Key Motivators to Build a Stronger cPHM Workforce

We commend Jackson et al, for continuing to explore what motivates pediatricians to choose a career in community pediatric hospital medicine (cPHM) and, ultimately, to stay or leave it. cPHM is a field that is diverse in its scope of practice, program size, access to resources, and geography.¹  It is a critical component of pediatric health care that provides high-value care to hospitalized children and newborns. The authors of recent publications continue to show that the majority of hospitalized children in the United States will be cared for in a community hospital.^2,3  However, despite the necessity of cPHM, individual programs are often at risk of closure, which places the entire field at risk. The results of the current study highlight the importance of cPHM and how we can develop and sustain programs at this critical access point for children. As community pediatric hospitalists, we will add our perspective on these topics and future areas of research to support this field.

This study builds on previous qualitative data that were referenced with a larger cohort and quantitative analysis.⁴  The data reveal that lifestyle factors are key motivators when choosing cPHM as a career and retaining a satisfied workforce.^4,5  The top motivating factors for cPHM include work–life integration, location, and flexibility. However, this study cannot clarify what these factors might mean to an individual as they choose their career. As the adage goes, “if you have been in one community hospital, you have been in one community hospital.” The most recent source of data on cPHM sites was collected via a survey conducted in 2014,^6,7  which is almost 10 years old and has likely changed for various reasons ranging from regionalization to coronavirus disease 2019. We would like to see more specific data built from this work to potentially understand how specific lifestyle factors may influence hospitalists’ choices and the ways in which they select locations for their jobs. As the authors point out, highlighting these factors could be helpful in developing recruitment and retention strategies. The development of a pediatric hospital medicine (PHM) dashboard that includes information on these factors could help to match hospitalists with programs that support them.

The article reveals that those who choose this field find it to be a rewarding career choice. The authors identify general themes that guide people, such as location and scope of practice. The authors of future studies could delve deeper into a few of these areas, such as what factors about location make it important. One of us (KM) chose her program because she was from that area, and the position in her program was created for her. However, for others, location may be important because they want to be near a city or a particular region of the country, etc. Although it may be difficult to build a strategy around location because it is a personal factor, understanding the intricacies of motivators is beneficial when designing a recruiting plan. Another theme was scope of practice as a motivating factor. Previous studies have revealed that scope of practice can be a motivating factor to stay in cPHM,⁴  whereas the current study revealed that a motivating factor was to transfer to an academic institution. The significant variability between community hospital programs makes it challenging to understand how these themes impact retention and recruitment, and future study is needed to better use the information presented in the article.

We found it surprising that the data revealed that respondents interested in research and quality improvement (R/QI) are more likely to plan to transition to academia because research networks are now vying for cPHM participants. National quality initiatives via groups such as the American Academy of Pediatrics Value in Inpatient Pediatrics and Pediatric Research in Inpatient Settings have revealed that offering mentorship and utilizing these types of networks has been successful. This raises the question of whether this motivation to transition is due to candidates not being introduced to projects or a lack of administrative infrastructure to join them. Community hospitals often have limited ability to support academic projects that require time, information technology support to obtain data from the electronic medical record, institutional review boards, and grant support staff. Whereas academic centers often have students, residents, and fellows who can help perform this work, in the community, R/QI work falls to a small group of physicians who often have multiple roles both clinically and administratively within their program. Advocating for protected time to participate in R/QI activities would likely help retain those who are contemplating a transition out of cPHM. This demonstrates a potential area for growth in cPHM but also a need for more information on the barriers to joining these projects. Further efforts to improve cPHM recruitment and retention need to include advocacy within PHM as a whole to support the development of cPHM networks that can remove the barriers to R/QI participation.

We also think that the timing of this survey makes a difference in the interpretation of the results because the survey was distributed shortly after the first PHM certification examination. The authors comment on the distribution of the data population across experience levels in cPHM; however, the majority of respondents are mid- to late-career hospitalists who could use the practice pathway for certification. Indeed, most respondents either passed or planned to take the certification examination, and younger hospitalists were more likely to consider transitioning to an academic center. The authors note an interesting finding in their survey: the majority of those who were currently practicing cPHM, even if cPHM was not their original career choice, planned to stay in cPHM. This further supports the idea that cPHM is a rewarding career and increasing exposure to cPHM during training may facilitate choosing cPHM as a career.

Increasing cPHM exposure during residency and PHM fellowships can have other benefits for both trainees and hospitalists. Community hospitals often have fewer pediatric subspecialists and lower volumes of trainees, offering trainees an opportunity to have more autonomy and more direct patient care.⁵  According to current Accreditation Council for Graduate Medical Education recommendations, only 4 weeks of cPHM are required during PHM fellowship.^8,9  Given the potential for scholarly activity in cPHM and increased clinical training, we strongly feel that this should be increased. One of the authors (JM) has been a pediatric hospitalist in a community hospital that was an integral component of a PHM fellowship. In this program, PHM fellows performed ∼50% of their clinical duties at the community site, and community faculty members were part of the fellowship core faculty. This cPHM experience broadened the scope of practice for fellows and allowed hospitalists to remain academically engaged. Engagement with academic programs and trainees can provide opportunities for hospitalists in the community who want to maintain an academic affiliation, which may help to retain hospitalists who would otherwise transition into academic settings. Respondents to the survey who were considering transitioning to a freestanding or university-based children’s hospital indicated that mentorship and teaching were the most significant reasons for their choice. Although we also acknowledge that working with trainees may not be seen as a benefit for everyone, the potentially symbiotic relationship between cPHM and pediatric training would benefit the future of cPHM by connecting pediatric residencies and PHM fellowships to establish a pipeline for this rewarding career. Bridging the gap between academic and community hospital medicine can enhance clinical training, reinforce R/QI opportunities, and improve job satisfaction for those who want a balance between community and academic hospital medicine.

Two factors not addressed in this study are respondents’ sense of job stability as a motivating factor, and the impact of fellowship training on career choice. The field of cPHM is shifting because of changes in the health care system, and pediatric unit closures are increasingly common.^10–12  Although those units with low volumes or those without an onsite PICU are at risk, the last year’s respiratory virus epidemic revealed the importance of having cPHM programs that are able to quickly and effectively increase capacity when needed. At the same time, we do not have enough information on the impact of fellowship on cPHM. The increase in fellowship-trained hospitalists, and the perception that fellowship is needed for a career in PHM, may decrease the perceived value of cPHM. The potential stigmatization of cPHM and concerns about job stability could result in shortages of pediatric hospitalists in the community. Without a sustainable pipeline of future hospitalists, there will be fewer resources to support pediatric communities when needed.

This article highlights the need to consider various approaches to measure factors affecting community hospitalists and understand their overall association with outcomes. These findings suggest key areas for future research. This novel data on motivators in cPHM builds on previous data, illustrating that continued study is crucial to recruit, retain, and build our community workforce. Although this data provides a valuable foundation, they are only a starting point. Further research and data are necessary to delve deeper into the unique challenges of cPHM. We appreciate this work and hope that it will lead to continuous collaborative efforts to ensure the viability and growth of cPHM because it is so impactful to the communities they serve.