Neonatologist staffing models: urgent change is needed.

To the Editor:

Many current neonatologist staffing models do not support the needs of the evolving neonatology workforce, administrative obligations, and patient population. Decades ago, NICU coverage involved daily rounds by a neonatologist followed by night coverage using a home-call model [1]. Due to increasing patient volume and acuity, adequate NICU coverage now often requires 24-hour in-house neonatologists [2] in both private practice and academic settings. Since the same neonatologist may round before and after an overnight shift, shifts may last up to 36 h [3]. Weekends have always been expected, but are now compounded by frequency, in-hospital requirements, weekend conferences, and not balanced by commensurate days off. Meanwhile, expectations of academic productivity, teaching, quality improvement work, and administrative obligations are unchanged or increased, and must be done during increasingly scarce “non-clinical” time.

These factors tend to affect hospital-based practices, pediatricians in intensive care subspecialties, and women most frequently [4, 5]. Lack of standardized staffing models further contributes to workforce dissatisfaction and difficulty advocating for changes with institutional leadership and payors. Additionally, staffing models often do not have sufficient reserve for the inevitable needs that arise for medical, personal, and family leave that all neonatologists encounter at multiple points during their career. This, coupled with medical and academic cultures that discourage taking leave due to effects on career advancement or causing extra work for colleagues, has progressively contributed to workforce burnout and attrition [6]. The COVID-19 pandemic has amplified these issues, increased burnout in health care providers [7-10] and widened the workforce gender gap [11]. These collective issues are particularly concerning as the neonatology workforce is both aging and majority female [12-14].

Staffing models based on clinical productivity have also proven problematic in their ability to translate work productivity measures, including scholarly achievements, into meaningful staffing and compensation data [15]. The clinical productivity of neonatology divisions is often measured as relative value units (RVUs) produced per clinical full-time equivalent physicians (cFTEs) [1, 16]. This definition of productivity not only fails to consider the value of quality of care, it incentivizes decreased physician time per patient. High work RVU (wRVU) to cFTE ratios have played a key role in expanding institutional and departmental revenue, but are not sustainable due to the global daily codes and payor expectations [16]. The Leapfrog Group, a national nonprofit healthcare watchdog organization, incentivizes quality practices and safety standards due to potential cost containment and improved clinical outcomes [17, 18]. One such regulatory guideline relevant to neonatologists is the intensive care unit physician staffing (IPS) standard. The IPS standard codifies the responsibility to maintain adequate in-house and on-call staffing by intensivists, even if it decreases the wRVU:cFTE ratio, to support quality of care [18].

While compensation benchmarks for neonatologists and pediatric intensivists are similar, productivity benchmarks for neonatologists are nearly double those of pediatric intensivists [1]. In a recent publication in the Journal of Perinatology, Lakshminrusimha, et al. suggest an alternative method of staffing academic pediatric departments using a time- or point-based staffing model to more accurately capture physician effort in domains additional to clinical care, such as research [19]. This model is coupled with a reduction in clinical productivity (wRVU) benchmarks for academic neonatologists, thereby promoting physicians’ other professional contributions and wellness with transparency and respect for physician time [1]. In the current COVID-19 era where understaffing seems to be the new normal in all areas of patient care, addressing these issues and determining how to appropriately finance them may seem insurmountable but is even more critical because the health of the workforce is key to the health of our patients. Without a commitment to change the culture around staffing and advance supportive benefits such as pay equity, paid family leave, and childcare, the neonatology workforce will suffer to the detriment of our patients and scientific innovations. If the economic, environmental, and social factors influencing staffing are not addressed, recruiting and retaining neonatologists will become more difficult as work models become unsustainable [20].

The AAP Leadership Conference selected a resolution to promote sustainable staffing models for pediatric physicians and their healthcare teams as one of the top 10 areas of focus in 2022–2023 [21]. This resolution advocates for a repository of research, education, and ongoing advocacy for innovative and humane staffing models, scheduling flexibility, development of best practices, and transparency to attract and retain the future workforce [22]. We must build on this momentum, work with leadership in the AAP, our field, institutions, and payors to drive change now, and foster a safe and healthier environment for our patients and ourselves.