Expanding PHM Fellowships: Current Landscape, Challenges, and Potential Solutions Free

To understand the current training landscape in PHM, it is important to review the history. The term “hospitalist” first emerged in a 1996 article,²  and the first modern PHM fellowship opened nearly a decade later (2005) at Children’s National Hospital.²  By 2013, there were 20 PHM-specific fellowship programs. In October 2016, the American Board of Medical Specialties approved the petition for PHM to be designated as a pediatric subspecialty.³  The practice pathway for American Board of Pediatrics (ABP) certification stipulates that attending physicians meet work-hour requirements for the direct care of hospitalized pediatric patients during a 5-year look-back window and pass the PHM board exam by 2024.¹  Thus, a PHM fellowship became the only pathway toward ABP PHM board certification for those completing pediatric residency training after 2019.⁴  The Accreditation Council for Graduate Medical Education (ACGME) published requirements for PHM fellowship training in September 2019, and the first fellowships received accreditation in January 2020.² 

PHM has consistently been one of the most competitive pediatric subspecialties, with a 67% Match rate in 2020 and 2021 and an 83% Match rate in 2022.⁵  This mismatch between demand from residency graduates and available positions is evident when reviewing the American Academy of Pediatrics Annual Survey of Graduating Residents. Historical data show ∼275 pediatric residents join the PHM workforce every year.⁶  In 2022, there were 122 applicants for the fellowship, which is almost double the number of applicants in 2018.⁵  The PHM community has worked hard to increase the number of available positions, from 44 in 2017 to 104 in 2022.⁷  Although many residents may not choose the fellowship route, the annual increase in fellowship applicants and new board requirements suggest that fellowship spots would need to increase to accommodate the demand.

The challenge in expanding is not only about quantity, but also quality of fellowship spots. To fulfill their responsibility to the field, PHM fellowship directors must ensure that training programs are rigorously designed to graduate individuals who will provide outstanding care to hospitalized children. Starting a PHM fellowship or expanding one is an arduous task that requires securing funding, obtaining adequate full-time equivalent (FTE) for fellowship leadership, ensuring adequate faculty mentors and scholarly output, and providing sufficient patient care experience, particularly at community-based hospital sites.

Graduate medical education (GME) funding is a complex terrain that requires thoughtful navigation, a task that often exceeds the scope of expertise of a pediatric hospitalist.⁸  The cost of training a fellow for 3 years, including salary, benefits, and educational expenditures, is estimated at $250 000,⁹  which is a substantial expense even when scaled down to a 2-year training program. Fellowship directors must petition multiple, often organizationally distinct, sources for funding, including their division directors, pediatric department chairs, and GME department chairs. The process necessitates the creation of a comprehensive business proposal that outlines the anticipated return on investment. However, the unfortunate closure of children's hospitals and financial challenges and uncertainty about funding to support pediatric GME further complicate these discussions.^10,11 

Apart from funding for fellows, financial support for fellowship directors and administrative staff is required. Many PHM fellowships are being built from the ground up, and, although national collaboration helps with the extensive curriculum development required, programs must still define learning goals and objectives, train faculty, identify local mentors and rotation leads, create assessment tools, and complete local GME documentation. The hallmark of PHM is its varied array of clinical and nonclinical opportunities, making it a diverse and rewarding career. However, this diversity presents unique challenges when it comes to providing fellows with a comprehensive range of clinical rotations. To ensure fellows are prepared to practice the full scope of PHM, programs must complete all the steps listed above for each different rotation. Programs must complete this time-consuming process, sometimes before any protected time from clinical duties is available to those involved. Achieving initial ACGME accreditation requires months of planning, research, and documentation.¹²  After accreditation, programs typically undergo a site visit within the next 1 to 2 years, which again involves significant documentation and preparation.

It is worth noting that the minimum FTE required by the ACGME for program leadership (both program directors and associate program directors combined) recently decreased from 0.25 to 0.2 for programs with 4 to 6 fellows.¹³  This change has impacted approximately half of PHM fellowships.¹⁴ 

Identifying faculty members who can offer appropriate mentorship and oversight of scholarly activities is another significant challenge in PHM. Many PHM leaders have not completed a PHM fellowship and may lack experience conducting scholarly activity. Another challenge is the absence of a dedicated National Institutes of Health institute with a specific focus on hospital-based research. Although most pediatric subspecialty fellowships are 3 years in length, PHM fellowship is only 2 years long. Thus, fellows must meet ABP scholarly activity requirements within this shorter period to be eligible for the board exam. Additionally, PHM faculty involved in fellowship programs must themselves demonstrate significant accomplishments in research, peer-reviewed grants, quality improvement/patient safety, publications, innovations in education, creation of curricula, or national leadership.¹³  Smaller programs and those without extensive scholarly infrastructure may struggle to ensure robust faculty mentorship and supervision for fellows given these requirements. Furthermore, effective 2024, ACGME requires that all faculty supervising PHM fellows hold current subspecialty certification in pediatric hospital medicine.¹³  This regulation introduces a limitation on the pool of individuals eligible to oversee fellows.

Community pediatric hospital medicine and newborn care are important components of PHM practice, and the ACGME fellowship requirements therefore include dedicated time in each.¹³  Fellowship directors must ensure that each clinical experience has the appropriate patient load, complexity, and diversity. Unfortunately, the growing trend of pediatric community site closures has made it increasingly difficult for fellowships to provide community experience, with some programs even having to look out of state.¹⁵  The board certification and scholarly requirements for faculty prove even more challenging at community hospital medicine sites, where board certification, grants, and publications have not traditionally been required for faculty.^16,17  Additionally, the ACGME mandates that community sites must have an inpatient pediatric unit, and merely having newborn care or emergency department consultation alone does not fulfill this requirement. Similarly, the responsibility of overseeing newborn care may not always be assigned to PHM board-certified physicians, depending on the historical division of labor at each institution.

Growing PHM fellowships will require careful attention to the above challenges. We propose several potential solutions, again considering the distinctiveness of PHM fellowship compared with other training programs. Please see potential solutions included in Table 1. Increased funding and support are essential for program leadership and trainees alike to increase fellowship positions. Because institutions may use ACGME guidance to determine FTE allocation for fellowship leadership, an increase in the proposed minimum requirements is important.

In addition to funding, national collaboration and advocacy are essential. The PHM Fellowship Directors Council, now the American Academy of Pediatrics Section on Hospital Medicine PHM Fellowship Directors Task Force (Task Force), has been instrumental in supporting PHM fellowship leaders across the country, both as a starting point for new programs and a reference for existing programs. The Task Force designation itself is a solution-in-progress, because it provides formal representation in national conversations around fellowship expansion and facilitates communication with other national organizations.

To address the challenges faced by PHM fellowships, we must explore expansion of the available faculty and reduce limitations on mentors and clinical supervisors. We strongly recommend granting clinical supervision and mentorship eligibility to local leaders such as community hospitalists who may lack board certification but possess a deeper understanding of the system and are better positioned to meet the unique needs of their trainees. Additionally, increased local, regional, and national faculty development around the effective supervision of fellows is essential to cultivate PHM leaders who can support the increased number of trainees.¹³  This includes continued expansion of the faculty development foundation built by the Task Force, with national webinars, monthly virtual and annual in-person meetings, PHM conference workshops, and a shared repository of faculty resources.

By focusing on these solutions and harnessing the collaborative spirit which has long distinguished our PHM community, we remain optimistic that our field will support continued growth of PHM fellowships and help meet the ongoing workforce demand for pediatricians specializing in the care of hospitalized children.

We thank the PHM Fellowship Directors Task Force, formerly known as the PHM Fellowship Directors Council, for the incredible collaborative spirit and support.