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

Neonatal mortality rates in the United States stand as a testament to the gains achieved by the specialty. Since 1975, when neonatal mortality was recorded at 11.6 deaths per 1,000 live births, the figure has impressively declined to 3.6 per 1,000 in 2022. This substantial reduction stems from rigorous scientific inquiry, innovation in clinical care, and a robust relationship between research and practice. The proposed truncation of fellowship duration poses a real danger to this delicate ecosystem, raising concerns that a compressed timeline might deprive trainees of essential experiences and scholarly development necessary for advancing neonatal medicine.

Central to this discourse is the Association of Academic Neonatology Division Directors’ (AANDD) recent comprehensive evaluation of the proposed two-year fellowship agenda. Convened in April 2026, this body of experts recognized the theoretical benefits of competency-based training but unanimously voiced reservations about the sufficiency of a mere two years for clinical mastery and academic preparation. Their consensus highlighted that such compression forces an unrealistic consolidation of 18 clinical training blocks into a compressed 24-month period, which could undermine the depth of clinical acumen acquired by fellows.

Beyond clinical training, the AANDD emphasized that scholarly activities, a cornerstone of academic medicine, risk being marginalized in a truncated fellowship. Scholarly work is not merely an academic exercise but a critical process that ensures neonatologists remain equipped to evaluate emerging literature critically and integrate evidence-based practices into their care protocols. Reduced time devoted to research and academic rigor could lead trainees to become competent technicians but not necessarily innovators or leaders in neonatal science.

The challenge is further compounded by the observation that many current fellows graduate feeling inadequately prepared for independent practice, which suggests that even the existing timeline requires careful scrutiny. The push to condense training, therefore, raises questions about quality versus quantity, with strong arguments favoring sufficient duration to allow burgeoning neonatologists to mature clinically and intellectually. Cutting training periods may accelerate entry into the workforce but at the potential cost of clinical expertise and scholarly development that ensure high-quality care.

Academic neonatology operates at a delicate intersection where clinical expertise and research must synergize to foster continuous improvement in patient outcomes. The proposed two-year model threatens to disrupt this synergy by diluting the time allocated for scholarly endeavors. Early career neonatologists particularly depend on the depth and breadth of fellowship training to generate meaningful academic contributions—an element integral to achieving academic promotion and sustaining the intellectual vitality of the field.

It is important to situate this debate within the broader context of competency-based medical education, which aims to ensure proficiency in essential skills without unnecessarily prolonging training. While competencies are critical, the nuanced clinical scenarios faced in neonatal units, especially when managing extremely preterm infants or those with multifaceted conditions, require extensive exposure and reflective practice. Rapid compression could lead to insufficient experiential learning, limiting fellows’ ability to build a comprehensive clinical framework.

Moreover, neonatal medicine is distinguished by its continuous innovation in therapeutics and interventions, driven by an intricate understanding of physiology, pathology, and developmental biology. To uphold this tradition, the training pipeline must encourage intellectual curiosity alongside clinical expertise. Shortened fellowships risk eroding the culture of inquiry that fuels novel discoveries and the translation of research findings into bedside care, ultimately stalling the pace of progress achieved over the past half-century.

The dilemma thus unfolds as a tension between efficiency and excellence. Proponents of the two-year fellowship underscore benefits like reduced training costs, earlier workforce entry, and streamlined pathways. However, these must be carefully weighed against potential sacrifices—such as the erosion of deep clinical knowledge, diminished scholarly output, and weakened preparedness for the complex demands of academic neonatal practice. These concerns have elicited strong opposition from leaders in the field, many of whom argue that current training durations remain necessary for cultivating well-rounded neonatologists.

The discourse also touches on workforce dynamics and the future trajectory of neonatology. Compression without adequate safeguards may exacerbate existing challenges in recruiting and retaining physician-scientists—a group crucial for integrating cutting-edge research into clinical paradigms. The dwindling presence of clinician-researchers would undermine the feedback loop that propels both scientific innovation and improvements in neonatal outcomes.

Looking forward, the neonatal community faces a critical juncture. Decisions made today about training structures will have ripple effects on research productivity, clinical care standards, and academic vitality for years to come. It is imperative that any reform balances the need for efficiency with the uncompromising demand for depth in education and scholarship. A nuanced approach might integrate milestones and assessments with protected research time to maintain academic rigor within a feasible timeframe.

Ultimately, the resistance to the ABP’s two-year fellowship proposal underscores a broader principle: that the future of neonatal-perinatal medicine hinges on preserving a comprehensive training environment that nurtures both clinical excellence and scientific inquiry. Cutting corners in training may yield short-term gains but risks longer-term stagnation. The commitment to saving and improving the lives of the tiniest patients demands nothing less than robust and well-rounded preparation of neonatologists.

The coming months will be pivotal as stakeholders, including the ABP, academic institutions, and practicing neonatologists, engage in dialogue to refine fellowship structures. Constructive collaboration is essential to develop training pathways that honor the specialty’s legacy while adapting to contemporary challenges. Such an approach must prioritize both competency and scholarship, ensuring that neonatology remains a dynamic field at the forefront of pediatric medicine.

As the neonatal community navigates this complex debate, the lessons learned may well extend beyond one specialty, informing how medical education reforms can be pursued in other domains without compromising the core values of patient-centered care, rigorous scholarship, and clinical mastery. The future of neonatal-perinatal medicine may depend on finding the equilibrium between tradition and innovation in training paradigms.

In summary, the proposed compression of neonatal-perinatal fellowship training to two years has sparked critical examination and considerable opposition. While embracing competency-based education is laudable, truncating training without safeguarding scholarly development threatens to diminish clinical readiness and weaken the pipeline of academic leaders. Preserving comprehensive, well-paced fellowship programs remains paramount to sustaining the transformative progress that has defined neonatology in recent decades.

Subject of Research: Training structures and outcomes in neonatal-perinatal medicine, focusing on the impact of fellowship duration on clinical and academic preparedness.

Article Title: Compressing neonatal-perinatal medicine fellowship training: a critical appraisal of the American Board of Pediatrics proposed 2-year pathway.

Article References:
Vergales, B., Scala, M., Bruno, C. et al. Compressing neonatal-perinatal medicine fellowship training: a critical appraisal of the American Board of Pediatrics proposed 2-year pathway. J Perinatol (2026). https://doi.org/10.1038/s41372-026-02743-5

Image Credits: AI Generated

DOI: 03 June 2026