The American Board of Pediatrics recently announced a plan to alter pediatric subspecialty fellowship training, moving toward a competency-based framework that would, for neonatal-perinatal medicine, condense what has traditionally been a three-year fellowship into a shorter pathway. Proponents of such reforms point to workforce shortages, the financial strain of prolonged training, and evidence that clinical competence can be demonstrated and certified through entrustable professional activities rather than time served. The board’s stated goal, articulated in its 2026 announcement on ensuring readiness for practice, is to advance competency-based subspecialty training so that physicians enter independent practice sooner without sacrificing skill. For a field grappling with persistent recruitment challenges and rising demand for neonatal intensive care, the appeal is obvious.

Yet Kukora and her colleagues argue that this framing overlooks something fundamental: professional identity formation, often abbreviated as PIF in the medical education literature. Drawing on decades of scholarship, including the influential schematic model developed by Richard and Sylvia Cruess and colleagues at McGill University, the authors describe professional identity formation as the process through which trainees internalize the values, behaviors, and norms of medicine, gradually coming to think, feel, and act like the physicians they are training to become. This transformation does not occur through the mere accumulation of procedures or checklists. It unfolds within what educational theorists call a community of practice, an immersive social environment in which novices learn by participating alongside experienced mentors, absorbing not only explicit teaching but also the hidden curriculum of daily clinical life.

Neonatal-perinatal medicine presents a particularly demanding context for this transformation. Neonatologists care for infants at the very margins of viability, make life-and-death decisions under profound uncertainty, and navigate emotionally charged relationships with families in crisis. The ethical terrain is notoriously difficult: decisions about initiating, withholding, or withdrawing life-sustaining treatment; the interpretation of aggregate outcome statistics for individual counseling; and the negotiation of family-centered care in settings where evidence is often incomplete. The authors emphasize that the entrustable professional activities defined for neonatology, the specific tasks considered essential for independent practice, are themselves deeply rooted in professional identity formation. Competence in these activities presupposes mature moral reasoning, the capacity to experience and manage distress, and the resilience to sustain a career in an emotionally punishing environment.

The literature on moral distress in neonatology underscores why this matters. Studies by Prentice, Janvier, Gillam, and colleagues have documented high levels of moral distress among neonatal clinicians, the anguish that arises when providers know the ethically appropriate course of action but feel constrained from pursuing it. Repeated episodes of moral distress leave behind what Epstein and Hamric have described as moral residue, a cumulative erosion that contributes to the crescendo effect of escalating distress over time. Compassion fatigue, secondary traumatization, and burnout are well documented among neonatologists, and physician burnout has been linked in multiple studies to increased medical errors and worse patient outcomes. Professional identity formation, the authors argue, is one of the key mechanisms through which clinicians develop the meaning and purpose that buffer against these occupational hazards. Research by Toubassi and colleagues has explicitly linked professional identity formation to well-being, suggesting that a coherent sense of professional self is not a luxury but a protective factor.

Against this backdrop, the prospect of condensing fellowship raises a series of ethical concerns. First, there is the problem of time itself. Identity development is longitudinal and cannot be reliably compressed without consequence. Qualitative longitudinal research on how residents develop virtues suggests that character formation in medicine depends on sustained experience, reflection, and mentorship over time. A trainee who spends fewer months in the neonatal intensive care unit has fewer opportunities to witness and internalize how seasoned clinicians handle uncertainty, communicate bad news, repair errors, and honor the values of family-centered care. Second, the authors point to the discontinuity problem in medical education, a topic recently analyzed in the New England Journal of Medicine by Warm and colleagues. Shortened, fragmented training pathways risk disrupting the continuity of relationships, between trainees and mentors, and between trainees and the patients and families they follow over weeks and months, that make deep learning possible.

Third, the perspective highlights the hidden curriculum, the informal and often unspoken lessons trainees absorb from their environments. When institutions signal that training is primarily a throughput problem to be optimized, trainees may internalize a transactional view of their profession. Conversely, when programs deliberately protect time for reflection, ethics education, and relationship-building, trainees are more likely to develop the habits of moral attention that neonatal practice demands. Ethics education in neonatology, as recent work in NeoReviews by Sullivan and colleagues illustrates, increasingly integrates theory, multimodal teaching methods, and even artificial intelligence innovation, but it requires protected space within the training structure to take root. A compressed pathway that crowds out these formative experiences may produce technically competent graduates who are nonetheless underprepared for the ethical weight of their role.

The authors are careful to acknowledge the legitimate pressures motivating reform. The pediatric subspecialty workforce faces genuine shortages, and neonatal intensive care admissions in the United States have risen steadily, according to National Center for Health Statistics data covering 2016 through 2023. Burnout and workload concerns have prompted serious discussion of hours-based scheduling in neonatology, and some have argued in the Journal of Perinatology that the field should indeed move to two-year fellowships. A companion critical appraisal by Vergales and colleagues examined the American Board of Pediatrics’ proposed two-year pathway in detail, questioning whether the required competencies can realistically be achieved in the condensed timeframe. The debate is thus not between reform and stagnation, but between competing visions of what fellowship is ultimately for.

What distinguishes the Kukora paper is its insistence that the answer must be framed in ethical rather than merely operational terms. The authors argue that it is an ethical imperative for neonatal-perinatal medicine fellowship programs to nurture the evolving professional identities of their learners, because those learners will guide future innovation and progress in the field while providing ethical, family-centered, high-quality clinical care. If professional identity formation is foundational to every essential entrustable professional activity in neonatology, then any reform that undermines it risks compromising not only individual careers but the profession’s core mission. The stakes, in other words, are borne ultimately by newborns and their families, who depend on physicians trained not just to perform interventions but to deliberate wisely about when interventions serve the patient’s best interests.

The perspective closes with a call for the pediatrics community to take these risks seriously before implementing the new pathway. Rather than treating identity formation as an intangible byproduct of training, the authors suggest it should be treated as an explicit outcome to be protected and measured, alongside clinical competence and procedural skill. As the American Board of Pediatrics moves forward with competency-based subspecialty training, the challenge will be to design programs that achieve efficiency without hollowing out the human and moral development that makes a neonatologist more than a technician. The paper’s central message is stark: how the profession trains its future members will shape, for better or worse, the care that the smallest and most vulnerable patients receive for decades to come.

Subject of Research: Ethical implications of condensing neonatal-perinatal fellowship training for neonatologists' professional identity formation

Article Title: Threats to neonatologists’ professional identity formation: ethical implications of condensing neonatal-perinatal fellowship

Article References: Kukora, S. K., Gray, M. M., McLean, C. K., & Krick, J. (2026). Threats to neonatologists’ professional identity formation: ethical implications of condensing neonatal-perinatal fellowship. Journal of Perinatology. https://doi.org/10.1038/s41372-026-02899-0

Image Credits: AI Generated

DOI: 10.1038/s41372-026-02899-0

Keywords: neonatology, professional identity formation, medical education, fellowship training, American Board of Pediatrics, moral distress, medical ethics, neonatal-perinatal medicine, competency-based training, burnout, family-centered care, Journal of Perinatology

Reproductive psychiatry, sometimes described as an emerging subspecialty, focuses on the assessment and treatment of mental illness across the reproductive lifespan. Hormonal fluctuations tied to the menstrual cycle, pregnancy, the postpartum period, and perimenopause can precipitate or exacerbate mood, anxiety, and psychotic disorders, and the clinical evidence linking these transitions to psychiatric onset is robust. Perinatal mental illness is a leading contributor to maternal morbidity and mortality, and untreated illness carries consequences for both parent and child. Despite this, reproductive psychiatry has never been embedded as a standardized requirement in graduate medical education, leaving programs to decide individually how much, if any, of this content their residents will encounter.

The new study, led by Kristen Chalmers of the University of Washington with colleagues at the University of Chicago, Harvard Medical School and Brigham and Women’s Hospital, and the University of Colorado, was designed as a follow-up to a 2018 national survey that documented substantial gaps in residency education. That earlier work, published by Osborne and colleagues in Academic Psychiatry, established a baseline showing that exposure to reproductive psychiatry varied enormously from program to program. To measure change over time, the research team distributed a 30-item cross-sectional survey between January and March 2025 to all 315 US general psychiatry residency program directors identified through the American Medical Association FREIDA database.

The survey instrument covered program characteristics, didactic and clinical training opportunities, pathways toward specialization, anticipated curricular changes, and perceived barriers to expansion. Thirty-five programs responded, corresponding to an 11 percent response rate, a limitation the authors acknowledge but one consistent with typical rates for national program director surveys. Descriptive statistics were used to summarize responses, and the institutional review board of The University of Chicago Medicine granted an exemption for the work. The reported data therefore represent a snapshot of the field as seen from the administrative vantage point of residency leadership.

The headline finding is one of cautious progress. A large majority of responding programs now report offering didactic education in reproductive psychiatry, at 88 percent, and clinical exposure, at 79 percent. Both figures represent growth compared with prior national assessments, suggesting that advocacy from faculty, fellows, and trainees has gradually moved reproductive mental health into the mainstream of residency curricula. Didactic content most commonly addressed perinatal mood, anxiety, and psychotic disorders, reflecting the weight of evidence and public attention surrounding postpartum depression and related conditions. The scope and structure of this teaching, however, varied widely across programs, with no uniform standard governing what must be taught or how competence should be measured.

Beneath the encouraging headline numbers lies a more complicated picture of uneven coverage. Topics such as menstrual-related mood disorders, including premenstrual dysphoric disorder, perimenopausal depression, reproductive loss, LGBTQ+ reproductive health, and sexual health were covered far less consistently than perinatal conditions. This means a resident graduating from one program may feel confident managing postpartum depression while remaining unprepared to evaluate cyclical mood symptoms or support a patient navigating pregnancy after loss. Outpatient reproductive psychiatry clinics were the most common clinical setting for hands-on learning, which concentrates experience in a single context and may leave residents with limited exposure to inpatient perinatal psychiatry, consultation-liaison work on obstetric units, or integrated care within reproductive health services.

One of the most striking signals of momentum involves formal specialization. Twenty-six percent of responding programs reported offering a dedicated track, pathway, or certificate in reproductive psychiatry, a structure that allows motivated residents to pursue concentrated training alongside core requirements. Among programs without such an opportunity, nearly half expressed interest in developing one. This appetite mirrors the slow but steady growth of reproductive psychiatry fellowships nationally, which were first systematically characterized by Nagle-Yang and colleagues in 2018. The development of tracks and certificates suggests that reproductive psychiatry is following a recognizable institutional path toward subspecialty maturity, similar to trajectories seen in geriatric psychiatry and addiction psychiatry, although it has not yet achieved formal board recognition.

Yet the barriers that constrained training a decade ago remain stubbornly familiar. Program directors most frequently cited limited faculty expertise, at 30 percent, and insufficient curricular time, also at 30 percent, followed by a lack of specialized clinical sites, at 26 percent. These constraints are interlocking in ways that make them difficult to untangle. Without faculty trained in reproductive psychiatry, programs cannot easily build didactics or supervise clinical experiences. Without dedicated clinical sites such as perinatal outpatient clinics or reproductive psychiatry consult services, there is nowhere for residents to practice the skills even when enthusiasm exists. And within an already crowded four-year residency curriculum, adding content requires removing something else, a trade-off that programs facing competing accreditation demands are often reluctant to make.

The workforce implications of these findings extend beyond residency walls. Recent research published in JAMA Network Open by Koire and colleagues documented the prevalence of community perinatal psychiatrists in the United States and found access to this expertise to be scarce in many regions, particularly outside major academic centers. When residency training is heterogeneous and elective, the pipeline of psychiatrists equipped to manage psychiatric illness during pregnancy and postpartum remains thin, and patients in underserved areas face the longest waits for specialized care. Other work, including a trainee needs assessment by Koire and colleagues published in Psychiatric Quarterly, indicates that residents themselves often perceive these gaps and want more education in women’s mental health than their programs currently deliver.

The authors conclude that while training opportunities have expanded since 2018, they remain heterogeneous and largely optional, and they argue that greater standardization of foundational training could better prepare psychiatrists to address mental health needs across reproductive life stages. In practice, standardization could mean requiring core didactic content on perinatal, menstrual-related, and perimenopausal disorders within accreditation milestones, embedding reproductive psychiatry exposure into required rotations rather than electives, and expanding faculty development pipelines to cultivate the expertise that programs say they lack. The Milestones 2.0 framework adopted for graduate medical education offers a potential mechanism for such change, and scholarship on systems-based practice has emphasized the importance of training physicians to recognize structural and equity dimensions of reproductive health. As demand for perinatal mental health services continues to climb and public awareness grows, the survey suggests the specialty is at an inflection point, with clear interest among programs and trainees, demonstrated feasibility at a quarter of residencies, and a well-defined set of barriers that, if addressed, could transform an emerging interest into an educational guarantee.

Subject of Research: Reproductive psychiatry training and barriers in US psychiatry residency programs

Article Title: Reproductive Psychiatry Training in Psychiatry Residencies: A 10-Year National Update on Persistent Barriers and Emerging Interest

Article References: Reproductive Psychiatry Training in Psychiatry Residencies: A 10-Year National Update on Persistent Barriers and Emerging Interest. (n.d.). https://doi.org/10.1007/s40596-026-02439-0

Image Credits: AI Generated

DOI: 10.1007/s40596-026-02439-0

Keywords: reproductive psychiatry, psychiatry residency, perinatal mental health, graduate medical education, postpartum depression, perimenopause, curriculum, fellowship training, program directors, women's mental health, Reproductive, Psychiatry