Pediatric Hospital Medicine: Cultivating a Sustainable Field Free

Rather than focusing on a single certification for decisions regarding employment, we should instead take a more holistic approach and consider the unique experiences, skills, and aptitudes that allow each of us to positively impact our patients, institutions, and communities. Individuals should not be excluded from institutions solely because of certification status, something that is already starting to occur based on recent postings on pedsjobs.org. Although the additional academic training gained through a PHM fellowship would make those individuals a natural fit for certain academic positions, there are many clinical and nonclinical roles that would be well-served by passionate individuals, regardless of their certification status.

To ensure that non-PHM-certified hospitalists can thrive in every aspect of their work, we need to dedicate effort and resources toward developing those individuals as teachers, leaders, and scholars. There are programs already in place at the national level, including the American Academy of Pediatrics Advancing Pediatric Educator Excellence Teaching Program, the Society of Hospital Medicine Leadership Academy, and the Academic Pediatric Association Quality and Safety Scholars Program, and we encourage all those in our community to consider whether their careers would be advanced by participation in such programs. These same national organizations should also consider how they can form partnerships with hospital systems and each other to provide more opportunities for faculty development for all early-career hospitalists. Institutions and employers likewise should be encouraged to focus on the development of all hospitalists so that those who show an interest in specific nonclinical subjects, such as quality improvement, can gain new skills and broaden their contributions to our field.

The relationship between community-based and university-based PHM programs also deserves attention. We should work toward a spirit of collaboration in which we can leverage the strengths of both settings to improve access to evidence-based pediatric care. Allowing a 2-tiered system to develop that places fellowship-trained hospitalists in university-based settings and non-PHM-certified hospitalists in community-based settings would be counterproductive toward developing these collaborative relationships. Surveys suggest that this separation may be starting to take place, with the majority of fellowship graduates practicing in children’s hospitals and university-based settings.⁵  Fellowship-trained individuals should be encouraged to consider careers in community-based settings and develop partnerships with those institutions to bring research closer to more of our patients and overcome some of the barriers to conducting research in community settings.^1,6  Non-PHM-certified hospitalists, particularly those with experience in community settings, likewise have their own unique perspectives and clinical skills that would benefit university-based programs.⁷ 

Fundamentally, the future of our field and its ability to deliver care relies on well-trained individuals choosing PHM as a career. There are concerns that the lack of PHM fellowship positions could have negative effects on the “pipeline of pediatricians pursuing PHM.”¹  Initial work suggests that the fellowship requirement in PHM is discouraging residents, especially those in med-peds programs, from considering PHM as a career path.^8–10  To continue attracting talented residents to our field, we need to make it clear that fellowship is not the only means of having a long-term, fulfilling career in PHM. As Dudas and Krugman so eloquently stated in their 2022 commentary, “there cannot be a 1-size-fits-all path to becoming a pediatric hospitalist.”¹¹  Mandating additional training could have the unintended effect of driving medical students and residents toward other fields. A smaller workforce would almost certainly hasten the consolidation of inpatient pediatric care that is already taking place, limiting children’s access to care in rural and community settings even further.^12–14  Although it is unknown whether these changes will negatively affect the diversity in our field, this will undoubtedly be an important area of research over the coming years.

There have been many spirited discussions about how the Accreditation Council for Graduate Medical Education’s updated residency curriculum requirements will affect resident proficiency in PHM, with the concern that reduced time in the inpatient setting will produce graduates who are unable to safely perform the duties of a pediatric hospitalist. We can ensure this possibility does not become an inevitability by capitalizing on the time allotted in the individualized curriculum to build PHM-specific tracks within residency that will cultivate the skills necessary to be an effective hospitalist.¹⁵  Guidelines to create such tracks could be conceptualized at the national level with input from key stakeholders (including the American Academy of Pediatrics, Society of Hospital Medicine, and Academic Pediatric Association) and then implemented at the local level based on the availability of institutional resources.

The long-term health of our workforce depends on keeping the members of our field engaged throughout their careers with a relentless focus on physician wellness and ensuring each member of our community feels valued.¹⁶  To allow a system and culture to develop in our institutions that devalues some members of our community could cause irreparable harm to our field either directly, with fewer individuals choosing to join or remain in our field, or indirectly, by contributing to the burnout that leads to higher turnover rates for physicians.¹⁷  Instead, we can help every member of our field, regardless of certification status, feel valued in their work by supporting policies and practices within our institutions that help everyone grow and develop as physicians.

Because career satisfaction has been positively associated with career longevity in PHM,¹⁸  we should also seek a greater understanding of what motivates the members of our field and how the elements that affect career satisfaction vary between individuals and practice settings.^19,20  Some may find the most fulfillment in providing care at the bedside, whereas others may instead find the most satisfaction in interactions with trainees. By providing all of the members of our field the opportunity to explore their interests and passions, we will be better able to sustain a workforce aligned with its core value:¹⁷  to provide exceptional care to every child.

PHM is a community in which every individual can make their own unique, but important, contribution toward our common goal of improving the health of children. It is vital for the future of our field, and most importantly the children we care for, that we secure buy-in from every individual, institution, and national organization to commit the resources needed to nurture an inclusive community in which every member, regardless of certification status, can participate fully. Although many of these changes will take time and resources to implement, each of us today can take the first, but by no means small, step toward realizing that future by affirming the worth of non-PHM-certified hospitalists as full and equal members of our field.

We wish to thank the editorial staff of Hospital Pediatrics for inviting us to submit this commentary.