The false promise of efficiency

The latest punditry calls for three-year medical schools, stripped of ethics and other vital subjects, with less clinical training. The rationale? Efficiency. The result? A generation of physicians unprepared for the complexity of children’s lives.

General pediatricians themselves admit in published surveys that they “know squat” about developmental-behavioral pediatrics (DBP) after residency. Yet the proposed solution is to shorten training further. That is not reform; it is abdication.

A white paper, not a poster

The Society for Developmental and Behavioral Pediatrics recently circulated a poster of “solutions” that read more like a fourth grader’s wish list to Santa than a serious plan. Aspirations are not enough. Pediatrics requires a logical, structured, and enforceable blueprint.

Here is that blueprint.

Tailored training tracks

Primary care pediatricians

• Rotations: Two DBP rotations (first year and third year), each four to six weeks.
• Competencies: Autism spectrum disorders, ADHD, trauma-informed care, family systems, and school collaboration.
• Deliverables: OSCEs in counseling families, chart audits for DBP documentation, and coding accuracy for prolonged consultations.
• Outcome: Graduates earn Clinical Instructor status, signaling baseline DBP competence.
• Accountability: Primary care pediatricians must be held responsible for accurate DBP documentation, coding integrity, and closed-loop follow-up with families. Failure to meet these standards should be subject to professional review and liability.

General academic (teaching) pediatrics

• Fellowship: One to two years.
• Core blocks: Six months DBP, interdisciplinary training with psychology/social work/education law, teaching skills, and leadership.
• Deliverables: Teaching portfolio, curriculum design, bedside teaching evaluations, and quality improvement projects in outpatient continuity clinics.
• Outcome: Entry as Clinical Assistant Professor of Pediatrics (Teaching track).
• Accountability: Teaching pediatricians must demonstrate competence in curriculum design and interdisciplinary leadership, with measurable outcomes in outpatient continuity clinics. They are responsible for ensuring trainees achieve DBP milestones, subject to faculty evaluation and institutional oversight.

Teaching + research pediatrics (clinician-scholar)

• Fellowship: Two years.
• Core blocks: Six months DBP, six months statistics and research design, plus protected time for prospective studies.
• Deliverables: IRB-approved project, first-author manuscripts, and demonstrated competence in statistical modeling and equitable recruitment.
• Outcome: Entry as Assistant Professor of Clinical Pediatrics (Clinician Scholar track).
• Accountability: Clinician-scholars are responsible for research integrity, statistical rigor, and ethical recruitment. Misrepresentation of data or failure to meet IRB standards should trigger academic sanctions and jeopardize advancement.

Tenure track (research exclusive)

• Fellowship: Two years exclusively in research, with optional third year for multisite trials.
• Deliverables: Funded research plan, K-level grant submission, and mentorship committee oversight.
• Outcome: Entry into tenure track contingent on scholarly output and grant pipeline.
• Accountability: Tenure candidates must maintain transparency in funding sources, reproducibility of results, and adherence to ethical research standards. Breaches of integrity should disqualify tenure consideration.

Hospitalists (internal medicine/pediatrics)

• Fellowship: One year.
• Focus: Interdisciplinary training, care coordination, discharge planning, and subspecialty integration.
• Competencies: Hospitalists must serve as “head chefs,” accountable (including being subject to malpractice suits) for integrating subspecialty plans and ensuring closed-loop follow-up.
• Outcome: Certified competence in transitions of care, reducing the fragmentation that cost families dearly.

Historical precedent

This is not unprecedented. In the early 1980s, University of Minnesota graduates were required by HMOs to complete a one-year fellowship in General Academic Pediatrics because their training lacked outpatient skills. Systems have imposed corrective fellowships before. Better to build them in from the start. My own pivot to Yale was fueled by this reality, and by the recognition that DBP was the “new morbidity” of the 1990s.

Payment reform: Aligning value

Training alone is not enough. Congress must raise RVUs for the 96xxx CPT codes to properly compensate DBPs. Reinstate 99245 (high-level Office or Other Outpatient Consultation) as a high-intensity consultation, not a code (99205) equivalent to a complicated ear infection. Pay for questionnaires, prolonged consultations, and interpretation.

I went deep into the Congressional Record to find those codes. Hospitals refused to mill what I coded, and insurers rejected Congressionally approved CPT codes and their RVU units. Congress itself has failed to pass a health budget in years, relying on continuing resolutions. The result? DBPs are penalized for rigor, while proceduralists are rewarded for volume. Reform must align compensation with the actual work.

Ethics as safeguard

Eliminating ethics from medical education is not liberation; it is surrender. Ethics is the safeguard against fragmentation, coercion, and corporate capture. Without it, pediatrics becomes a technical service line, not a civic discipline. Ethics must be expanded, not erased.

Vulcan logic

Shortening training creates cheaper, less knowledgeable doctors that could be at extreme risk for malpractice: false economy. Tailored, deeper training creates accountable physicians. DBP is not optional; it is the core of pediatrics in the 21st century.

If the AAP, ABP, and SDBP have the courage to act, pediatrics can be rebuilt as a discipline of compassion, rigor, and civic accountability. If not, we will continue to lose children in the gaps between subspecialists, hospitalists, and systems that prize efficiency over dignity.

This is the shot across the bow: not a poster, not a wish list, but a white paper with enforceable solutions. Pediatrics deserves nothing less.

History will judge pediatrics not by how quickly we trained doctors, but by whether we trained them to protect children with dignity.

Ronald L. Lindsay is a developmental-behavioral pediatrician.