For two months, I have been deeply engaged in the domain of developmental and behavioral pediatrics (DBP), championing change through testimony, opinion pieces, and coalition-building efforts. The specialty, which once held great potential, now finds itself burdened by idealistic slogans rather than implementing genuine reform. This piece reflects on the present state of DBP, considering both its past and possible future directions.
**The Poster Problem**
Recently, the Society for Developmental and Behavioral Pediatrics (SDBP) circulated a flyer titled “Critical Outcomes in DBP.” The second page proposes remedies for the recruitment dilemma: boosting BIPOC trainees, empowering DBPs in leadership roles, enhancing reimbursement rates, shortening fellowship durations, broadening telehealth parity, and increasing research funding. Although these suggestions are framed as optimistic strategies, they lack actionable substance. On paper, they are simply catchphrases, devoid of the necessary framework to effect real change.
The situation is harsh. DBP has the lowest “lifetime relative net present value” (NPV) among all pediatric subspecialties—roughly $2 million less than general pediatrics. This statistic is not simply a number; it serves as a significant deterrent. Why would any graduate, especially from a marginalized background, choose a field with such daunting financial prospects? Other specialties like cardiology and neurology provide more lucrative and esteemed career paths. DBP continues to present an uninviting blend of lower compensation, increased burnout, and reduced institutional backing.
The flyer illustrates the gap between rhetoric and reality and should not be regarded as mere adornment. It represents the systemic obstacles we encounter.
**Leadership Without Action**
The downturn of DBP is not an abrupt phenomenon. Historically, DBP had representation at the leadership level within the American Academy of Pediatrics (AAP). Previous presidents like James M. Perrin and Judith S. Palfrey were DBP physicians. Their terms were opportunities for transformative progress on issues such as reimbursement disparities and training pipelines. Regrettably, those chances were not capitalized upon.
A leadership presence without substantial action is merely performative—providing visibility without influence. In contrast, leaders outside DBP, such as Toni Eaton and Howard Pearson, recognized the significance of our field through their involvement with task forces. Their advocacy spotlighted DBP priorities. However, even their contributions were inadequate in the face of inertia from within.
**My Own Path**
My journey included a two-year DBP fellowship grounded in four years of experience in the United States Air Force. The blend of these experiences made it clear that slogans could not replace structural solutions. When I engaged in a LEND program, I concentrated on concrete, interdisciplinary strategies—focusing on funding and accountability. LEND programs thrive because they are organized and encourage participation, highlighting the distinction between action and mere aspiration.
**The Pipeline Illusion**
In 2022, only 28 applicants nationwide sought DBP fellowships. Over half of the programs were unfilled. This is not a talent pipeline; it’s a mere trickle. Posters will not bridge such substantial gaps. Solutions like loan repayment forgiveness and reimbursement equity could provide greater hope, alongside well-supported interdisciplinary programs akin to LEND.
Current responses proposed by the SDBP do not tackle the economic realities. BIPOC graduates, often encumbered by higher debt levels, are invited to join the lowest paying specialty. This paradigm cultivates exploitation, not equity.
**Why I Stayed, Why I Still Speak**
My entrance into DBP was not driven by financial gain. I felt a calling to serve—a calling I honored throughout my fellowship, military service, and practice. Eventually, burnout led me to retire early. Financial prudence afforded me this choice, but I did not completely exit the field. My advocacy persists as I write and speak for a specialty deserving more than hollow commitments. Families and children require more than slogans—they deserve leadership that listens to and acts upon their needs.
I bear witness to this period so that history accurately reflects our collective struggle. Some of us remain, dedicated to action, urging reform when others settle for mere aspiration. I will remain in this field, serving as a witness, for as long as I am able.