A vacant expression covered the face of a 14-year-old boy who lay almost lifeless in a hospital bed, completely unaware of the frantic hustle that surrounded him. Once an extraordinary student-athlete, intracerebral hemorrhage unjustly robbed him of his robust character. This was my most significant interaction with a patient. I knew him not as the student-athlete, nor the boy from neurosurgery, but as my youngest brother. With limited access to pediatric health care, I witnessed my family struggle to make the profound decision of transporting him two hours away to a pediatric hospital or accepting the risks of operating locally without pediatric expertise. While we ultimately chose the latter, this was a decision that no family should ever have to make in a moment of crisis.
Being raised in Lackawanna County, I witnessed the struggles of a medically underserved community. My brother’s near-fatal injury was not an isolated case but a reflection of a greater systemic issue of pediatric care deficits in rural and underserved regions across the country. This tragedy unfolded while I was completing my undergraduate education at the University of Pennsylvania. When I compared the clinical scene at numerous hospitals in Philadelphia to my hometown, the contrast was almost palpable. While Philadelphia faces many of its own health care challenges, access to world-class care is minutes away. In Scranton, families rely on the limited pediatric care options, often hoping they are never faced with an emergency where the necessary care is over an hour away.
While my family’s strife is contained to Pennsylvania, geographical imbalances in pediatric care are seen across the country. According to a 2024 NASEM on pediatric health care, there has been an 11.5 percent decrease in pediatric residency applicants and an overall drop in pediatric subspecialty fellowship applications. In more rural areas, hospitals and health care centers already operate on very thin financial margins, which makes it unsustainable to employ full-time specialists and surgical staff. This is especially problematic because while nearly 20 percent of Americans live in rural areas, only 9 percent of physicians practice there. The consequences of this are considerable, as families are left needing to make seemingly unthinkable decisions to endure significant delays in care or uproot their livelihoods to seek care farther away, where lost treatment time can lead to adverse outcomes.
Numerous health care advocacy organizations, including the Children’s Hospital Association, have proposed physician workforce redistribution to help attenuate geographic shortages in pediatric care. Suggested methods of achieving this include expanding eligibility for loan repayments or forgiveness, increasing financial support for pediatric specialty residency programs, and providing stronger rural practice incentives. Establishing strong programs across Pennsylvania, especially in concordance with professional organizations, is paramount for ensuring justice and adequate health care for children and their families, regardless of their zip code.
Physician workforce redistribution is an attainable, realistic objective. Historically, the National Health Service Corps offered loan repayment programs for primary care clinicians who chose to provide care to underserved communities in medicine. This is especially important, given the notable salary differences between pediatricians and physicians trained in adult medicine. Additionally, there are significant disparities in payment reimbursement rates for pediatric services between Medicare and Medicaid. Employing a similar model to target pediatric subspecialists may further transform care in these areas. Research has emphasized the value of geographic exposure in medical training, with physicians being more likely to practice in underserved areas when they trained in them.
Without action, these data are nothing more than numbers found in publications. Politicians and leaders at the local, state, and federal levels must take action. It is imperative for legislators to invest in children’s health and allocate greater funding for pediatric subspecialist payment, attenuating the income gap. Furthermore, changes at the national level should be made to at least achieve parity between Medicare and Medicaid payment rates. Change takes all of us. As a profession, all members of a health care team should recognize workforce redistribution as key for medical justice and advocate for addressing the structural discrepancies in pediatric subspecialist income and service repayment.
Caretakers should not be forced to make the preventable decision my parents had to make regarding their child’s health outcomes in the face of a crisis. Children in underserved communities are more than deserving of the same quality of care as children in urban health care hubs. Change is needed now: A child’s zip code should not determine their clinical outcome.
James Bianchi is a medical student.
