DOI: 10.1056/NEJMc2404054. Ten-Year Outcomes after Bariatric Surgery in Adolescents

    Methods: The Teen Longitudinal Assessment of Bariatric Surgery (Teen-LABS) is a prospective multicenter observational cohort study involving adolescents (13 to 19 years of age) undergoing bariatric surgery. Participating adolescents underwent either gastric bypass (161 participants) or sleeve gastrectomy (99 participants) at a mean age of 17 years. Overall, 83% of the 10-year postoperative visits were completed.

    Key findings:

    • The changes in BMI were similar with gastric bypass (mean change, −20.6%) and sleeve gastrectomy (mean change, −19.2%)
    • Ten years after bariatric surgery, the modeled percentages of participants with remission of coexisting conditions (55% for type 2 diabetes, 57% for hypertension, and 54% for dyslipidemia)

    My take (borrowed from authors): “These findings show the long-term durability of weight loss and remission of coexisting conditions after bariatric surgery, as well as the greater health benefits and durability of the effects in adolescents than would be expected in similarly treated adults.”

    Related article: H Bliddal et al. N Engl J Med 2024;391:1573-1583. Once-Weekly Semaglutide in Persons with Obesity and Knee Osteoarthritis. Key finding: “treatment with once-weekly injectable semaglutide resulted in significantly greater reductions in body weight and pain related to knee osteoarthritis than placebo.”

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    Cefdinir Stool in Infants

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    A D’Agrosa et al. J Pediatr 2024; 273; DOI: 10.1016/j.jpeds.2024.114129. Cefdinir Stool

    This 5 month old infant was brought to ED due to diarrhea and dark stools for 2 weeks. She had completed cefdinir for a UTI.

    Cefdinir may cause red or maroon stools when administered with iron or products that contain iron, such as infant formula. This typically occurs within two days of antibiotic administration.

    My take: Familiarity with this reaction is helpful to avoid extensive evaluations. Also, it is worthwhile to keep in mind that false-positive testing with guaiac testing is common (up to 34% in healthy infants).

    Other references:

    From: E Khalid et al. Journal of Infection and Chemotherapy; 2020; 26: 286-288. Cefdinir-induced red stool and purple discoloration of nutritional formula: A case report

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