How Should Pediatric Residents Prepare for a Career in Pediatric Hospital Medicine? Free

Recently, the American Academy of Pediatrics Section on Hospital Medicine Subcommittee of Pediatric Hospital Medicine (PHM) educators created a task force to develop a resident-focused PHM curriculum. In this issue of Hospital Pediatrics, Patel et al¹  present their findings from a needs assessment survey that was undertaken as part of the work of their task force. The authors surveyed practicing pediatric hospitalists, PHM fellowship program directors, and graduating PHM fellows to understand what skills and experiences were most needed during residency to become a hospitalist. The majority of the 200 respondents were not fellowship trained, and most worked in a free-standing children’s hospital (FCH). The top 3 clinical electives they recommended for completion during residency included complex care, surgical comanagement, and pain management. They noted that nonclinical experiences should include quality improvement, teaching skills and research methodology. What is noteworthy of the respondents is that only 4% identified as community hospitalists. Given these demographics, we have to wonder if the opinions from a larger number of community hospitalists on what was most important in residency may have been different, especially given the distribution of hospitalized children and pediatric hospitalists in the United States.

Each year there are approximately 2 million pediatric hospitalizations, of which only a minority (30%) occur in a FCH with the remainder dispersed across more than 3000 general hospitals (GH) with considerable heterogeneity in pediatric volumes, services, and resources.²  As a result, pediatric patient populations differ significantly between settings with regard to patient volumes, diagnoses, medical complexity, and severity of illness. Additionally, some GH may have such low pediatric volumes that they risk closure.³  As 1 possible solution some GH may combine several hospital-based pediatric services to compensate. For example, some GH combine or share resources with the emergency center^4,5  or nursery,⁶  whereas others may choose to limit pediatric hospital services to newborn care only.⁷  It is worth mentioning the additional classification of non-free-standing children’s hospitals located within general hospitals. These hospitals also range in size and scope with some more closely resembling FCH, whereas others face similar challenges to large community hospital inpatient units.

This heterogeneity in patient populations is similarly reflected in the types of providers caring for these patients. In 2015, the American Board of Pediatrics approved PHM for subspecialty status to train future hospitalists to care for hospitalized children in a variety of clinical settings. The Society of Hospital Medicine defines hospitalists as “clinicians who engage in clinical care, teaching, research, and or leadership in the field of general hospital medicine.”⁸  Whereas this definition seems pretty straightforward, it is actually problematic. For example, some physicians may exclusively care for hospitalized children without having the necessary teaching, research, or leadership responsibilities. Or, some may only care for a select subset of hospitalized children or provide care in clinical areas outside the inpatient setting. It is also generally accepted that hospitalists possess expertise in quality improvement methodology as well as an understanding of health care delivery systems, which is not well-captured by that definition.

Generally, in a free-standing children’s hospital the definition and role of a hospitalist is straightforward, although it may be highly subspecialized (eg, surgical hospitalist). However, in community hospitals it is much murkier with pediatric hospitalists having vastly different roles across sites requiring different skills. Two common examples are critical care skills and newborn care. In FCH critical care, expertise is generally readily available by board-certified critical care physicians. However, GH pediatric units are much less likely to have subspecialty care readily available, and the available hospitalist frequently leads the code team and is asked to provide critical care while awaiting transfer to a hospital with a higher level of care. Additionally, management of infants in well newborn nurseries may comprise a much larger proportion of effort for community hospitalists as compared to FCH hospitalists.

In addition to different roles, it is highly unlikely that all children hospitalized at FCH and GH are cared for by hospitalists. Conservative estimates have suggested that the number of pediatric hospitalists is approximately the same as the number of general hospital pediatric inpatient units (1500–3000) but pediatric hospitalists aren’t equally distributed in GH and FCH across the country.⁹  There are clearly many more physicians needed to provide care for those in community hospitals. But who are they? And what do we call them? It is difficult to know. In fact, very little is known about inpatient pediatric care delivered in GH. Community hospital medicine is the blind spot of PHM research, and the current report is just 1 example of the bias toward FCH present in PHM research.

The time is now to ensure that PHM research is expanded to include community hospitals.¹⁰  To prepare future pediatricians to care for all hospitalized children we need to know more about the care provided in all settings. While there are databases, such as the Kids Inpatient Dataset (KID), and National Inpatient Sample (NIS) that include community sites, they are not ideal, especially for research in pediatric outcomes and quality measures as reflected by the paucity of literature in these areas.¹¹  Community hospitals generally lack the infrastructure to contribute to research efforts and community hospitalists are seldom afforded time, salary or resources to conduct research. As a result, there are many unknowns about PHM occurring in community hospitals. What are the necessary clinical skills in a community hospital setting? What are the clinical outcomes for children?

One potential path forward would be for academic centers to partner with more community hospitals. Alternatively, community hospitals could create networks or partnerships that cross healthcare systems and regions. Most importantly, the care of children in community settings needs to be valued not just by the PHM research community, but by the general hospital systems across the country. More often than not, pediatric services are devalued at general hospitals because they are not profitable and are reliant on the good will of a mission-driven not-for-profit hospital or system. As such, whereas adult medicine is afforded scores of data analysts and population health managers, in a general hospital setting pediatrics is often left behind with no ability to gather the data needed to make the best decisions for children in hospital settings.

PHM is a new “ish” field, so it is not surprising that it is both dynamic and heterogeneous. Compared to all other pediatric specialties it is likely that the least is known about this newest subspecialty. We do not have (and are unlikely to develop) 1-size-fits-all definitions for PHM and pediatric hospitalists. And thus, there cannot be a 1-size-fits-all path to becoming a pediatric hospitalist. The fellowship pipeline will never be able to meet the clinical needs of hospitalized children nationally in all settings because there are currently <80 available training spots available annually. Furthermore, approximately 10% of recent graduates have stated that they intend to become hospitalists, although the recent development of fellowships may actually discourage some from doing so.¹²  As is true for pediatric emergency medicine, the majority of inpatient care will continue to be delivered by physicians without fellowship training. And whereas Patel et al¹  offer some suggestions to residents and their programs as to how best use their time during training, an even better approach may be for a resident to identify the specific type of hospital-based position they seek and then select electives that match those needs.

The field of pediatric hospital medicine and those who practice it are a tremendously heterogeneous group. For residents who seek to work as hospitalists in a FCH, choosing clinical electives focusing on medically complex children, surgical comanagement, and pain management are reasonable as suggested by this task force. For residents who seek employment in 1 of the thousands of community hospitals, it would be of interest to replicate this study by surveying only community hospitalists and GH stakeholders. But until then, the best advice would be for residents to identify a specific setting to determine the most relevant skills including those that foster lifelong learning skills. We hope this also sparks a larger conversation about the need to expand PHM research into the community setting.