**Background:** Children with medical complexity (CMC) represent less than 1% of the pediatric population but account for at least one third of healthcare expenditures. Despite ACGME mandates for longitudinal management of children with special health care needs and published Entrustable Professional Activities (EPAs) for CMC care, it is unknown what US pediatric training programs provide for CMC education and whether educators perceive residents as prepared to care for CMC upon graduation.
**Methods:** From June 2021 through March 2022, the authors surveyed US pediatric residency program delegates (associate program directors or designees) via the Association of Pediatric Program Directors (APPD). The survey assessed practice settings, current educational offerings, perception of resident preparedness regarding care of CMC (using a 5-point Likert scale across 11 EPAs), and likelihood to implement CMC education in the future. The survey was constructed using Messick's validity framework with expert content review and cognitive interviews. Chi-Square, Fisher's Exact, and Kruskal-Wallis tests were used for statistical analysis.
**Key Results:** The response rate was 29% (56 of 195 programs). Respondent demographics did not differ significantly from the APPD as a whole by region (p=0.13), affiliation (p=0.79), or size (p=0.28). A third of responding programs (34%, n=19) provide a specific educational CMC offering, including combinations of traditional didactics (84%, n=16), asynchronous modules/reading (63%, n=12), experiential learning (58%, n=11), and simulation-based didactics (26%, n=5). The majority (93%, n=52) of respondents agreed residents should be competent in providing primary care for CMC upon graduation, and 84% (n=47) agreed CMC should receive primary care from a resident. However, only 49% (n=27) of respondents reported their residents are very or extremely well prepared to care for CMC after graduation, while 52% (n=29) judged residents as somewhat, slightly, or not at all prepared. Only 33% (n=18) of programs reported CMC receive primary care from residents. In seven of eleven EPAs, a majority of programs rated graduating residents as somewhat, slightly, or not at all prepared. Respondent average perception of resident preparedness was significantly higher in programs with educational offerings for five of eleven EPAs: nutrition and weight (p=0.008), transitions (p=0.006), feeding tubes (p=0.003), advocacy (p=0.028), and care coordination (p=0.047). The majority (78%, n=29) of programs without educational offerings are at least somewhat likely to implement CMC curricula in the next three years. Key barriers included clinical time constraints, competing educational interests, and lack of financial resources.
**Clinical Implications:** This study reveals a significant gap between the near-universal agreement that pediatric residents should be competent in CMC care and the actual availability of intentional educational offerings. Only one-third of programs have specific CMC curricula, and only half of respondents feel their graduates are well prepared. The finding that any educational offering is associated with higher perceived preparedness in several key EPAs suggests that even modest curricular interventions may improve outcomes. The authors recommend that governing bodies such as the ACGME consider specific program requirements for CMC education, and that programs leverage published EPA frameworks, simulation, and flipped classroom strategies to enhance training without requiring extensive clinical exposure. Further research is needed to directly assess resident and graduate perceptions of preparedness and to evaluate the effectiveness of standardized curricula on patient outcomes.