The loss of pediatric beds in the community has contributed to decreased access to pediatric inpatient and emergency services. Community pediatric hospitalist programs could reduce the overhead of inpatient care, promoting the financial feasibility of caring for hospitalized children closer to home. This study aims to determine which career motivators are the most important for pediatric hospitalists to begin working in, remain in, and leave the community setting.
A survey was sent to a convenience sample of 269 community hospitalists from 31 different sites. Sites were invited if the program director was known to the authors. Responses were evaluated and χ-square or Fisher’s exact test were used to compare the differences.
One hundred twenty six community pediatric hospitalists completed the survey (response rate 49.1%). The 3 most important motivators for pediatric hospitalists to begin working in the community were work-life integration (80%), geographic location (75%), and flexible hours (71%). Pediatric hospitalists who planned to leave the community setting were more likely to cite mentoring and teaching opportunities (76% vs 32%, P = .0002), opportunities for research and quality improvement (29% vs 10%, P = .021), and paid time for nonclinical interests (52% vs 26%, P = .02) as very important.
This study demonstrates key motivators for pediatric hospitalists to work in the community and elucidates motivators for transitioning to larger pediatric centers. This knowledge may be used to guide community pediatric hospital medicine recruitment and program development that could lead to improved retention.
Community hospitals are essential in caring for children, accounting for 60% to 75% of pediatric hospitalizations in the United States.1,2 Recently, closures of pediatric inpatient units have increased, and there has been a movement toward the regionalization of pediatric healthcare. Between 2008 and 2018, pediatric inpatient units decreased by 19.1% (34 U per year), and pediatric beds decreased by 11.8% (407 beds per year).3 Despite these closures, there are important and impactful reasons to maintain pediatric hospital medicine (PHM) serving the community. Because of these closures, nearly one quarter of children in the United States are experiencing increased distance to their nearest pediatric inpatient unit, with rural areas being most affected.3 Children also have decreased access to emergency care from a pediatric specialist, resulting in a near 25% increase in interhospital transfers.4 The reasons for these closures are multifaceted but often include financial considerations,5 as pediatric units are suboptimally reimbursed and often minimally profitable.6
Although the finances are complex, community PHM provides significant benefits for children, their families, and the healthcare system in general. Having dedicated pediatric hospitalists (as opposed to inpatient management by outpatient pediatricians) has been shown to decrease length of stay and cost of admission for commonly admitted diagnoses.7 Pediatric hospitalists are also more likely to report using evidence-based guidelines when caring for hospitalized children.8 According to Alvarez et al, 89% of community hospitalist programs provide pediatric consults in the emergency department,9 and therefore could potentially decrease unnecessary and costly transfers.10 Additionally, it has been shown that community PHM programs can improve their finances by adding emergency department and nursery coverage to their responsibilities.11,12 Community pediatric hospitalists also participate in national quality improvement initiatives, which are essential for improving the care of all hospitalized pediatric patients.13
One of the challenges of maintaining a community pediatric hospital medicine (CPHM) program is recruitment and retention. Most residency graduates who enter PHM choose to work at a tertiary care center.14 Additionally, pediatric hospitalists who work at an “academic” medical center are more likely to report job satisfaction than those who work in the community.15 This is particularly relevant as career longevity in PHM has been linked to job satisfaction,16 and recruitment efforts are costly.17 It is imperative that we understand what draws people to careers in CPHM so we can focus efforts on recruiting pediatric hospitalists interested in serving the community and building sustainable CPHM programs. Little has been done to explore motivators for pediatric hospitalists to work in the community. Building on a prior exploratory study,18 this study aimed to (1) determine the most important factors for physicians to start working in CPHM, and (2) identify the most important factors for physicians to remain in CPHM.
Methods
Survey Development
We conducted a cross-sectional survey-based study to evaluate motivating factors for pediatric hospitalists to work in the community. The survey was designed by 3 investigators with significant experience and various roles in PHM using self-determination theory19 as a conceptual framework. Specific questions were developed based on preliminary qualitative research done by the same authors.18 The Survey Laboratory at 1 of the author’s home institutions revised the questions to ensure adherence to best practices for questionnaire design. Five practicing community pediatric hospitalists reviewed the survey via cognitive think-aloud. The investigators and Survey Laboratory collaborated on all revisions through an iterative process. The survey was programmed into the Qualtrics online survey platform.
The survey consisted of 4 sections (Supplemental Fig 4). These sections asked questions regarding important motivators to enter CPHM, 5-year career plan and most important factors in creating that plan, questions related to coronavirus disease 2019 (COVID-19) (not included in this study), and demographic characteristics. When asked to rank the importance of factors, a 3-point Likert scale (very important, somewhat important, not important) was used for participant convenience and adaptability to mobile platforms. To better quantify the importance of each factor in entering CPHM, participants were presented with the factors they deemed “very important” and asked to choose the 2 most important factors. The study was deemed Institutional Review Board-exempt by the institutional review board at the principal investigator’s institution.
Sampling Strategy
A convenience sample was recruited through direct communication with site leads at community pediatric hospital programs known to the authors. Consideration was taken to ensure a similar number of programs were invited in each geographic region. In regions where relatively more site leads were known to the authors, those who were thought more likely to participate were approached. To be included in the study, participants dedicated at least 50% of their clinical time to the care of pediatric patients in a US community hospital. Each site lead identified physicians in their group who met inclusion criteria. They subsequently chose to provide the e-mail addresses of those hospitalists to the Survey Laboratory for direct disbursement of a survey link or act as an intermediary to deliver anonymous links to the participants at their site.
Data Collection
Initial invitation emails were sent on March 10, 2021, either by the survey laboratory with a direct link to the survey or via the site lead with an open link. Links sent by the survey laboratory were unique to the individual and the survey could be re-entered. Open links could not be re-entered and were more likely to result in partial completion. Reminder emails were sent to the direct link group from the Survey Laboratory and site leads of the intermediary group in 1 to 2-week intervals until reminders produced completion of only 1 additional survey. The survey was closed on April 24, 2021, and data were compiled by the Survey Laboratory. In total, 269 survey links were distributed from 31 unique sites. Survey participants remained anonymous.
Statistical Analysis
The data were analyzed using Statistical Analysis Software, version 9.4 (SAS Institute Inc., Cary, NC, USA). Descriptive statistics are reported as total number and percentage. The χ-square or Fisher’s exact test were used as appropriate to test group differences of proportions. Statistical significance was defined as a P value of <.05.
Results
Leaders from 23 programs across the United States (13% Northeast, 36% Midwest, 26% South, 26% West) provided e-mail addresses for 147 participants, whereas 8 site leads directly distributed the link to 122 participants. There were 126 completed cases and 6 partial cases. Two partial cases were from the direct e-mail link group, and 4 were from the open link group. Of the completed cases, 71 were direct e-mail and 55 were open link (Fig 1). The direct e-mail link cases had a response rate of 49%, and the intermediary group had a response rate of 48% for a combined rate of 49.1%.
Demographics
Participants were diverse in gender, age, geographic location, hospital setting, and years of experience (Table 1). Ninety-three percent initially wanted to work in PHM, with 73% of these preferring to work in the community. Fewer than half of participants held a leadership role in their current position. Three participants (2%) had completed a PHM fellowship. Twenty-five percent of participants were board certified in PHM, whereas 22% of participants were not board-eligible or did not plan to take PHM boards.
Demographic Characteristic . | Variable . | N (%) . |
---|---|---|
Gender | Male | 26 (20) |
Female | 100 (79) | |
Other | 1 (1) | |
Age | 40 y or younger | 69 (54) |
41–50 y | 37 (29) | |
Greater than 50 y | 21 (17) | |
Years in PHM | 0–5 | 52 (41) |
6–10 | 34 (27) | |
Greater than 10 | 41 (32) | |
Years in CPHM | 0–5 | 60 (47) |
6–10 | 30 (24) | |
11+ | 37 (29) | |
Geographic Location | Midwest | 62 (49) |
Northeast | 14 (11) | |
South | 13 (10) | |
West | 38 (30) | |
Hospital Setting | Rural | 17 (13) |
Suburban | 86 (68) | |
Urban | 24 (19) | |
Distance to closest university-based or free-standing children’s center | <20 miles | 43 (34) |
20–50 miles | 43 (34) | |
51–100 miles | 23 (18) | |
>100 miles | 18 (14) | |
Hold a leadership role in current job | Yes | 52 (41) |
No | 75 (59) | |
PHM fellowship graduate | Yes | 3 (2%) |
No | 124 (98) | |
PHM board certification status | Passed | 32 (25) |
Board eligible by 2023, probably or definitely will take PHM boards | 66 (52) | |
Board eligible by 2023, probably or definitely will not take PHM boards | 11 (9) | |
Not board eligible by 2023 | 17 (13) | |
Did not respond | 1 (1) |
Demographic Characteristic . | Variable . | N (%) . |
---|---|---|
Gender | Male | 26 (20) |
Female | 100 (79) | |
Other | 1 (1) | |
Age | 40 y or younger | 69 (54) |
41–50 y | 37 (29) | |
Greater than 50 y | 21 (17) | |
Years in PHM | 0–5 | 52 (41) |
6–10 | 34 (27) | |
Greater than 10 | 41 (32) | |
Years in CPHM | 0–5 | 60 (47) |
6–10 | 30 (24) | |
11+ | 37 (29) | |
Geographic Location | Midwest | 62 (49) |
Northeast | 14 (11) | |
South | 13 (10) | |
West | 38 (30) | |
Hospital Setting | Rural | 17 (13) |
Suburban | 86 (68) | |
Urban | 24 (19) | |
Distance to closest university-based or free-standing children’s center | <20 miles | 43 (34) |
20–50 miles | 43 (34) | |
51–100 miles | 23 (18) | |
>100 miles | 18 (14) | |
Hold a leadership role in current job | Yes | 52 (41) |
No | 75 (59) | |
PHM fellowship graduate | Yes | 3 (2%) |
No | 124 (98) | |
PHM board certification status | Passed | 32 (25) |
Board eligible by 2023, probably or definitely will take PHM boards | 66 (52) | |
Board eligible by 2023, probably or definitely will not take PHM boards | 11 (9) | |
Not board eligible by 2023 | 17 (13) | |
Did not respond | 1 (1) |
Motivators to Start Working in the Community
Greater than 50% of the respondents noted the following areas as “very important” motivating factors for them to start working in a community hospital: work-life integration (80%), geographic location (75%), flexible hours (71%), feeling valued as a member of the local and/or hospital community (61%), work in a variety of inpatient settings (55%), salary (53%), benefits package (53%), support from subspecialists (52%), and sense of belonging to the local or hospital community (50%). The most frequently cited as 1 of the 2 most important motivating factors in choosing to enter CPHM were work-life integration (34%), geographic location (27%), flexible hours (21%), average daily census (21%), and work in various hospital settings (20%) (Fig 2).
Career Plans for Community Pediatric Hospitalists
Of the respondents, 66% planned to continue working in a community hospital for at least 5 years, and 16% planned to transition to a stand-alone or university-based children’s hospital during that time. The remaining participants planned to enter a PHM fellowship, pursue a different area of pediatrics, retire, or “other” (Table 2). Free text responses to the “other” category could be categorized into undecided, look for a hybrid model of community and university-based medicine, and transition to a role with more leadership and mentoring responsibilities. Pediatric hospitalists who initially preferred to work in the community were more likely to plan to stay in CPHM for the next 5 years (88% vs 61%, P = .001).
5-y Career Plan . | Respondents (%) . |
---|---|
Continue CPHM | 85 (66.4) |
University-based or stand-alone children’s hospital | 21 (16.4) |
PHM fellowship | 1 (0.8) |
Different area of pediatrics | 1 (0.8) |
Retire | 5 (3.9) |
Other | 15 (11.7) |
Total | 128 (100.0) |
5-y Career Plan . | Respondents (%) . |
---|---|
Continue CPHM | 85 (66.4) |
University-based or stand-alone children’s hospital | 21 (16.4) |
PHM fellowship | 1 (0.8) |
Different area of pediatrics | 1 (0.8) |
Retire | 5 (3.9) |
Other | 15 (11.7) |
Total | 128 (100.0) |
Motivators to Continue in the Community or Transition to a University-based or Stand-alone Children’s Hospital
The 5 most important factors for physicians to continue working in CPHM were lifestyle factors (flexible hours, work and life integration, geographic location) (88%), sense of belonging and feeling valued (81%), scope of practice (variety of inpatient settings, acuity and complexity of illness, procedures, patient volume, and subspecialist support) (63%), salary (51%), and benefits (50%). The 5 most important factors for transitioning to a university-based or stand-alone children’s hospital were scope of practice (81%), mentoring and teaching opportunities (76%), sense of belonging and feeling valued (71%), paid time for nonclinical activities, such as research or education (52%), and lifestyle factors (48%).
There was statistical significance between the groups in the importance of 4 of the motivating factors. Physicians who planned to stay in CPHM were more likely to list lifestyle factors as very important (88% vs 48%, P = .0001). Practicing community pediatric hospitalists who planned to transition to a university-based or free-standing children’s hospital were more likely to rank the following as very important: mentoring and teaching opportunities (76% vs 32%, P = .0002), research opportunities (29% vs 10%, P = .021), and paid time for nonclinical activities (52% vs 26%, P = .02) (Fig 3).
Demographic Factors Associated With Plan to Continue in CPHM
Younger respondents were less likely to plan to continue working in CPHM for the next 5 years relative to older participants (68% less than or equal to 40 years versus 90% of those 41–50 years and 100% of those 51 years or older, P = .003). There was no difference between participants who plan to continue working in CPHM and those who plan to leave for a position at a stand-alone or university-based children’s hospital with respect to the following demographic characteristics: gender, current position at a hospital affiliated with a stand-alone or university-based children’s hospital, hospital setting (rural, suburban, urban), or holding a leadership role at the participant’s current job.
Variation in CPHM Motivators by Demographic Characteristics
The career motivators of participants who planned to remain in CPHM for at least 5 years were evaluated by demographic characteristics. Of the 9 motivators evaluated, only lifestyle factors were statistically different between male and female respondents (very important to 92% of females and 74% of males, P = .029). With respect to age, pediatric community hospitalists who planned to remain in the community were more likely to indicate that benefits are a very important factor if they were 41 to 50 years old (36% less than or equal to 40 years old, 71% of 41–50 years old, and 47% of 51 years or older reported benefits to be a very important factor, P = .015). Among pediatric hospitalists who plan to continue working in the community, there were no statistically significant associations between number of years in CPHM and any of the motivating factors.
Discussion
To the best of our knowledge, our data are the first to quantitatively study factors that motivate pediatric hospitalists to start and continue working in the community setting. We found that geographic location, work-life balance, clinical factors, and salary and benefits were the most important motivators for pediatric hospitalists to start working at community hospitals. The same factors were important motivators for pediatric hospitalists to remain working in the community along with a sense of belonging and feeling valued.
Optimizing motivators for community pediatric hospitalists may improve recruitment and retention by increasing engagement and decreasing burnout.20–22 Although the ideal work-life integration varies by person, work schedule and geographic location play a significant role in maintaining this balance. Allowing for job sharing, considering time off requests, and offering nocturnist and weekend positions may be beneficial.23 Additionally, highlighting the strengths of the community, such as local attractions, access to nature, cost of living, safety, and quality of the school districts could impact recruitment.
Based on our survey results, it is important for community pediatric hospitalists to feel as though they are valued members of the community. In the pediatric unit, this could mean creating a consistent and well-rounded pediatric care team, as contributing to a team has been shown to decrease turnover intention in the hospital setting.24 Within the larger hospital, encouraging relationship development with physician peers in other subspecialties is another way to nurture a sense of community. Providing support for physicians from various specialties to meet in small groups to focus on mindfulness, reflection, and shared experiences has been shown to increase engagement and decrease depersonalization.25,26
Over 50% of respondents in our study listed salary and benefits as very important motivators to start and continue working in a community hospital. When rural hospitals are financially able, offering a salary that is 5% to 10% higher than in major metropolitan areas is often practiced.27 Although maintaining a higher salary may not always be feasible, other financial draws for physicians could include 1-time signing bonuses and education loan repayment packages.27
Overall, the surveyed community pediatric hospitalists plan to continue their careers in CPHM. Over half of the participants who did not initially want to work in CPHM now plan to remain in the field for at least 5 years, suggesting that exposure to the community setting contributes to the hospitalists’ dedication to it. Increasing interest in joining the CPHM workforce could rely on exposure during pediatric residency and PHM fellowship. The 2022 Accreditation Council for Graduate Medical Education mandates that PHM fellows get 4 weeks of exposure at a community hospital site.28 Pediatric residents do not have a community hospital requirement.29 A survey sent to members of the Association of Pediatric Program Directors in 2019 demonstrated that community hospital rotations were required for residents at only 24% of the respondents’ institutions and were not even offered at 48%.30 To increase trainee exposure, community hospitals could offer CPHM rotations with nearby residency or fellowship programs or establish housing options for visiting learners from more distant programs. This would allow residents and fellows to experience CPHM and build the unique skillsets that it requires, whereas the community hospital would develop relationships with potential candidates.
A small subset of our study population planned to leave CPHM for a university-based or stand-alone children’s hospital. These pediatric hospitalists were more likely to cite mentorship, teaching, research, quality improvement projects, and paid time for nonclinical interests as very important career motivators. This is consistent with previous publications about career satisfaction in pediatric hospitalists.31 To recruit and retain physicians who identify these as motivators, leadership must develop an infrastructure that supports them. One possible solution for this is forming partnerships with major pediatric centers. This could provide community pediatric hospitalists with access to mentors and resources, allowing them to participate in teaching and research. Clinically, these partnerships could include service time at the larger center or teaching opportunities with resident rotations at the community hospital. University-based hospitals would benefit from a broadening of their research population and an increased breadth of curriculum for trainees who rotate at the community site.
In situations where a university partnership is not feasible, it may be possible for community hospitals to participate in quality improvement projects. A systematic review demonstrated that quality improvement projects can produce financial benefits that justify their costs.32 Funding quality projects and possibly creating a formal quality leadership role with dedicated time for this pursuit may benefit both leadership and community hospitalists.
It is clear that community pediatric hospitalists value and find satisfaction in their career niche. As community hospitals aim to recruit and retain exceptional hospitalists, it is important that they target their efforts on high-yield interventions. This study provides a foundation for future research on potential interventions.
There were some limitations to this study. First, a convenience sample was used. Given the exact number of practicing CPHM physicians and the demographics of that cohort are unknown, we cannot verify this is a representative sample. However, 79% of our respondents were female, which is similar to the 69% of female pediatric hospitalists estimated to make up the entire PHM workforce.33 Additionally, participants were recruited from community PHM programs across the continental United States and varied in practice setting, distance from free-standing or university-based children’s hospitals, and size. This variation in program size likely contributed to a larger number of respondents from the Midwest and perhaps suburban areas. It is possible that certain data, such as each participant’s plan to remain in or leave CPHM, may have more to do with satisfaction at those large programs than commitment to CPHM. However, we further identified motivating factors for remaining in or leaving the community setting, which should mitigate this limitation. Finally, this survey was administered at a unique time. Data were collected during the COVID-19 pandemic when patient volumes were low, salary was often reduced, and there was some amount of job uncertainty in CPHM.34 In addition, most participants either were or would be eligible for PHM board certification through the practice pathway. It remains unclear if and how PHM board certification will affect the field and its workforce. Future studies should focus on further exploring several motivators, including geography, as well as changes in career motivators as the next generation of pediatric hospitalists, both fellowship-trained and nonfellowship trained, emerges.
Conclusions
The majority of community pediatric hospitalists who participated in this survey emphasized clinical and lifestyle factors as reasons to enter into and remain in the field of CPHM. Focusing on these aspects when hiring and keeping these factors in mind as programs develop may help with successful recruitment and retention of qualified physicians. Additionally, community PHM programs may improve their retention by forming relationships with university-based programs and focusing on quality improvement.
Acknowledgments
We thank the site leads for the distribution of the survey and The University of Chicago Survey Laboratory for guidance on the wording, ordering, and formatting of survey questions, as well as support for data collection operations.
Drs Jackson, Marek, and Fromme conceptualized and designed the study, recruited survey participants, and critically reviewed the final manuscript; Dr Jackson drafted the initial manuscript and worked with the University of Chicago Survey Lab to coordinate and conduct data collection; and Mr Yildiz performed statistical analysis and drafted the statistical analysis section of the manuscript.
COMPANION PAPER: A companion to this article can be found online at https://www.hosppeds.org/cgi/doi/10.1542/hpeds.2023-007492.
FUNDING: Internal divisional funding was provided from one of the author’s institutions for survey laboratory support and from another of the author’s institutions for statistical support.
CONFLICT OF INTEREST DISCLOSURES: The authors have no conflicts of interest relevant to this article to disclose.
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