Financial Concerns Linked to Declining Interest in Pediatric Dermatology Fellowships

Interest in dermatology subspecialty fellowships often evolves during residency training, and new research suggests that financial and structural factors may play an important role in shaping those decisions. A recent cross-sectional survey of US dermatology residents examined how interest in three fellowship pathways—pediatric dermatology, dermatopathology, and micrographic surgery and dermatologic oncology—changes during training and identified key factors that may discourage residents from pursuing additional subspecialty education.¹

The findings, along with commentary from the Society for Pediatric Dermatology Workforce Committee, highlight a potential workforce challenge for pediatric dermatology and suggest areas where policy and training reforms could help sustain resident interest.²

Fellowship Interest Declines During Residency

In the survey of 101 dermatology residents, investigators evaluated both initial interest in fellowship training and how that interest changed over time. Approximately half of residents who reported moderate to strong initial interest in at least one subspecialty fellowship experienced a decline in that interest during residency.

Importantly, the decline in fellowship interest occurred at similar rates across the three subspecialties studied: pediatric dermatology, dermatopathology, and micrographic surgery and dermatologic oncology. This finding suggests that shifting priorities during residency—rather than subspecialty-specific dynamics alone—may contribute broadly to decisions about additional training.

Residents most frequently cited practical considerations as deterrents to fellowship training. Across subspecialties, extended training time and the additional year spent at a trainee salary ranked among the most common concerns.

Demographic variables such as educational debt and underrepresented status in medicine were not associated with changes in fellowship interest in this study.

While the overall decline in interest was comparable among subspecialties, the specific concerns influencing those decisions varied.

Financial Concerns Prominent in Pediatric Dermatology

Among residents who initially considered pediatric dermatology but later lost interest, concerns about future income potential emerged as the most significant deterrent.

In contrast, financial concerns appeared less influential for residents considering other subspecialties. In the study sample, only a minority of residents who lost interest in micrographic surgery and dermatologic oncology cited future earnings as a concern, and financial issues were also less prominent among those reconsidering dermatopathology.

Members of the Society for Pediatric Dermatology Workforce Committee noted in a commentary letter that this discrepancy may reflect broader structural differences within dermatology subspecialties. Residents appear to recognize income disparities between pediatric dermatology and other fellowship pathways, and these perceptions may influence career planning during residency.

According to the committee, identifying these financial concerns represents an important first step in addressing barriers to fellowship recruitment.

Structural Factors in Subspecialty Recognition

Beyond income considerations, the committee highlighted potential structural factors that may affect how pediatric dermatology is perceived relative to other subspecialties.

Historically, pediatric dermatology has not always required board-certified pediatric dermatologists as subspecialty faculty within residency training programs. In contrast, training in dermatopathology and micrographic surgery and dermatologic oncology typically involves faculty with formal subspecialty board certification.

Committee members suggested that this discrepancy may inadvertently diminish the perceived value or rigor of pediatric dermatology training. Aligning faculty requirements with other dermatology subspecialties through collaboration with the Accreditation Council for Graduate Medical Education and the American Board of Dermatology could help reinforce the specialty’s standing.

Another structural issue involves the professional differentiation of fellowship-trained pediatric dermatologists. In many practice settings, general dermatologists routinely provide pediatric care, and fellowship training does not consistently confer additional employment advantages or higher reimbursement.

When additional training and board certification offer limited financial or professional distinction, residents may perceive fewer incentives to pursue a fellowship year.

Reimbursement and Policy Considerations

The commentary also emphasized the role of reimbursement policy in shaping workforce trends.

Pediatric dermatology practices often care for a high proportion of patients insured through Medicaid. Lower reimbursement rates compared with Medicare may therefore disproportionately affect the financial sustainability of pediatric dermatology practices.

Advocacy efforts aimed at improving reimbursement—such as increasing pediatric dermatology representation in valuation discussions and promoting Medicaid payment parity with Medicare—could help address some of these concerns, according to the committee.

Implications for the Dermatology Workforce

Taken together, the survey findings and subsequent commentary suggest that maintaining a robust pediatric dermatology workforce may require targeted interventions addressing both financial and structural factors.

Potential strategies include strengthening mentorship opportunities, reinforcing the value of subspecialty certification, and pursuing policy initiatives that better reflect the complexity of pediatric dermatologic care.

As the demand for specialized pediatric dermatologic services continues to grow, ensuring sustained resident interest in fellowship training may be critical to meeting future patient care needs.

References

1. Lee S, Kim EJ, Huang JT. Analysis of factors influencing dermatology residents' decisions to pursue subspecialty fellowships: A cross-sectional study. Pediatr Dermatol. Published online September 24, 2025. doi:10.1111/pde.70053
2. Buethe MG; Society for Pediatric Dermatology Workforce Committee. Addressing the financial barrier to pediatric dermatology fellowship: A Call to Action for Systemic Change. Pediatr Dermatol. Published online March 2, 2026. doi:10.1111/pde.70181