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Background: Few studies have been published about specialty-specific fourth-year medical student leadership in any discipline. This paper provides insight from pediatric educators about the current status and recommendations for pediatric-specific fourth-year leaders. Objective: To identify the prevalence of pediatric fourth-year medical student directors across the US and Canada and to compare current and ideal responsibilities for this role. Methods: Five multi-part questions were written and submitted for the 2019 Council on Medical Student Education in Pediatrics (COMSEP) Annual Survey and subsequently disseminated to all COMSEP member physicians. Anonymous responses were collected and results analyzed. The study was IRB exempt. Results: The program-level survey response rate was 79%. Of 115 respondent medical schools, 37% reported having a pediatric fourth-year director separate from the clerkship director, with an average of 9.8% full-time equivalent (FTE) protected time for the role. In contrast, individuals indicated 20% FTE would be ideal for fourth-year director responsibilities. The most common role identified for pediatric fourth-year directors was directing sub-internships. Respondents indicated it would be ideal for pediatric fourth-year directors to have an increased level of involvement in all areas queried in the survey, especially directing a pediatric residency preparatory course/boot camp, faculty development for educators of fourth-year students, and remediating fourth-year students. Conclusions: As specialty-specific experiences have grown in the fourth year of medical school, there is an increasing demand for faculty leadership separate from direction of the pediatric clerkship. In this national survey, pediatric educators expressed a need for additional protected time to lead fourth-year specific activities. Similar findings in other disciplines would support advocating for more protected time and expanded roles for specialty-specific fourth-year directors nationally. [ABSTRACT FROM AUTHOR]