A key pillar in advancing human health is the medical workforce [1]. In Saudi Arabia, the central structure of the healthcare system is based upon free healthcare services from publicly-owned facilities and government-employed healthcare providers [2]. Subsequently, healthcare providers are a cornerstone of the healthcare system. Moreover, studies conducted on the Saudi population have uncovered a significant annual population growth rate ranging from approximately 3% to 3.5% in 1994 [3,4]. However, recent data indicates a further increase in the growth rate to 4.5% [5], accompanied by a total fertility rate of 7.1% [4]. These findings, coupled with previous research that established chronic neurologic disorders as the most prevalent type of disorders among the pediatric population [6], underscore the utmost importance of comprehending the landscape of pediatric neurology and its workforce.The child neurology field underwent great transformation in the past few years and it continues to grow and expand across various aspects. The expansion of residency programs and the establishment of new traning centers throughout the country have contributed to the growing number of pediatric neurologists entering the workforce. However, this growth also brings about a range of issues and challenges that necessitate a thorough and rational assessment. Natural questions to ask are whether the workforce is equipped to handle these challenges. One key challenge is the current number of pediatric neurologists and the future need. The only available national studies which were published in 2005 and 2017 concluded that the total number of pediatric neurologists per 100,000 children remains way less than the standardized international ratio (0.4:100,000) with even shortage in some regions despite significant improvement as observed by the recent study [7,8]. Ever since the literature witnessed a scarcity in updates on the reality of the Saudi pediatric neurology workforce. On the other hand and as the workforce expands, more challenges arise, such as the occurrence of delays in the employment of recently trained pediatric neurologists. This study aims to investigate and analyze the current characteristics of the workforce, with a specific focus on their employment status and related data.

The aim of this study was to analyze the pediatric neurology workforce in Saudi Arabia in terms of demographics, educational and research activity and level, and employment status. Furthermore, the study represents a contemporary update of previous studies [7,8] that analyzed the same workforce amid growing challenges and changes. The significance of this study is underscored by the growing population and the subsequent increase in referrals and counseling demands placed on pediatric neurologists [11]. Furthermore, advancements in diagnostic modalities, particularly next-generation sequencing (NGS), have emerged as a pivotal technology for gene discovery, equipping clinicians with the capability to identify novel mutations [12,13]. Consequently, this has resulted in a notable rise in the detection of previously unknown mutations [14], which are frequently encountered in pediatric neurology clinics. Nonetheless, this study presented evidence of a growing number of pediatric neurologists in-training in comparison to prior literature. A shift in their demographic data was also remarkable as the previous studies highlighted a major male predominance in the specialty reaching a percentage as high as 73% [8] while our current study estimated male and female percentages of 46.34% and 53.66%, respectively. This remarkable change is consistent with growing trends of medical specialties becoming more feminized even in eastern-conservative communities [15,16,17]. Despite the fact that more than two-thirds of participants are married (68.29%), 63.41% of participants had no form of health insurance. However, this could be attributed to the current reality of a universal healthcare model adopted in Saudi Arabia giving free access to all citizens to health services [18] but this requires careful attention as the country shifts into privatizing the health sector and introducing amplifying the number of health insurance holders [19]. This issue is of great importance as studies concluded a correlation between insurance and good health [20] which is eventually reflected in patients in terms of the quality of services provided by their healthcare provider. The vast majority of participants were locally trained which confirms growing trends nationwide in expanding residency programs at the expense of international, government-funded, scholarships. The majority, nonetheless, are either trained or practicing in a main city leaving peripheral cities and provinces in need of intensive planning and strategies to ensure fair distribution of programs and care providers. The engagement in clinical pediatric neurology research remains low as our study reported. This issue was echoed in multiple medical specialties among Saudi trainees [21] despite an increasing number of research resources and newly-introduced tools including artificial intelligent software. Such tools if acclimatized by trainees can potentially advance the practice [22]. EEG and epilepsy was also the most prevalent type of fellowship training. Moreover, a concerning point has been risen in the current data in which nearly half of the participants (47.57%) experienced some form of delay in acquiring their first job after graduating from the residency program while others were either still in-training or obtained an immediate job following their graduation. The issue is that there were nearly 25.62% had their first job after 4-6 months of graduating and some reaching multiple years of unemployment (4.88%). The struggle remains in the reality of job listing in which pediatric neurologists continue to compete with general pediatricians for vacancies. An issue that could be addressed if independent job vacancies were offered to pediatric neurologists. Furthermore, in the previous workforce analysis it was found that nearly 18% of pediatric neurologists reported to >20 patients per clinic [8], however, this number has increased according to our data in which 31.71% of participants reporting to see more than 20 patients per clinic (Figure 3). As for supporting services, EEG remains the leading service in the current study and in previous data (Figure 4) [8] while observing an increasing number of physical therapy at the expense of EMG which used to rank second [8] as the leading service for pediatric neurologists while currently being third following physical therapy.

Due to the study design (cross-sectional), the absence of some participants in the study may cause selection bias. The lack of sufficient update and previous studies nationwide made it difficult to compare the findings to others. Unequal sampling can also be a potential limitation to the study. These limitations, however, were addressed by increasing the sample size.

Our analysis leads us to the conclusion that the demographic characteristics of the pediatric neurology workforce are undergoing significant transformations, particularly with an increasing number of female practitioners joining the field. However, it is crucial to note that the distribution of this workforce remains concentrated in limited areas across the country, primarily major cities, leaving peripheral cities in a perpetual need for qualified professionals. Real-life challenges, such as the delay in securing employment after graduation, have been comprehensively described and analyzed, but further evaluation by stakeholders is necessary to fully comprehend the multifaceted impact of such issues. Addressing these critical challenges that persist throughout the journey of pediatric neurologists should be prioritized. Enhancing employment opportunities and reducing staffing turnover are essential aspects that must be considered when formulating strategies in the field of pediatric neurology. Given the confined sample in this study, it is highly recommended that similar research efforts be supported and expanded to yield more detailed findings.