Preparing for a Career in Pediatric Hospital Medicine: A Needs Assessment and Recommendations for Individualized Curricula Free

We conducted a needs assessment survey. Exempt status was obtained from the Institutional Review Board before study initiation.

Pediatric hospitalists, PHM fellowship program directors (FPDs), and graduating PHM fellows were selected as the groups believed to be most knowledgeable regarding beneficial activities for residents entering PHM.

Using the PHM core competencies and clinical experience as guides, the task force developed 13 to 15 item surveys for each of these key stakeholder groups.¹⁰  Open-ended questions were included in all surveys to allow respondents to identify experiences that may not have been included in question answers. Surveys were piloted and revised by local and national educational experts before dissemination. Subcommittee members and other medical educators reviewed multiple iterations to ensure questions reflected the areas of interest. Survey questions were directed to each group on the basis of relevant expertise and were divided into 3 general categories: PHM-specific residency track, resource suggestions, and general demographics. Surveys are included in the Appendix.

Convenience sampling was used to ensure community and university-based pediatric hospitalists inclusion. Task force members representing 13 children’s hospital with community and university-based settings were tasked with distribution of the electronic survey to their division members. FPDs were identified through an online database, contacted directly via e-mail, and asked to complete the survey. FPDs were also asked to send the fellows’ version of the survey to their graduating fellows.

Participants at the study sites were invited by e-mail to complete the survey electronically via REDCap, a secure, Web-based data capture instrument. Surveys were distributed at 1-month intervals. Each group received an invitation to take the survey 3 times; the initial request, with 2 monthly reminders. Participation was voluntary.

Because each group received a different version of the survey, we report descriptive statistics for our data. Answers were reported in aggregate by REDCap. Thematic analysis of the free text answers was completed independently by the primary investigators (S.P. and J.L.) to identify, analyze, organize, describe, and report common themes from the responses. Common themes were discussed until reviewers were in agreement.

Surveys were sent to a total of 451 potential participants within all 3 groups. We had an overall response rate of 44% (200 of 451). Forty-six percent of PHM fellows (16 of 35), 42% of pediatric hospitalists (149 of 356), and 58% of FPDs (35 of 60) completed the survey.

The majority of pediatric hospitalist respondents were not fellowship trained (84% n = 124) and practiced on the general inpatient wards (100%, n = 149) in a standalone children’s hospital (74%, n = 110). Community hospitalists represented 4% (n = 6) of respondents. Nearly half (44%, n = 66) practiced surgical comanagement. Twenty percent (n = 30) practiced in a newborn nursery setting (well newborn care, no delivery attendance). More than half (54%, n = 81) were 5 or more years removed from the completion of their residency or fellowship training.

FPDs reported that the majority of their graduated fellows became university-based hospitalists (63%, n = 22), with most graduates practicing on the inpatient wards (97%, n = 34) and newborn nursery (60%, n = 16). FPDs anticipated that 89% (n = 31) of their graduating fellows would have nonclinical duties, with the majority of their time spent on quality improvement (90%, n = 28) and education of medical students (87%, n = 27), residents (77%, n = 24), and PHM fellows (45%, n = 14).

The majority of PHM fellow respondents were from 2-year programs (81%, n = 28). All fellow respondents anticipated working in pediatric wards after graduation, primarily in university-based settings (81%, n = 81). Nearly all anticipated working with learners (94%); 38% anticipated a full-time equivalent supported administrative component to their position.

Hospitalists identified complex care (85%, n = 126), surgical comanagement (60%, n = 89), and pain management (44%, n = 65) as the top 3 clinical electives for PHM career preparation. PHM fellows and FPDs also identified complex care as the most important clinical elective for fellowship preparation (81%, n = 13 and 66%, n = 23, respectively); surgical comanagement was the next most popular choice, selected by 50% (n = 8) of PHM fellows and 40% (n = 14) of FPDs. Other top-rated clinical experiences were pain management, selected by 31% (n = 5) of fellows, and hospice and palliative care, selected by 40% (n = 14) of FPDs. Community hospitalists identified surgical comanagement (83%, n = 5), complex care (67%, n = 4), and procedural skills (67%, n = 4) as important clinical experiences. (Table 1) Hospitalists identified lumbar puncture (95%, n = 142), electrocardiograph interpretation (71%, n = 105), and airway management (69%, n = 102) as critical procedural skills.

Nonclinical experiences judged by hospitalists to be important for PHM career preparation were quality improvement (90%, n = 134), development of teaching skills (75%, n = 112), and research methodology (34%, n = 51). These 3 topics were also considered most important for fellowship preparation: 89% (n = 31) of FPDs and 50% (n = 8) of fellows selected quality improvement, 49% (n = 17) of FPDs and 44% (n = 7) of fellows chose development of teaching skills, and 69% (n = 24) of FPDS and 63% (n = 10) of fellows specified research methodology; grant preparation was also highly rated among fellows (44%, n = 7). (Table 1) Seventy-five percent (n = 12) of fellows deemed PHM-specific mentorship important during residency.

Thematic analysis of open-ended questions highlighted skills and experiences important for PHM-bound residents. Recurring themes included newborn care encompassing newborn delivery and resuscitation experiences, community hospital medicine, and a procedural elective with particular focus on intravenous catheter placements, intubations, and lumbar punctures. Triaging patients from other medical facilities and transport time were also highlighted. Nonclinical experiences in administration, hospital committee involvement, communication, conflict resolution, health care operations, and patient safety were also recommended. Respondents believed that electives and experiences should be adapted to residents’ ultimate practice goals and interests.

Hospital medicine tracks were initially developed to close clinical gaps in training for hospital medicine–bound residents and have now evolved to include development of skills to drive high-value care, process improvement, and scholarship.^11,12  Because there are no current recommendations, the goal of our task force was to query key stakeholders to determine the most beneficial clinical and nonclinical electives for pediatric residents interested in entering PHM. To our knowledge, this initiative represents the first attempt by a national subspecialty group to articulate recommendations for IC since its implementation.

Future hospitalists may choose fellowship or direct entry into the workforce and may work in a multitude of clinical settings. One domain described in the framework for the IC is competence, with the goal to develop targeted clinical skills and knowledge, ensure comprehensive exposure, and address learning gaps.⁴  For residents to have exposure to varied PHM career paths, residency programs should incorporate IC experiences that are recommended by practicing hospitalists. To promote both fellowship and career preparedness, particular consideration should be given to experiences regarded as high-yield across stakeholder groups. Residency programs should offer residents the opportunity to learn about complex care, acute and chronic pain management, surgical comanagement, and hospice and palliative care. Elective experiences that develop skills in quality improvement, education, and research along with to hospital administration are also strongly encouraged.

As with any survey-based research using convenience sampling, participation bias exists. The majority of our respondents practiced in a university-affiliated setting, so our results are not fully representative of the views of PHM members working in a community setting. To improve the generalizability of our results, we targeted hospitalists from multiple settings as members of our subcommittee representing divisions across the country distributed surveys. We sought to maximize survey response rate through repeated reminders. We also recognize we only collected partial evidence to support the validity of our findings: (1) content validity whereby our instrument was informed by the literature and (2) response process: we piloted our instrument for clarity and results informed minor instrument revisions. Another limitation of our study is that stakeholders were not asked to delineate which experiences would better prepare a resident for community versus university-based practice.

Pediatric hospitalists who practice in a community setting make up approximately one-third of the PHM workforce.⁶  Hospitalists in community hospitals are more likely to be called on to provide resuscitative services in delivery rooms, newborn nursery care, and consultations in emergency departments when compared with their counterparts in university-based settings.¹³  This indicates that the clinical scope of practice for community hospitalists may consist of additional skills, including increased focus on neonatal resuscitation and procedures. Given the response demographics, our findings may be more applicable for residents with plans to work in a university setting. However, there is a wide range in clinical practice among both environments, and we did not list all skills that are inherent within the scope of PHM. Residents should be encouraged to choose electives that not only increase their exposure to specific clinical skills but also address their unique interests. Further efforts to survey community hospitalists would be helpful to inform curriculum specific to residents planning to practice in a community setting.

Fellow respondents’ emphasis on the need for mentorship underscores the importance of faculty guidance and relationship building in addition to pursuing suggested electives, and ACGME requirements for the IC specifically state the need for faculty mentor guidance.¹  To be successful, these recommendations need to be supplemented with effective mentorship. Umoren and Frintner¹⁴  found residents with a subspecialist mentor were more likely to have subspecialty career goal at the time of graduation. We anticipate the next steps for our group will be to build on PHM-specific mentorship resources for faculty and residents interested in entering community PHM.

Identification of key clinical experiences, nonclinical activities, and mentorship for residents interested in PHM may assist with customizing the IC in residency. These recommendations, vetted by key stakeholders, present an opportunity to optimize the value of IC. Incorporating these suggested experiences can improve preparedness for entering the field of PHM, whether entering a position directly after residency or pursuing PHM fellowship.