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