Pediatrics Has Lost Its Compass

I’ve spent much time lately thinking and writing about pediatrics and what’s happened to it. Maybe that’s because I’ve now lived it from every angle—hospital, emergency department, and the primary care office. From each side, the view is starting to look the same: too many families who can’t get care where they should, and too many clinicians running faster just to stay in place.

When I was training, the emergency department was for emergencies. Most of what I see there now are problems that once belonged in the office: ear infections, asthma flares, sore throats, anxiety, constipation, and even diaper rashes. Parents tell me they called their doctor but couldn’t get in, or they were told to go to urgent care. Sometimes the appointment was weeks away. Sometimes they just gave up and came to the ER.

Now that I’ve been working in the office myself, I understand why. Every slot is double-booked, every minute counted. Patients are pushed to portals and phone trees. Staff are stretched to the edge. The waiting room fills with children while the clinicians try to catch their breath. It’s not that anyone stopped caring—it’s that there’s no space left for caring to happen.

Recently, someone told me that I don’t really understand primary care. They said it’s all about the numbers: how we keep them up, how we double-book, how we overcome high no-shows to make sure the math works. I was told that experience and expertise matter less than volume, that what counts is how many patients you see and whether it adds up to your pay.

I listened. I understood the logic. But I also realized something more unsettling—maybe we’ve built an entire system around that logic. Maybe we’ve mistaken the ability to keep up for proof that the system works.

The System We Built

It’s easy to blame administrators, insurers, or regulations for what’s gone wrong—and they all play a part—but those of us who’ve been here a while need to own some of it too.

When I started practicing, fee-for-service was becoming the standard. We were told it was the only way to stay viable, to keep the lights on, to compete, to quantify value. It was supposed to make things fairer and more transparent.

We accepted it, and then we learned to master it. We learned to code, to document, to optimize. One checkbox at a time, we adapted to the game, and the game slowly redefined the goal.

We told ourselves it was progress—that we were being efficient. If we couldn’t bill for it, maybe it wasn’t valuable. Looking back, I can see how the structure reshaped the meaning of the work. We stopped measuring in trust and started measuring in throughput. We equated value with revenue, and quality with compliance.

We didn’t mean to trade mission for metrics, but somewhere along the way, we did.

Younger pediatricians have never known anything different. They entered a profession already running on spreadsheets. They never followed their own patients in the hospital, or had a nurse who stayed after hours to call a worried parent. They’ve inherited a system that feels impersonal, fragmented, and exhausting—and it’s easy to believe this is just how medicine has to be.

Those of us who remember another way owe them something more than nostalgia. We owe them honesty about how we got here.

The Hero Model and Its Cost

There’s a certain romance to the old image of the pediatrician who did it all—the trusted, ever-present doctor who knew every family and carried every worry. It was beautiful, but it was also unsustainable. The work has always been too complex, the needs too vast, for one person to carry it alone.

What replaced it hasn’t been much better. Many clinicians are still trying to be that hero, but now they’re doing it behind a computer, juggling metrics, portals, prior authorizations, and back-to-back visits. They’re working just as hard, but with less joy, less connection, and less impact.

We can’t keep pretending that pediatric care can be sustained by personal sacrifice. It can’t. It has to be shared. True team-based care means trusting others to carry part of the load. It means nurses, behavioral health clinicians, care coordinators, and front-desk staff all play meaningful roles that contribute to outcomes, not just throughput.

That shift takes humility and courage. It also takes systems that value people for what they contribute, not just how many they see.

Efficiency Without Direction

Medicine has become obsessed with efficiency. Faster visits. Shorter notes. More clicks per hour. More patients per day.

We tell ourselves efficiency is the only way to survive, but survival is not the same as purpose. We’ve built a system that runs faster and faster without asking if it’s heading anywhere worth going.

Efficiency without direction is motion without meaning.

I’ve watched physicians stay late to finish notes, then come in early the next morning to start again. They’re efficient, but not fulfilled. The patients aren’t happier, the outcomes aren’t better, and the quiet satisfaction that used to come from helping a family has been replaced by fatigue.

We’ve become experts at throughput and amateurs at reflection. Somewhere along the way, we stopped asking the simplest question of all: Is this working?

The Fragmented Child

What worries me most is how children are being divided by this system. Their care is fractured between the office, urgent care, and the ER—each silo doing its best, but rarely connected.

From the ER, I see children who belong in a clinic. From the clinic, I see children who can’t get in anywhere else. From the hospital, I see the results of a system that catches problems late because there was never time to catch them early.

Everyone is working hard, but we’re all working in parallel, not together. The hospital doesn’t talk to the clinic. The clinic doesn’t have time to follow up on the ER visit. Families move between settings without continuity or trust. And all the while, we’re measuring the wrong things.

We know this isn’t sustainable, but we’ve grown so used to the motion that we mistake it for progress.

Remembering the Mission

The calling that brought most of us into pediatrics wasn’t a business plan. It was a belief that caring for children and families was meaningful, that the work mattered beyond revenue or metrics.

We’ve built impressive systems of documentation, billing, and efficiency, but they don’t nourish that purpose. We can meet every metric and still fail the mission.

The path forward isn’t to abandon structure but to rebuild it around meaning. To design schedules that flex for need. To measure continuity, trust, and developmental progress—not just compliance. To create care teams that truly share the work, freeing physicians to spend time where their experience matters most.

Technology can help, but only if we use it to restore time, not to steal more of it.

The Next Generation

I see such hope in younger pediatricians. They’re bright, compassionate, and adaptable. But they’ve been trained inside a system that treats overload as normal and burnout as inevitable. They’ve learned how to survive, not how to question why survival became the goal.

That’s not their fault—it’s ours. We taught them how to code, how to document, and how to stay afloat. What we forgot to teach was how to pause and ask what all this work is supposed to mean.

If we want to help them, we have to offer more than advice. We have to offer perspective. We have to show them that pediatrics can still be about people, not productivity.

Finding Our Way Back

The race we are running isn’t working, but that doesn’t mean we can’t stop.

It begins with honesty. Those of us who have seen the old and the new must admit that we helped build this. We didn’t mean to, but we did. We helped turn caring into counting. We accepted the logic that survival required volume. And we looked away as the mission became harder to see.

But we can also be the ones to find our way back.

The next version of pediatrics must be built on trust, teamwork, and time. We need systems where good care doesn’t depend on heroics. We need to measure success not by the number of boxes checked, but by the number of families who feel understood.

And maybe, before we design the next workflow or chase the next metric, we should pause long enough to ask one another: Is this still the work we meant to do?

Because if it’s not, it’s time to find our compass again.