Congenital heart disease (CHD) affects approximately 1% of live births and requires coordinated care from pediatric cardiologists (PCs) and cardiac surgeons (PedCSs), spanning prenatal diagnosis to long-term management [1]. In addition to CHD, these specialists also treat acquired heart conditions such as myocarditis, arrhythmias, and Kawasaki disease.

As of 2023, 298 PCs and PedCS were registered with the Korean Pediatric Heart Society (KPHS). However, only 151 PCs and 44 PedCSs either maintained or temporarily suspended their board certifications, while others had subspecialty certifications that were either expired or revoked. Compared to 2011, the number of certified PCs increased (from 137 to 151), whereas that of certified PedCSs declined (from 61 to 44). A growing shortage of residency applicants in pediatrics, thoracic and cardiovascular surgery, and obstetrics has become a major concern in Korea [2-4]. This trend has directly contributed to the aging of the PCs and PedCS workforce, as fewer young specialists are entering the field to replace the retiring generation. As of 2023, the median age had increased from 47 to 51 years for PCs and from 48 to 52.5 years for PedCSs (Supplementary Fig. 1). These aging trends, combined with Korea’s declining birth rate and regional disparities in medical resources, have raised urgent concerns about the long-term sustainability of the pediatric cardiac workforce. Reflecting this concern, the number of practicing PedCSs in Korea is projected to decline from 35 in 2021 to 17 by 2035, representing a 51.4% reduction over 14 years [5].

While workforce assessments are regularly conducted in the US, and Japan has recently carried out a similar study on PedCSs, such evaluations are still lacking in Korea [6-8].

To better understand and address the growing challenges in the pediatric cardiac workforce, the KPHS conducted a nationwide survey in June 2023. The survey aimed to identify key issues faced by PCs and PedCSs, including workload, job satisfaction, and burnout. This study analyzes the survey findings to provide evidence for future workforce planning and policy development in Korea.

This study is a secondary analysis of data from a cross-sectional survey conducted by the KPHS. The survey targeted 149 KPHS members (115 PCs and 34 PedCSs) who were actively engaged in pediatric cardiac care, including those whose subspecialty board certification was either active or temporarily suspended, as well as those actively practicing in the field regardless of certification status.

To collect data, we distributed a structured online questionnaire via email in 3 successive rounds between June 1 and June 30, 2023. A task force led by the KPHS chairman developed the questionnaire based on existing surveys from the Korean Society of Emergency Medicine, the Japanese Society of Pediatric Cardiology and Cardiac Surgery, and the American Academy of Pediatrics, adapting the content to the Korean healthcare context [7-9].

The anonymous web-based survey collected information on demographics (sex, age, and career stage), work environment, job satisfaction, burnout, fellowship training, career development, and healthcare policy perceptions. Given the differences in roles and workloads between PCs and PedCSs, separate but parallel questionnaires were used for each group. This analysis primarily focused on workforce status and burnout-related outcomes.

This national survey highlights the critical workforce challenges facing PCs and PedCSs in Korea. Factors contributing to dissatisfaction and burnout among these specialists include excessive workloads, frequent postwork night shifts, emergency callbacks, declining case volumes, legal risks, and insufficient support systems. The findings confirmed that excessive working hours and frequent emergency callbacks are closely associated with burnout. Particularly, being on-call and called back to the hospital more than 6 times per month remained a strong independent predictor of burnout. Dissatisfaction with professional pride or identity and dissatisfaction with the work environment were also significant contributing factors.

Beyond the issue of burnout, maintaining procedural skills is essential for ensuring patient safety and delivering quality care [10-12]. However, only 48.2% of PCs in the SMA and 7.1% in non-SMA reported performing more than 51 catheterizations annually, a threshold respondents considered necessary for maintaining technical proficiency. Similarly, among PedCSs, only 62.5% in SMA and 20% in non-SMA regions performed over 30 CHD surgeries annually. Lower case volumes were particularly evident among junior surgeons, indicating the impact of declining birth rates and regional centralization of pediatric cardiac care. International studies consistently show that higher surgical and procedural volumes are associated with better outcomes, including lower mortality and complication rates [10-14].

Recommendations from professional societies in Europe and Japan have emphasized the need for minimum institutional volumes and specialist numbers to sustain high-quality pediatric cardiac surgery [15-17]. For instance, Japan’s Ministry of Health, Labour and Welfare recommends that institutions performing congenital heart surgery conduct at least 100 cases annually, with each surgeon ideally performing 30 or more. Similarly, in the United Kingdom and parts of Europe, expert consensus and accreditation standards often suggest institutional volumes of 250–300 surgeries per year to ensure optimal outcomes. Given these international benchmarks, the low procedural volumes observed in our survey raise concerns about skill maintenance and patient safety, particularly in hospitals in non-SMA regions.

In addition to clinical workload concerns, medical-legal risks were widespread. A substantial proportion of PCs (66.7%) and PedCSs (84.6%) reported direct or indirect involvement in legal disputes. Among PCs, nearly half of those who had experienced litigation subsequently reduced the scope of care provided to high-risk patients. Although most PedCSs continued their practice scope following legal disputes, many cited legal risks as a major contributor to psychological burden and dissatisfaction with the work environment (Table 3). These findings underscore the urgent need for legal protection measures to support physicians managing high-risk pediatric patients.

Interestingly, despite the burdens, many respondents expressed satisfaction with their professional roles. However, this sense of fulfillment often coexisted with significant dissatisfaction towards their work environment. Major causes of dissatisfaction, particularly among PCs, included limited time for research activities, disruption of professional identity owing to nonspecialized clinical tasks, revenue pressures, and legal risks (Table 3). Nonspecialized duties, such as general pediatric care or administrative responsibilities, may dilute one’s sense of professional identity and contribute toward disengagement. PedCSs reported similar challenges, including constraints on research, financial burdens, and psychological stress, although issues related to professional identity were relatively less prominent compared to PCs. This contrast underscores the need not only to support individual motivation and resilience, but also to implement system-level improvements in working conditions, institutional support, and job design.

Furthermore, regional disparities exacerbated workforce instability. PCs and PedCSs practicing outside the SMA encountered lower case volumes, fewer opportunities for skill development, and greater employment insecurity. Notably, this study highlights a structural paradox: despite facing excessive clinical workload, including long working hours and frequent postwork night shifts, many PCs and PedCS specialists reported limited procedural volumes—particularly in nonmetropolitan areas. This mismatch between workload intensity and opportunities for procedural reinforcement undermines both skill maintenance and workforce morale, posing a serious threat to long-term retention. Addressing this imbalance is critical to ensuring both the quality and sustainability of pediatric cardiac care nationwide. In particular, the lack of surgical backup regional centers was a significant barrier to performing invasive procedures; this led to reduced procedural opportunities and further erosion of professional identity.

The Korean government's 2024 initiative to expand medical school enrollments may not adequately address specialist shortages in pediatric cardiology and cardiac surgery. Without addressing the fundamental issues of declining pediatric populations, low procedural volume, employment insecurity, and legal vulnerability, merely increasing the number of trainees alone will be insufficient.

To effectively confront these challenges, targeted strategies are required. First, reimbursement policies should be revised to offer differentiated, higher compensation for complex and high-risk pediatric cardiac procedures, better reflecting their clinical difficulty and the resources required. Adequate financial incentives are essential not only to sustain the clinical practice of high-risk pediatric specialists but also to attract new trainees to this demanding field. Second, legal reforms should be introduced to establish structured mediation systems for medical disputes and to strengthen legal protections for physicians managing high-risk pediatric patients. Reducing litigation risks and psychological burdens is critical to maintaining professional engagement in high-risk pediatric care. Third, proactive government interventions are needed to address the overconcentration of pediatric cardiac patients in the SMA and to support medical infrastructure in non-SMA regions.

Proposed strategies include strengthening regional referral systems, supporting interregional patient transfers, providing direct funding to non-SMA hospitals, and implementing workforce incentive programs to encourage a more equitable distribution of specialists beyond metropolitan areas. Enhancing the capacity of non-SMA hospitals is essential to ensure nationwide access to high-quality pediatric cardiac care. Fourth, addressing the erosion of professional identity, particularly in non-SMA regions, will require not only institutional efforts but also coordinated action at the national level. A more in-depth discussion is needed to identify strategies that preserve the specialized roles of pediatric cardiac professionals while ensuring sufficient procedural exposure and ongoing skill development. Professional societies must take a leading role in establishing standardized guidelines for minimum procedural volumes, institutional requirements for invasive practice, and support systems for specialists working in resource-limited settings.

Moreover, national health policy initiatives should prioritize the reinforcement of pediatric cardiac services in non-SMA regions through targeted resource allocation, workforce incentive programs, and the development of structured regional networks for patient transfer and surgical support. Collaborative efforts between academic societies and government agencies will be essential to stabilize the workforce, protect specialist identity, and sustain high-quality pediatric cardiac care across all regions. Collectively, these strategies are crucial for addressing the current workforce challenges, ensuring continuous recruitment of new specialists, and sustaining a stable pediatric cardiac care system in the long term.

However, this study has certain limitations, including potential selection bias and limited generalizability owing to the voluntary nature of survey participation. Nevertheless, this study provides the first comprehensive national data describing the current status, burdens, and professional challenges faced by pediatric cardiology and cardiac surgery specialists in Korea. These findings offer critical insights for future workforce planning and policy development.

In conclusion, urgent systemic reforms are necessary to sustain the pediatric cardiac workforce. While this study focuses on Korea, similar challenges are likely to arise in other countries with shrinking pediatric populations and high-intensity specialties. Our findings may offer broader insights for international workforce planning in pediatric cardiac care. Ensuring appropriate procedural volumes, legal protections, and supportive work environments will be essential to preserve the professional pride and clinical excellence of future generations of pediatric cardiac specialists. Regular surveys and continued research are necessary to guide future improvements and inform long-term healthcare workforce projections in these critical fields.