Growth and Development of Pediatric Hospital Medicine Fellowships
Pediatric hospital medicine (PHM) has experienced incredible growth in the last 20 years, including the creation of >50 PHM fellowships since the first program in 2003. In 2013, a National Pediatric Hospital Medicine Leaders Conference concluded that the best path forward for the field would be subspecialty certification with a 2-year accredited fellowship.1 This process culminated in formal recognition of PHM as a subspecialty by the American Board of Medical Specialties in 2016 and the first American Board of Pediatrics (ABP) certification examination in 2019.2,3 Also, in 2019, the Accreditation Council for Graduate Medical Education (ACGME) published requirements for PHM fellowships and began accrediting programs.4 Established PHM fellowships and programs in development now need to implement standardized curricular components to improve the consistency and educational quality of training and be compliant with ACGME accreditation requirements.
During the initial period of PHM fellowship expansion, before American Board of Medical Specialties recognition of PHM as a subspecialty, PHM fellowship program directors (PDs) mobilized and formed a national PHM Fellowship Directors’ Council to oversee the evolution of PHM fellowships and provide a community for collaboration and development of shared resources. In 2014, the council created subcommittees to address areas of need within PHM fellowship programs. These included the curriculum subcommittee, which was composed of both new and established PDs as well as 2 community hospitalist representatives, all with specific interest and skills in curriculum development. Between 2014 and 2016, the council, led by the curriculum subcommittee, created a standardized 2-year fellowship curricular framework to reflect the competencies of pediatric hospitalists and meet future board certification requirements.5,6 This curricular framework was developed through an iterative process, with input from stakeholders representing fellowship PDs, fellowship graduates, and leaders in PHM and within medical education at large as well as clinical experts from a variety of practice settings, including community, internal medicine-pediatric, and newborn and/or neonatal hospitalists. The council recognized that, despite the curricular framework, the breadth and depth of PHM could still result in different program areas of emphasis and varied educational experiences. Therefore, the council set out to standardize the goals and objectives for each curricular component so that fellows and program leaders could have a common understanding of the learning goals for each educational experience.
In this article, we (1) describe the method by which the council’s curriculum subcommittee developed standardized goals and objectives for PHM fellowship curricular components and (2) discuss how these goals and objectives can be used by programs to guide the education and assessment of fellows.
Methods for Development of Goals and Objectives
The council has been committed to a scholarly, organized, collaborative method in their process of fellowship curriculum development, and, therefore, Kern et al’s7 Six-Step Approach to curriculum development was used as a guide (Fig 1). For steps 1 and 2, the general and targeted needs assessment, we identified a rationale for our curriculum rooted in patient, institutional, and societal needs, with input from key stakeholders, as previously noted.5,6 Kern et al’s7 step 3, creation of goals and objectives, is crucial in directing choice of curriculum content, identifying effective learning methods, and enabling the evaluation of learners and curriculum.
In July 2017, at the annual PHM Fellowship Directors’ Council meeting, the curriculum subcommittee was tasked with developing goals and objectives for each component of its newly proposed 2-year PHM curricular framework. The subcommittee prioritized goals and objectives for the core clinical requirements (hospital medicine, complex care, comanagement, assessment and stabilization of the critically ill child, newborn care, and community hospital medicine) and systems and scholarship requirements (improvement science and patient safety, medical education, leadership, business administration, and advocacy). Curriculum subcommittee members organized into pairs or small groups to address each curriculum component. Clinical and translational research, also a component of the systems and scholarship domain, was addressed separately by the 2019 Pediatric Hospital Medicine Fellowship Research Training Conference, which convened to develop research-specific goals and objectives for PHM fellowships.
At the outset of this project, curriculum subcommittee cochairs organized a faculty development session for the subcommittee members regarding the scholarly approach to curriculum design. A curriculum subcommittee member and 1 subcommittee cochair with advanced training and graduate degrees in education reviewed the relationships among competency-based postgraduate medical education, ACGME milestones, and Entrustable Professional Activities (EPAs). Additionally, the session reviewed goals and objectives within the context of Kern et al’s7,8 conceptual framework for curriculum design and Bloom et al’s9,10 taxonomy as a model for classifying cognitive processes of thinking and learning. These educational resources were also made available via shared cloud folders for subcommittee members to reference throughout the process. The curriculum subcommittee cochairs designed a template for each group to use when drafting the goals and objectives (Fig 2). The template was organized by ACGME core competency domains (patient care [PC], medical knowledge [MK], systems-based practice, practice-based learning and improvement, professionalism, and interpersonal and communication skills [ICSs]). Within each core competency, authors defined an overarching goal, followed by individual learning objectives mapped to knowledge-skills-attitude (KSA) domains and subspecialty and/or PHM-specific EPAs. PHM EPAs served as the guide for what should be expected of an independently practicing pediatric hospitalist.11
In October 2017, the curriculum subcommittee issued a call for content from the PHM Fellowship Directors’ Council to gather existing goals and objectives from individual institutions (Fig 3). Twenty-three sets of goals and objectives for various PHM fellowship rotations were shared from 12 different PHM fellowship programs across the country. These shared resources, together with the published PHM Core Competencies,5 were used to draft the goals and objectives for each assigned curricular component. First drafts then underwent peer review by another curriculum subcommittee small group (eg, members assigned to work on the hospital medicine rotation reviewed the complex care rotation draft and vice versa). The original small group authors then incorporated suggested edits and forwarded second drafts to current and former leaders within the PHM Fellowship Directors’ Executive Council. The executive council members provided feedback before the 2018 annual PHM Fellowship Directors’ Council meeting.
During the July 2018 PHM Fellowship Directors’ Council meeting, the curriculum subcommittee delivered a faculty development session on competency-based medical education and writing effective goals and objectives for all 77 PDs in attendance. The curriculum subcommittee then elicited specific verbal and written feedback on each set of goals and objectives from all the PDs via an evaluation form (Supplemental Information). The evaluation form prompted PDs to review specific characteristics for each objective: SMART format,8 appropriate action verb from Bloom’s taxonomy9 , appropriate ACGME core competency, correct KSA designation, and accurate EPA mapping. The form also included free-text options for additional comments and feedback. After the July 2018 PD meeting, the curriculum subcommittee small groups updated their working drafts on the basis of the feedback obtained from the larger PD council.
In December 2018, expert reviewers outside the council were identified on the basis of national reputation as a PHM leader or content expertise relevant to a specific curriculum domain (Supplemental Table 1). The expert pool included experienced hospitalists from geographically diverse institutions of varying sizes. In the spring of 2019, each draft of goals and objectives underwent review by at least 2 expert reviewers (with the exception of 1 rotation [care and stabilization of the critically ill child], which only underwent review by 1 expert) to allow for multiple perspectives. After the expert review, the original authors developed their final drafts, which were disseminated to the PHM fellowship PDs at the annual PHM Fellowship Directors’ meeting in July 2019. The final product was a collection of peer-reviewed goals and objectives for the 12 PHM fellowship core components in the proposed curricular framework, mapped to KSA domains and EPAs (see Supplemental Tables 2 through 7 for a sample of hospital medicine goals and objectives). The completed goals and objectives are available in an online repository accessible to all PHM fellowship PDs.
We present an innovative, collaborative approach to developing peer-reviewed, evidence-informed curricular goals and objectives for PHM fellowships that align with ACGME Core Competencies, pediatric subspecialty EPAs, and PHM-specific EPAs. Before ABP and ACGME recognition, during a time of rapid growth of our field, the PHM fellowship PDs created a grassroots council to develop resources quickly and methodically, ensuring that PHM fellowship programs are well equipped to train future generations of pediatric hospitalists. Since 2008, the council has committed to collaborating with one another and key stakeholders in the PHM community to establish fellowship standards, with the ultimate goal of producing effective training programs and highly competent pediatric hospitalists. In doing so, the PDs were able to define what training in our specialty should look like, providing recommendations for the ACGME as they defined the formal requirements for PHM training. For example, the 2-year fellowship curriculum the council developed in 2016 was adopted, with few exceptions, as the standard for ACGME program requirements. The council now has standardized goals and objectives for each required curricular component that have been thoroughly vetted by the national PHM Fellowship Directors’ Council as well as other PHM leaders and remain available for any PHM program to use or adapt to meet their program and learner needs. To our knowledge, although pediatric emergency medicine has published their collaborative approach to identifying essential requirements for administrating and managing a pediatric emergency medicine fellowship program,12 no other established subspecialty has committed to standardizing goals and objectives for their fellowship curricula.
Previous literature reveals that clear goals and objectives increase the quality of an educational experience, and, therefore, we anticipate that these standardized goals and objectives will serve as a tool to facilitate high-quality educational experiences for fellows.13,14 With the widespread adoption of competency-based medical education and the emergence of EPAs,15 we wanted to ensure our goals and objectives aligned with the ACGME Core Competencies, the PHM Core Competencies,5 and the PHM EPAs.11 EPAs describe what activities clinicians should be trusted to do by integrating multiple competencies,16 translate competencies into clinical practice, and provide more tangible activities that can be observed and evaluated. They also guide evaluation tools and provide an objective map for trainees of how we expect them to apply their training in clinical practice. Mapping the goals and objectives for the ACGME-required curricular elements to the ABP PHM EPAs ensures the curriculum aligns with the competencies expected of a graduating PHM fellow. This process also aided us in staying within the scope of PHM practice and avoiding extraneous expectations for fellows in an already full 2-year curriculum. Having standardized, competency-based goals and objectives is especially important for a relatively young, diverse field to ensure fellows, PDs, and fellowship faculty have a shared understanding of the expectations of trainees.
We adhered to an academic approach and completed the first 3 steps in the Six-Step Approach to curriculum development by Kern et al.7 The next 2 steps, educational strategies and implementation, must be addressed by each individual program but can be guided by our shared goals and objectives. The goals and objectives were intended to be broadly applicable and could be implemented by individual programs without modification. However, the curriculum committee recognizes the need to align rotation goals and objectives with program- and institutional-level goals and objectives. Alignment of objectives optimizes the fellows’ educational experience and is required by ACGME. If a program has a focus on a particular clinical condition or a specific approach to delivering care, PHM PDs have the flexibility to add, remove, or modify objectives accordingly. The KSA domain is another area that is easily modifiable. PHM PDs may choose to keep the core content of an objective the same but shift from a knowledge-based to skill-based objective, for example. Educational strategies flow directly from goals and objectives. For the same content area, one program may have a knowledge-based objective, which it addresses through a lecture, whereas another program may have a skills-based objective, which it achieves through simulation.
Finally, step 6, evaluation and feedback, will be crucial as fellowship programs implement their curricula. Evaluation will need to occur both at the individual program level and at the national level, which we expect will involve collaboration among the council, ACGME, and ABP. Our hope with curriculum standardization is that we can create high-quality, effective PHM training experiences that produce competent pediatric hospitalists across all fellowship programs and sites. Although we now have the ACGME as an accrediting body tasked with ensuring compliance and monitoring outcomes, the PHM Fellowship Directors’ Council serves an essential role because it continuously reevaluates the fellowship training experience on the basis of real-time feedback from trainees and the field of PHM.
We faced challenges when pursuing this project. Although the curriculum subcommittee is composed of PDs with an interest in curriculum development, there were varying levels of experience in writing goals and objectives as well as varying fundamental knowledge about the interplay between competencies and EPAs. We attempted to mitigate this challenge through faculty development sessions, provision of medical education resources, and multifaceted feedback. Coordinating group work remotely and on a national scale was also a challenge, leading to the two-year timespan to complete the first stage of this project. Additionally, owing to the diverse nature of our field and practice settings, we were challenged to balance comprehensiveness with feasibility to attain goals and objectives of reasonable scope. Finally, our process was subject to inherent bias because we were relying on expert consensus, which could be influenced by geographic location, clinical setting, training, and/or work experience by each individual providing input and feedback throughout the process. We attempted to strengthen the validity of consensus via structured, iterative rounds of review with deliberate selection of authors and reviewers to help ensure representation across the PHM field.
The PHM Fellowship Directors’ Council curriculum subcommittee plans to use a similar process to create standardized goals and objectives for curricular components falling under individualized curriculum, which includes common electives, such as infectious diseases, sedation, child abuse, and palliative care. Additionally, the ACGME requires that a curriculum must contain competency-based goals and objectives for each educational experience designed to promote progress on a trajectory to autonomous practice in their subspecialty; objectives generally should be delineated on the basis of postgraduate training level.4 In response to this, the curriculum committee has committed to creating tiered goals and objectives by fellowship year for curricular components that span the duration of the two-year fellowship (eg, hospital medicine, complex care, improvement science, and patient safety). In addition, newly published updated PHM Core Competencies17 are available to inform future reiterations of our goals and objectives. Finally, we hope to collaborate with the PHM Fellowship Directors’ assessment committee as they work to develop standardized, competency-based assessment tools that align with our competency-based goals and objectives.
With an innovative, collaborative approach, the PHM fellowship PDs have developed a set of standardized goals and objectives for PHM fellowship programs that align with PHM Core Competencies, EPAs, and ACGME requirements and supplement the PHM fellowship curricular framework. We anticipate the goals and objectives will facilitate high-quality educational experiences across fellowship programs, while allowing for adaptation to suit individual program needs.
We thank the PHM PDs’ executive council and curriculum subcommittee for their significant contribution to this project: Helen Rhim, Valeriy Chorny, Rebecca Tenney-Soeiro, Nancy Chen, Michelle Hofmann, Allison Markowsky, Scott Carney, Sarah Denniston, Kim O’Hara, Navita Kumar, Joyee Vachani, Tony Tarchichi, Jeremiah Cleveland, Mikelle Key-Solle, Ann Allen, Kathryn McLeod, Nisha Gupta, Rebecca Purtell, Ann Marshburn, Steve Marek, Jeri Kessenich, Erin Knoebel, Miranda Kane, Whitney Browning, Stephen Pishko, Lauren Solan, John Andrake, and Shiela Liewehr.
Dr Librizzi conceptualized the project and drafted the initial manuscript; Drs Frank, Jerardi, Maniscalco, Rassbach, and Shah reviewed and revised the manuscript; Dr Walker conceptualized the project and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.
FUNDING: No external funding.
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.