Essentials of Neonatal–Perinatal Medicine Fellowship: careers in Neonatal–Perinatal Medicine
Since the recognition of the field in the mid-1970s [1], the measure of a successful NPM career has been recalibrated in response to medical advances, patient safety metrics, changing compensation, and promotional criteria. The original academic ideal, a “triple threat” physician, excelling in research, teaching, and patient care, was limited by clinical supervision and documentation standards beginning in the 1980s [1, 2]. During the 1990s, community NICUs offered careers with patient care as a greater focal point [3]. Despite reports of improved morbidity and mortality in infants born at level III+ facilities [4, 5] and efforts to regionalize perinatal care, NPM positions remain decentralized, particularly in states without limitations on hospital expansion [5]. Hybrid practice models, with providers cross-covering multiple NICUs, reduce distinctions between academic and private practice.
Neonatologists are meeting increased clinical needs across practice models. Attending in-house call has become more prevalent [6] and is associated with improved resuscitation outcomes and decreased NICU admissions [7, 8]. A recent fellowship program survey noted that 50% of programs provide routine in-house attending coverage (with 22% as needed for acuity or fellow inexperience) [9]. Neonatologists with home call may supervise advanced practice providers (APPs) at multiple clinical sites or cover lower acuity deliveries, as only 15% of general pediatricians/family physicians cover deliveries outside of rural settings [10].
To meet these coverage needs, providers may work long hours. American Board of Pediatrics (ABP) Maintenance of Certification data (2003–2015) show that 48% of neonatologists work 40–59 h/week, and concerningly, 47% work >60 h/week [11]. On average, neonatologists work 22 weekend days, 45 nights on call, and 24 weeks on service annually [12]. Female pediatric subspecialists more frequently work part-time (17.5% vs 2.7% for males) [11]. Of the 6.8% “part-time” neonatologists, 36% work ≥40 h/week and 7% work ≥60 h/week [11]. Growing clinical demands offer job security, but require careful attention given potential impacts on work–life balance and recruitment.
Financial considerations can influence career planning [13]. Following the dissolution of fee-for-service compensation in 1983, 58% of surveyed neonatologists considered changing subspecialties due to “excessive clinical loads” and “inadequate compensation,” although providers in academics and higher acuity NICUs reported higher job satisfaction [14]. In 2019, the median inclusive compensation for neonatologists was $256,000 [12]. While neonatologists are currently among the highest-paid pediatric subspecialists, the 2021 Medicare Physician Fee Schedule may reduce future compensation [15]. Over the past decade, academic healthcare systems employed ~50% of neonatologists [12], compared to 38% in private practice [16]. Neonatologists are not equally distributed across states or population centers, with ~84% practicing in metropolitan areas [12]. These factors impact compensation, with private practice neonatologists reporting $15,000 greater annual compensation [12] and neonatologists in Northeast, Mid-Atlantic, and metropolitan areas earning less [17]. Female neonatologists also receive 3.7% less annual compensation, potentially resulting in a net loss of $430,000 over a 35-year career [11].
