We read with interest “A Changing Landscape: Understanding Resident Perspectives on Pursuing Pediatric Hospital Medicine Fellowships.”1  The publication is timely, given the recent designation of Pediatric Hospital Medicine (PHM) as a subspecialty by the American Board of Medical Specialties and the American Board of Pediatrics (ABP), as well as initial accreditation of PHM fellowships by the Accreditation Council for Graduate Medical Education. Through this commentary, we seek to discuss the study findings and highlight the current landscape of PHM fellowship training as influenced by the PHM fellowship curricular framework, the ABP PHM subboard content, and the newly revised PHM Core Competencies.

The authors sought to characterize categorical pediatric and combined pediatric residents’ perceptions of PHM fellowships, including barriers and facilitators to pursuing such training. In 2018, an anonymous online survey was sent to residency program directors and 23% agreed to distribute the survey. A total of 2657 residents were surveyed; 32.2% (855) responded. Study findings suggest that although many residents saw value in PHM fellowships, they also reported concerns. A majority of respondents cited potential for higher future earnings and opportunity to gain new skills in both clinical and scholarly domains as important factors encouraging them to pursue fellowship. Specifically, half of respondents stated that they would value training in each of the following areas: medical education, quality improvement, hospital administration, research, and clinical medicine. However, a majority reported that they were “somewhat” or “less likely” to pursue a position in PHM after PHM fellowship became required for board eligibility. Personal and financial factors, including family obligations, forfeited earnings while in fellowship, and existing educational debt, influenced the decision to pursue fellowship for some. The authors also highlighted 3 specific populations who were significantly deterred by the PHM fellowship requirement to be board eligible: (1) those who envisioned practicing PHM at a community site, (2) internal medicine–pediatrics (Med-Peds) residents, and (3) those who intended to pursue PHM temporarily before embarking on another career path. Last, residents were asked about the career paths they were now considering if they were less likely to pursue PHM. In total, 341 (44.8%) respondents reported considering another subspecialty career, and 248 (32.6%) reported considering primary care.

There are several limitations to this study, including survey design, low response rate, and a potential for response bias. A methodologically rigorous approach that included survey validation and additional pilot testing may have led to a clear initial questionnaire, allowing researches in the study to focus on residents truly interested in PHM as a career, with or without pursuing board certification, given that there are currently numerous employment opportunities in PHM for which board certification is not a prerequisite. This would have allowed for more clear conclusions to be drawn from the results. The American Academy of Pediatrics annual survey of graduating residents (2006–2015) reported that only 10% (593) of 5969 respondents planned to enter PHM as career.2  In the 2018, 2019, and 2020 surveys, 10% to 15% of residents for each year planned to enter PHM as a career, versus 86% as reported in the current study.3 

The number of survey responses in this study encompasses only ∼8% of pediatrics and Med-Peds residents nationally.4  The low response rate limits generalizability of the study findings, as does the lack of program specific characteristic for responding residents. For example, program size, type of associated hospital system, and presence of PHM fellowship programs or PHM-trained attending physicians may all influence opinions and survey results. Finally, we would like to highlight that this survey was conducted in 2018. Although it was only 2 years ago, we believe that the field of PHM has grown substantially since 2018, and board certification has likely further defined the field in this time frame and thus, survey responses from 2018 may not reflect opinions today.

With the growth of the field, the additional skills and knowledge gained from PHM fellowship are notable. As former and current PHM fellowship directors and leaders within the PHM fellowship community, we wish to highlight the deliberate processes that have been used to establish a fellowship curricular framework, subboard content, and core competencies for PHM. Each of these have been created with input and evidence from a diverse group of practicing hospitalists to ensure inclusion of topics pertinent to practice and representative of the field, as well as topics not fully addressed during residency training.

The current PHM fellowship curricular framework was developed by PHM fellowship directors over a multiyear iterative process, which included thoughtful deliberation among many stakeholders, including community, newborn, and Med-Peds hospitalists.5  The development process also considered published evidence from practicing hospitalists that identified gaps in residency training.68  The curricular framework was closely followed by the Accreditation Council for Graduate Medical Education when creating fellowship requirements, affirming that it clearly represented the additional training needs and opportunities for those wishing to become board-certified pediatric hospitalists. Of note, the framework allots one-third of the fellowship for scholarly activities, which trainees may have insufficient time to pursue during residency. Additionally, the framework has one-third of the time spent in individualized curricula that can and should be designed to meet individual fellow needs and address future practice goals, which may include Med-Peds or community practice. Researchers in multiple studies have demonstrated that additional skills are indeed gained during PHM fellowship and likely translate to a more rapid career advancement in many cases.911 

Once a subspecialty certification program has been approved, the ABP assumes the responsibility for certifying the subspecialists in that field. Initial board certification involves 2 primary components: (1) successful completion of an accredited training program, and (2) passing a certification examination. The ABP uses a practice analysis process to develop the content specifications for the certification examination. For the PHM certification examination, the practice analysis process was structured, engaged the PHM community, reflected the breadth and depth of knowledge required for PHM practice and used an iterative process to create the final product. A total of 800 full-time pediatric hospitalists, 6% of whom were Med-Peds trained pediatric hospitalists, rated the draft content outline (V. Mittal, MD, personal communication, 2020). Both community and noncommunity pediatric hospitalists rated content domains similarly (P = .943).12 

The PHM Core Competencies delineate the knowledge, skills, attitudes, and systems improvement behaviors needed by pediatric hospitalists to care for hospitalized children across all practice locations in the United States.13  The rigorous, inclusive methods for the development of the initial and revised core competencies have been documented and included input from multiple stakeholder groups and relevant national organizations, including those representing community and Med-Peds hospitalists.1214  Implicit in the objectives, which range from foundational to more advanced items, is the expectation that pediatric hospitalists engage in educational or professional development activities that build on residency training to attain a level of competency at the advanced stages of a developmental continuum. As such, they have been used to support the development of curricular elements for PHM fellowship programs and a national conference for PHM fellows, among other educational offerings.

The authors of this article highlight potential perspectives among recent residency graduates related to the PHM fellowship requirement for board certification. However, given that the number of responses only represents 8% of Pediatrics and Med-Peds residents nationally, it is challenging to extrapolate this information to pediatric residency trainees at large. As PHM and PHM fellowship programs continue to grow, it is important to keep exploring the related perspectives of all pediatric residents and proactively address their needs and concerns. It is incumbent on PHM fellowship programs to continue including residents who have goals of working in the community or as Med-Peds hospitalists and to ensure that PHM programs can provide the robust clinical and scholarly experiences those trainees require. Finally, we must continue to study and evaluate outcomes for PHM fellowship graduates and share this information so that residents can appreciate the full value of choosing a PHM fellowship when weighing their options.

In today’s health care environment, pediatric hospitalists are caring for children with both high acuity and complexity. To meet the demand for highly skilled hospitalists, PHM fellowships were developed through an intentional, rigorous, and inclusive process. Current literature describes a multitude of training opportunities and benefits associated with completion of a PHM fellowship. We would propose that the clinical and academic skills gained through PHM fellowship are critical to providing high quality, value-based, safe, and effective care to hospitalized children.

We thank Dr Vineeta Mittal for her contributions.

Drs Jerardi, Maniscalco, Shah, and Walker conceptualized and drafted the initial manuscript; and all authors approved the final manuscript as submitted.

FUNDING: No external funding.

COMPANION PAPER: A companion to this article can be found online at www.hosspeds.org/cgi/doi/10.1542/hpeds.2020-0034.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.