BACKGROUND AND OBJECTIVES:

Within the field of pediatric hospital medicine, physicians can choose to work at community-based or university-based centers. The factors that motivate pediatric hospitalists to work specifically at community sites have not yet been fully explored. Our objective with this study was to elucidate the motivators for pediatric hospitalists to begin and continue work at community sites.

METHODS:

A qualitative study was performed via phone-based focus groups. Physicians were included if they were able to attend 1 of the offered group sessions and they self-identified as spending the majority of their time working as community-based pediatric hospitalists. Data were analyzed through a constant comparative analysis.

RESULTS:

Five themes emerged regarding factors that motivate pediatricians to begin and continue their careers as hospitalists in the community. The themes were (1) professional impact, (2) scope of practice, (3) personal and professional satisfaction, (4) community involvement, and (5) job availability.

CONCLUSIONS:

This study reveals the key factors that motivate community pediatric hospitalists to begin and continue working in the community.

In 1999, the American Academy of Pediatrics recognized pediatric hospital medicine (PHM) as a discrete area of practice.1  The American Board of Medical Specialties officially recognized PHM as the newest medical subspecialty in 2016,2  with plans for accreditation of fellowships and the first board certification examination in 2019.3  In addition to clinical excellence, the focus of PHM includes leadership in quality improvement and research.4 

Pediatric hospitalists are needed to care for children in both general hospitals and freestanding children’s hospitals. Authors of previous studies have shown that graduating residents and PHM fellows more frequently choose to work at university-based sites.5,6  A study of PHM fellowship graduates revealed that 72% worked in freestanding children’s hospitals and 96% worked in an environment where trainees provide a significant portion of patient care.5  Similarly, in a study of residency graduates from 2006 to 2015, 60.7% chose to work in a tertiary care setting.6  This suggests that fellowship and residency graduates prefer university-based positions over community-based jobs. However, only ∼30% of pediatric hospitalizations occur in freestanding children’s hospitals.7  Because there is a relatively finite number of university-based positions, and the majority of pediatric hospitalizations do not occur in freestanding children’s hospitals, it is increasingly likely that graduates of PHM fellowships and pediatric residencies will need to consider community positions. Few researchers have looked at career-motivating factors for pediatric hospitalists. We designed a qualitative study of practicing community pediatric hospitalists with the following goals: (1) to determine what motivates pediatric hospitalists to choose a career in community PHM and (2) to determine what aspects of their careers influence their decision to continue working in the community.

We conducted a qualitative study of community pediatric hospitalists through focus groups, allowing the physicians’ shared enthusiasm to elicit deeply motivating elements of community PHM. The questions were drafted through an iterative process of review and discussion by the authors who had methodologic and content experience. No piloting or revision of questions was done between focus groups. The questions were designed to determine why the physicians chose (and continue to choose) a career in community PHM. Three questions were analyzed:

  • “Why did you choose to enter a career in community-based PHM?”

  • “Which specific factors contribute to your decision to work in community-based PHM?”

  • “What are your career goals as a community-based pediatric hospitalist?”

A convenience sample of community hospitalist pediatricians was obtained through e-mail recruitment via the American Academy of Pediatrics Section on Hospital Medicine Community Hospitalist listserv and direct contact with several community PHM programs. Three focus group times were offered. Participants were included if they were available to participate during 1 of these sessions and self-identified as spending the majority of their clinical time at an inpatient community hospital site. No incentives were provided.

Structured focus groups with 6 to 11 physicians were held via conference call. Verbal consent was obtained at the beginning of each focus group. All calls were led by the same investigator (K.J.) and consisted of open-ended questions (Supplemental Information). There was sufficient time for discussion of each question, and additional responses were encouraged until there were no additional comments. Participants were asked to fill out a short demographic survey at the beginning of the focus groups. Surveys were returned via e-mail attachments, demographic data were extracted, and e-mails were deleted after receipt. Each call lasted 30 to 60 minutes.

We used qualitative analysis to determine the experience of participants in community PHM. The 3 focus groups were transcribed verbatim with personal identifiers removed. Audio recordings were destroyed after transcription. Transcripts were analyzed by 2 investigators (K.J. and Dr Andrew Johnson) via a constant comparative method.8  Coders met after analysis of the first focus group to create a codebook with emerging themes, which were further broken into subthemes. Coder agreement was at 83% before the discussion. Discordances were discussed, and 100% coder agreement was achieved. The remaining focus groups were reviewed independently, and the codebook was refined after additional discussion. No new themes emerged in the third focus group, suggesting that all themes had been discovered in this preliminary exploration of the topic. The study was deemed exempt by the Institutional Review Board at the principal investigator’s institution.

A total of 31 pediatric community hospitalists joined the conference calls, although 4 disconnected before completion of the focus groups. Demographic data were obtained from the remaining 27 participants.

Participants practiced in 14 different states. Three identified as having post-residency training (1 PHM fellow, 1 chief resident, and 1 PICU hospitalist). Additional demographic data for participating hospitalists can be seen in Table 1.

TABLE 1

Demographic Characteristics

Characteristicn (%), N = 27
Sex  
 Male 7 (26) 
 Female 20 (74) 
Age, y  
 31–40 13 (48) 
 41–50 12 (44) 
 51–60 1 (4) 
 >61 1 (4) 
Total time in practice, y  
 <5 7 (26) 
 6–10 8 (30) 
 11–20 9 (33) 
 21–30 2 (7) 
 31–40 1 (4) 
Time at current job  
 <5 y 15 (55) 
 6–10 y 4 (15) 
 11–20 y 6 (22) 
 21–30 y 1 (4) 
 Retired 1 (4) 
Region of practice  
 Midwest 9 (33.3) 
 Northeast 6 (22.2) 
 Southeast 2 (7.4) 
 Southwest 2 (7.4) 
 West 8 (29.6) 
Characteristicn (%), N = 27
Sex  
 Male 7 (26) 
 Female 20 (74) 
Age, y  
 31–40 13 (48) 
 41–50 12 (44) 
 51–60 1 (4) 
 >61 1 (4) 
Total time in practice, y  
 <5 7 (26) 
 6–10 8 (30) 
 11–20 9 (33) 
 21–30 2 (7) 
 31–40 1 (4) 
Time at current job  
 <5 y 15 (55) 
 6–10 y 4 (15) 
 11–20 y 6 (22) 
 21–30 y 1 (4) 
 Retired 1 (4) 
Region of practice  
 Midwest 9 (33.3) 
 Northeast 6 (22.2) 
 Southeast 2 (7.4) 
 Southwest 2 (7.4) 
 West 8 (29.6) 

Five themes emerged regarding factors that motivate pediatricians to begin and continue their careers as hospitalists in the community. We have defined these themes and their subthemes on the basis of response patterns of participants (Table 2). The themes were: (1) professional impact, (2) scope of practice, (3) personal and professional satisfaction, (4) community involvement, and (5) job availability. The first 4 themes were emphasized in response to all 3 questions. Interestingly, responses in the fifth theme of job availability were unique to the question of why physicians chose to enter a career in community-based PHM.

TABLE 2

Representative Quotes

FactorDescription
Professional impact  
 Leadership opportunity “I think one of the real key things in community hospital medicine is that you very quickly become a big fish in small pond as opposed to a small fish in a big pond.” 
 Quality improvement “Standardizing care [in our local emergency rooms] is where we as [pediatric] hospitalists can have a big impact.” 
 Ease of change “If we want to change a policy here it’s relatively simple […] but doing something similar at a bigger academic center would require multiple committees and multiple meetings.” 
 Advocacy “The hospitals that we’re in [are] essentially adult-based hospitals where we’re taking care of children and being part of medical executive committees […] is really important […] if we’re going to take quality care of our patients.” 
 Medical education “We have family medicine residents who don’t get to see as much pediatrics and so we are their window into the world of pediatrics and so that puts kind of a good onus on us to be able to give them a good exposure.” 
Scope of practice  
 Use of training and skills “You have to work on a lot of coming up with your own differential diagnosis and work up a lot more than relying on subspecialists.” 
 Job responsibilities “I still like that my day can go from talking to a new mom to admitting a sick kid in the ER, to going to a stat c-section all within two hours.” 
 Pathophysiology “I think a lot of complex cases at some of the big referral centers start out in the community, and so having people there who are well-versed and feel comfortable with that can have a positive influence on patient outcomes.” 
Personal fulfillment  
 Work-life balance “Knowing that my personal life [is] protected is very attractive as to why I stay doing what I’m doing.” 
 Relationship development “I felt like this job allowed me to spend time with my patients.” 
 Rewarding work “[To] see the patients get better really quickly and feel like I had a hand in that [is] very rewarding.” 
 Career exploration “It’s not that hard to get a week off to do some sort of global health program or […] shuffle things so I can do some teaching once a week for a couple of months.” 
Community involvement  
 Local community “We also identified what the needs were in the community and leveraged the vast resources of a community hospital […] to create services for children.” 
 Hospital community “The ambiance of a community hospital, the friendliness, the patient orientation.” 
 Medical community “[We have access] to a lot of community pediatrics and good primary groups [with whom] we have a relationship.” 
Job availability  
 Hospitalist job availability “I was interested in being more academic but there were no positions, so the positions were in the community.” 
 Pediatric job availability “My intention was actually to go into primary care, but I moved […] and found that it is very difficult to find a job if you don’t have connections in the city where you’re moving. Turned out that this hospitalist position was available, and I went into it thinking it was going to be a transitional job for me but loved it so much.” 
 Short-term job availability “Initially I did it because my wife was finishing her fellowship and I needed a job for two year while she finished.” 
FactorDescription
Professional impact  
 Leadership opportunity “I think one of the real key things in community hospital medicine is that you very quickly become a big fish in small pond as opposed to a small fish in a big pond.” 
 Quality improvement “Standardizing care [in our local emergency rooms] is where we as [pediatric] hospitalists can have a big impact.” 
 Ease of change “If we want to change a policy here it’s relatively simple […] but doing something similar at a bigger academic center would require multiple committees and multiple meetings.” 
 Advocacy “The hospitals that we’re in [are] essentially adult-based hospitals where we’re taking care of children and being part of medical executive committees […] is really important […] if we’re going to take quality care of our patients.” 
 Medical education “We have family medicine residents who don’t get to see as much pediatrics and so we are their window into the world of pediatrics and so that puts kind of a good onus on us to be able to give them a good exposure.” 
Scope of practice  
 Use of training and skills “You have to work on a lot of coming up with your own differential diagnosis and work up a lot more than relying on subspecialists.” 
 Job responsibilities “I still like that my day can go from talking to a new mom to admitting a sick kid in the ER, to going to a stat c-section all within two hours.” 
 Pathophysiology “I think a lot of complex cases at some of the big referral centers start out in the community, and so having people there who are well-versed and feel comfortable with that can have a positive influence on patient outcomes.” 
Personal fulfillment  
 Work-life balance “Knowing that my personal life [is] protected is very attractive as to why I stay doing what I’m doing.” 
 Relationship development “I felt like this job allowed me to spend time with my patients.” 
 Rewarding work “[To] see the patients get better really quickly and feel like I had a hand in that [is] very rewarding.” 
 Career exploration “It’s not that hard to get a week off to do some sort of global health program or […] shuffle things so I can do some teaching once a week for a couple of months.” 
Community involvement  
 Local community “We also identified what the needs were in the community and leveraged the vast resources of a community hospital […] to create services for children.” 
 Hospital community “The ambiance of a community hospital, the friendliness, the patient orientation.” 
 Medical community “[We have access] to a lot of community pediatrics and good primary groups [with whom] we have a relationship.” 
Job availability  
 Hospitalist job availability “I was interested in being more academic but there were no positions, so the positions were in the community.” 
 Pediatric job availability “My intention was actually to go into primary care, but I moved […] and found that it is very difficult to find a job if you don’t have connections in the city where you’re moving. Turned out that this hospitalist position was available, and I went into it thinking it was going to be a transitional job for me but loved it so much.” 
 Short-term job availability “Initially I did it because my wife was finishing her fellowship and I needed a job for two year while she finished.” 

Professional impact was a theme that emerged from the focus groups regarding the motivating value of nonclinical job responsibilities in community PHM. It included comments that described the opportunity to easily influence the care of children at a systems level. This theme consisted of several subthemes, including leadership opportunity, quality improvement, ease of change, advocacy, and medical education.

In our analysis, a leadership opportunity included any chance to have an influential role within the program, whether it was in hospital administration, in the pediatrics department of the community hospital, or on an individual project. A participant noted that “I have been encouraged by my boss and my division chair to sign us up for projects that I’m the lead on.” Another commented, “I have a lot more leadership roles and responsibilities than I ever thought I would.”

In the exploration of data, Quality improvement (QI) emerged as a theme that encompassed all opportunities for improvement in pediatric health care via implementation of QI projects, incorporation of guidelines, and standardization of care in emergency departments and pediatric units. A participant stated, “standardizing care and [my ability] to play a primary role in that […] is a big motivator.” Another predominant factor for participants was the ease of change, or the capacity to make significant changes in a short time period with strong administrative support and limited bureaucracy: “[I’ve been] able to get a lot more projects done in two years that I probably would not have been able to do […] in a larger academic institution.”

Several community hospitalists found purpose in advocating for the needs of children in their hospital system. In our sample, advocacy was described as fighting for the health care needs of children, whether it was in the local community, within the hospital system, or on a larger scale. Community hospitalists in this study were excited “to really show the value [of pediatric hospitalists], not only locally but also regionally when you look at overall health system integration.”

Finally, participants were motivated by the opportunity to provide medical education through developing curricula for rotating learners and teaching residents, students, and nurses on the inpatient units.

The scope of practice was a significant motivator for community pediatric hospitalists in our study. On the basis of comments from participants, the clinical scope of the community PHM physician included the ability to work independently in several settings within the hospital, to care for a variety of patients, and to perform procedures. This theme was made up of 3 subthemes, including use of training and skills, job responsibilities, and pathophysiology.

For the purposes of this study, the use of training and skills can be understood as the opportunity to use the medical knowledge and procedural skills that were emphasized during residency. A participant explained it as the use of “all of my training pretty much every day.” Additionally, working farther away from subspecialists and intensivists “tests your diagnostic skills and your ability to manage rough situations.” Participants were also motivated by the variety of responsibilities that were entrusted to them, saying “we do everything; we do inpatient pediatrics, we do deliveries, we do well-newborns, we do ER consults, and we […] cover the special care at night.”

Finally, participants were motivated by the pathophysiology. They watched patients go from sick to well, were the first touch point for complex and interesting cases, and took care of a variety of patients who may have otherwise been designated to subspecialty services at larger hospitals. A participant commented, “[our subspecialists remained] in their outpatient clinics and we took care of their inpatient. I got to grow and continue to learn.”

Participants noted that their careers as community pediatric hospitalists offered several intangible elements that contributed to an overall sense of fulfillment. The 4 subthemes that made up this theme were work-life balance, relationship development, rewarding nature of work, and opportunity for career exploration.

The theme of work-life balance arose as participants commented on the ability to dedicate oneself to a productive career while maintaining a flexible schedule in which personal time is protected. Participants commented that they do not “have to worry about the hospital when I’m home, and when I’m at the hospital I’m 100% there.” Additionally, several people commented on how the schedule made it easy to spend time with family and organize child care.

Relationship development was another subtheme that contributed to overall satisfaction. Several physicians commented on the influence of their mentors or relationships with other community hospitalists as a reason to enter and continue working in community PHM. In fact, a few participants mentioned that they had little exposure to community PHM as residents, and it was their mentors who initially highlighted the benefits of being a hospitalist in the community and suggested that they consider working in that setting. Additionally, the physicians in this study felt that “a community program allows you to spend a different amount of time with your patient and develop a little bit different type of relationship.” Many community pediatric hospitalists also found their work intrinsically rewarding and listed “to provide great care” and “to be a good pediatric hospitalist” are strong motivators.

Finally, many physicians mentioned the opportunity to explore their clinical and nonclinical career interests as something that contributed to their personal fulfillment and overall motivation to continue in their community roles. A participant noted that “in a lot of ways we are ideally positioned to pursue outside clinical work, be that advocacy, or teaching, or whatever it is we’re passionate about.” Additionally, several physicians mentioned that different community programs had varying levels of emphasis on several aspects of inpatient pediatric care, such as newborn nursery, general pediatrics, and delivery attendance. Participants appreciated that “when I felt like I needed a shift in my focus that there were other programs and configurations [to] meet that need.”

Community pediatric hospitalists in this study were motivated by a sense of belonging and feeling valued as contributing members of the local community, the hospital, and the medical community.

The participating community PHM physicians were “big believer[s] in the importance of community hospital medicine to ensure that we can keep the children close to home.” They also appreciated the sense of community they had within the hospital: “[I feel] like I’m really valued. I feel like the emergency department views me as an expert and a specialist.” Additionally, the participants liked working with “a medical staff that’s bonded […]. It’s just a different level of interaction and respect than I get than when I’m at the children’s hospital.”

Finally, the physicians in this study appreciated working with the outpatient pediatricians in the community and felt it allowed for seamless continuity of care. A participant said, “I feel like I’m a partner of every practice in town.”

Job availability emerged as a theme that was uniquely a motivating factor for physicians to enter community-based PHM. This theme was divided into the 3 subthemes of hospitalist job availability, pediatric job availability, and short-term job availability.

The subtheme of hospitalist job availability encompassed positions available to pediatricians who specifically wanted to be hospitalists. Many of the people who discussed this category mentioned that they would have initially preferred to work in a university-based setting or that they chose a community hospitalist position on the basis of its affiliation with a tertiary care center. Alternatively, 1 participant was glad there was a hospitalist job available in the community and “appreciated not being bound to live in a major urban area.”

The subtheme of pediatric job availability included all general pediatric positions such as inpatient, outpatient, emergency department, urgent care, and combination jobs. Many of the people who commented on this subtheme entered community PHM because they were looking for any pediatric position in a specific city. A few shared that they would have initially preferred to practice outpatient primary care, but the majority did not comment on a preference. Finally, some participants chose to work in community PHM because they felt it was the ideal configuration for a temporary job (eg, while waiting for a spouse to finish medical training).

We aimed to elucidate which aspects of community PHM drive physicians to begin and continue working in the community setting. We found several motivators, including professional impact, scope of practice, personal and professional satisfaction, community involvement, and job availability.

Not surprisingly, job availability was overwhelmingly mentioned as a reason to take a job at a community hospital but it did not arise as a reason to continue working in that setting. When looking for a job, participating physicians often found themselves tied to a certain location or needing a job for a short period of time. In these cases, they took the jobs that were available to them at the time. This is similar to previous studies, which indicated that community hospitalists were more likely to be working as hospitalists temporarily, whereas PHM physicians who worked at tertiary centers were more likely to have chosen hospital medicine as a career.9  Pediatricians in our study who actively sought community hospitalist positions did so for several reasons, which fell into the remaining themes that emerged in our research.

Although motivating factors for community PHM physicians had not previously been explored in depth, authors of previous studies did seek to determine which aspects of their careers are important to community pediatric hospitalists. Researchers demonstrated that new pediatric residency graduates who took positions at community sites were influenced by control over working hours and acceptable income in one study.6  In a different study, researchers found that community PHM physicians prioritized resource availability, work schedules, and clinical responsibilities over nonclinical responsibilities and career development.10  Although the physicians in our study were also motivated by work-life integration and various clinical responsibilities as seen in the themes of personal and professional satisfaction and scope of practice, income was not mentioned as a motivating factor.

Perhaps more interestingly, unlike previous studies,6,10  the most frequently cited motivator for community pediatric hospitalists in our study was professional impact, a theme that consists exclusively of nonclinical subthemes. We found that there are ample opportunities for career growth at community sites, including in the areas of scholarship and leadership. In fact, according to participants in our study, these opportunities often feel more available in the community setting and are strong motivating factors to work in a community hospital. This suggests a different perspective than a previous survey-based study, which indicated that pediatric hospitalists at large centers were more likely to report opportunities for professional advancement.9  Notably, in that study, physicians who worked at large centers also reported higher career satisfaction than community-based PHM physicians. This may suggest that motivation and satisfaction are more linked to feeling valued as a contributing member in a given setting than the setting itself. Given that the data for that study were collected nearly 1 decade before that of this study, it is also important to consider whether this is a reflection of the evolution of PHM and the expectations of its workforce.

A final point of differentiation between our results and those of previous studies is the perspective on the role of subspecialists. Pane et al9  demonstrated that hospitalists at large centers appreciated the support of having subspecialists on-site. However, participants in our study felt that they were able to broaden their scope of practice and maintain more ownership of their patients as a result of having fewer subspecialists available. This sentiment was corroborated by a commentary written by community hospitalists11  in response to the Pane et al9  study. This reveals an intrinsic difference between PHM in the community and at university-based centers that can be used to help pediatricians determine which setting is most appropriate for them to practice.

These data may be particularly beneficial for newly graduating pediatric residents and PHM fellows. When seeking their first position, residency and fellowship directors can highlight the many benefits of community PHM and help graduates determine if this arena fits with their career goals. Likewise, our results could be salient to program directors for community PHM programs when recruiting applicants who are seeking opportunities for growth in the nonclinical aspects of PHM or would like more autonomy over patients who would be delegated to subspecialty services at university-based centers. To ensure the utmost success in recruitment, Additional research should be done to explore the career factors that are most important to pediatric residency and PHM fellowship graduates in choosing their first job as well as perceived barriers to working in community PHM.

Additionally, we provide novel information that can be used by community PHM program directors in retention efforts. Our data suggest that when PHM physicians who are already working in the community feel supported by their leadership, they are more motivated to pursue professional growth and foster new interests. In turn, this motivates them to continue to contribute as community pediatric hospitalists.

There are limitations to this exploratory research. First, our study population was a convenience sample, which allows the chance of selection bias as participants who volunteered for this study may have a strong interest in the topic or a desire to participate in research. Approximately one-third of the participants in our study had worked in community PHM for >10 years and are likely committed to working in this setting. There were also few fellowship-trained pediatric hospitalists in our study. Additionally, job availability was a theme that was unique to the question of starting a career as a community pediatric hospitalist; although all 5 themes were discussed as a reason to start a job as a pediatric hospitalist in the community, it is difficult to say to what extent each of these themes had an impact in that initial decision. Finally, having only 3 focus group times resulted in a relatively small sample size.

We demonstrate key factors that motivate community pediatric hospitalists to begin and continue to work in the community in this study. Community pediatric hospitalists are motivated by the professional impact that they can have, the scope of clinical practice community PHM offers, the personal and professional satisfaction they derive, and the opportunity to be involved in the community. Although job availability may be a reason that individuals choose a job in community hospitals, there are far more robust and powerful reasons that they continue careers in the field.

Dr Andrew Johnson served as a second coder in the data analysis.

Dr Jackson conceptualized and designed the study, coordinated and conducted data collection and data analysis, drafted the initial manuscript, and critically reviewed the final manuscript as submitted; Dr Marek was integral in participant recruitment and critical review of the manuscript; Dr Fromme conceptualized and designed the study, oversaw data collection and analysis, and critically reviewed the final manuscript; and all authors approved the final manuscript as submitted.

FUNDING: No external funding.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

Supplementary data