Child Neurology Workforce Shortage: Challenges and Recommendations for Researching and Recruiting the Next Generation of Child Neurologists

Abstract

For subspecialities like child neurology in which demand is predicted to increase and further exceed supply, understanding what attracts individuals to the field and deters individuals from it is particularly valuable. To explore this, we recently surveyed medical students and residents who had completed child neurology clerkships at US medical schools within the last approximately 7 years to investigate the antecedent factors that led to interest in these clerkships and the factors that subsequently impacted residency choice, child neurology or otherwise. Current child neurology and neurodevelopmental disabilities residents (postgraduate years [PGY] 1 through 5) and current medical students who completed at least one child neurology clerkship at a US medical institution were invited to complete an online survey through their residency program coordinators/directors or clerkship coordinators/directors. While our 38 respondents gave us useful insights, our difficulty reaching a larger sample of the population of interest (likely ~1000−5000 individuals) highlights several barriers to conducting workforce research. Here, we share relevant literature and our observations on the pipeline for careers in child neurology, current research challenges, and potential paths forward.

Early exposure to child neurology is critical for sparking interest in the field. Although studies have used different definitions of “early,” frequently referring to college and medical school [1], it is becoming more apparent that no exposure is too early for igniting interest. In our study, the most common timeframe for initial exposure to neurology was during college at 39%; however, exposure in high school or earlier was almost equally as common (37%). Popular media such as books by Oliver Sacks and fictional characters like Sherlock Holmes have been cited in residency personal statements as motivating interest in neurology [2]. These exposures along with chance encounters with neurologists through personal or family experience with neurological conditions, pediatric or otherwise, appear to be relevant when medical students are planning their career paths. It remains to be explored whether the specific exposure (pediatric, e.g., a sibling with autism, or adult, e.g., a grandparent with Alzheimer's disease) influences whether one decides to go into child neurology or adult neurology, especially given the lack of awareness among premedical and medical students that child neurology is its own specialty. Studying these types of “early” exposures could be fruitful for understanding how early lifeexperiences influence motivation to enter medicine and eventual specialty choice.

Undergraduate neuroscience courses are another crucial early exposure to the field. At present, there are inequities in access to such courses, which has implications for recruiting a diverse workforce [3]. In our survey, 24% of participants indicated that their first exposure to neuroscience/neurology was during medical school. Appreciating that neuroscience pre-clinical courses in medical school are therefore often the first curricular exposure to the subject matter emphasizes their importance for recruitment. Greater inclusion of child neurology topics and careful consideration of the faculty involved in teaching these courses (i.e., including child neurology faculty, clinical instructors, etc.) in addition to maximizing their accessibility and appeal [4] would greatly benefit exposure and promote interest.

Student Interest Groups in Neurology and Pediatric Interest Groups provide extracurricular opportunities for exposure during medical school. These organizations depend on funding and partnership with neurology/child neurology divisions to maximize impact, which varies widely across institutions. We found a negative association between the COVID-19 pandemic and student group participation, and it will be important to support these groups in the years to come.

Clinical exposures and interactions with child neurologists are critical for sparking and sustaining interest in the field. Even students who are not interested in neurology or child neurology after their pre-clinical courses do sometimes go on to develop interest from subsequent clinical encounters and mentorship, including during required experiences such as the pediatrics or neurology core clerkships. We found that a higher proportion of our survey respondents had child neurology exposure during neurology core clerkships than would have been expected based on a prior workforce study (75% vs. 28%) [1]. There are many possible reasons for this discrepancy, but opportunities for greater child neurology exposure during required rotations may increase both awareness and interest. Once individuals have identified an interest in child neurology, they then must decide whether to pursue the specialty as a career. This is frequently accomplished through enrolling in child neurology and/or neurology rotations/electives. We found that medical school child neurology clerkships are generally well-received; however, there is desire for greater outpatient exposures and mentoring. Taking this feedback into account and creating opportunities for prospective child neurologists to connect with mentors and gain exposure to a variety of practice settings would improve awareness of what different “days in the life” of a child neurologist could look like and ensure that students are making informed decisions when it comes to choosing their careers.

Just as there are exposures and opportunities that increase interest in child neurology, some aspects of the field may be off-putting to prospective child neurology trainees. These aspects include not only those specific to the discipline (e.g., difficulty of caring for children with devastating neurological disease) but also the current training structure as it relates to financial prospects, work hours, length and composition, and overall wellness. Child neurologists face lower salaries and lifetime earning potential than adult neurologists [5]. Moreover, the requirement for a minimum of 5 years of training means that child neurologists must sustain themselves (and potentially their families) on lower resident incomes for longer than many other specialties. This may underpin data that suggest that a significantly lower percentage of child neurology trainees pursue additional fellowship training compared with adult neurology trainees [6]. Given the greater educational debt frequently carried by those from backgrounds traditionally underrepresented in medicine, longer training and lower long-term earning potential could further compound the lack of diversity in child neurology. Compared with the 2019−2023 Association of American Medical Colleges (AAMC) Graduation Questionnaire (GQ) data on all medical students, we determined that fewer respondents to our survey reported having ≥$100 000 of total debt (44% vs. ~59%−62% for all GQ respondents) [7]. This suggests that degree of debt may have influenced the decision to pursue child neurology clerkships. Discussions regarding decreasing the length of training and specific requirements for 12 months of adult neurology training and 2 years of general pediatrics training have been ongoing among leaders in the field [8]. On our survey, one respondent specifically mentioned the requirement to complete 2 years of general pediatrics training as a deterrent. Other barriers to recruitment include lifestyle factors and lack of available mentors due to the highly specialized nature of the field. Based on demographic data from a 2015 workforce survey showing 79.9% of practicing child neurologist respondents identifying as White, lack of diversity among mentors may be another deterrent for individuals from underrepresented backgrounds to pursue child neurology compared with other pediatric subspecialities [9, 10].

Considering the varying timeframes and experiences that lead individuals to pursue (or not pursue) careers in child neurology, deciding who, how, and when to survey prospective child neurologists is difficult. Shortly before or after medical school graduation are the closest times to specialty decision and are thus optimal. Ideally, studies would include those who considered child neurology even if they did not end up pursuing it. By nature of the relatively small number of medical school graduates who have considered child neurology, to obtain a large enough sample size to have statistically significant and practically meaningful conclusions, such studies must span multiple institutions. There are barriers to conducting such multi-institutional studies at present, as we encountered challenges with restrictions placed on external survey distribution both at individual institutions and through medical student and neurology clerkship director online communities through the American Academy of Neurology (currently there are not analogous structures through the Child Neurology Society). In addition, contrary to the readily available contact information for child neurology residency program directors and administrators, there is no compiled list of emails for child neurology medical educators/clerkship directors nor a straightforward way of finding this information online. While it is possible to reach recent medical school graduates who are child neurology residents through residency program administrators, surveying this population fails to capture medical students who were at some point interested in child neurology but decided not to pursue child neurology residency, a valuable group for understanding career decisions. Further, loss of contact information at the undergraduate to graduate medical education transition (i.e., medical school email addresses) makes it difficult to follow individuals longitudinally. The increasing number of osteopathic and international medical graduates who pursue US child neurology residencies also complicates researching prospective child neurologists as they require different outreach.

Increasing avenues for communication and collaboration, building databases, and partnering with the AAMC and American Association of Colleges of Osteopathic Medicine (AACOM) would be beneficial next steps to facilitate future research into child neurology careers.

It would be useful to identify all child neurology clerkship directors and medical education leaders at institutions across the US, potentially by way of snowball sampling or with the aid of the Child Neurology Society, to create an opt-in child neurology medical education listserv. These contacts could then develop and maintain a database of students who complete child neurology electives, with personal rather than school-based contact information, as the basis for longitudinal research. Separating these lists from professional society membership would be beneficial for comprehensive and equitable inclusion in these studies. Greater communication among child neurology medical educators would also facilitate assessment of the current landscape of child neurology opportunities across institutions and allow sharing of educational resources and approaches.

Additionally, it would be beneficial to take advantage of existing large-scale survey mechanisms such as the AAMC and AACOM's matriculation surveys and GQs, which have tens of thousands of respondents and excellent response rates (>60% most years), to learn more about what attracts individuals to and deters individuals from pursuing child neurology. This could include obtaining personal email addresses from students who opt into contact about research studies and working with survey creators to include more questions pertaining to specialty interest/choice considered at matriculation and graduation. In particular, it should be possible to identify students who consent to further research and completed a child neurology clerkship. Following up with a mixed methods survey or focus group would allow for more qualitative data collection, which would likely be limited if obtained within the context of a larger survey. Topics to explore would include better understanding the nature of “early” exposures and the influence that personal experiences, length of training, financial prospects, and specialty “fit” have on specialty choice.

Taking these steps would greatly improve our ability to survey prospective child neurologists and identify opportunities for increasing recruitment.

Sara A. Rubin: conceptualization, investigation, writing – original draft, methodology, writing – review and editing, software, formal analysis, project administration, data curation, validation. Peter E. Davis: writing – review and editing, conceptualization, investigation, supervision, methodology. Miya E. Bernson-Leung: conceptualization, writing – review and editing, investigation, funding acquisition, methodology, supervision, project administration, validation, resources.

The authors declare no conflicts of interest.