Factors Influencing Career Longevity in Pediatric Hospital Medicine

In this study, we used a cross-sectional design to analyze data from surveys conducted in 2012 and 2016 on 2 PLACES cohorts (2002–2004 residency graduates and 2009–2011 residency graduates). PLACES participants were randomly selected from a database that included all pediatricians graduating from US residency programs; participants are surveyed biannually.⁶  Pediatricians identifying as hospitalists in 2012 were followed-up longitudinally, and retention was defined as being a self-reported hospitalist on surveys administered in 2012 and 2016.

Variables hypothesized to be associated with retention in PHM were divided into 3 categories: (1) demographic characteristics, (2) position-related factors, and (3) factors related to stress and satisfaction. These predictor variables were derived from the 2012 survey data; these questions were unchanged between 2012 and 2016. χ² tests were used to analyze associations between these variables and retention in PHM. A multivariable logistic regression was then used to further examine variables associated with retention in the bivariate analysis (P < .10), controlling for demographic characteristics.

The AAP Institutional Review Board approved the study. All analyses were conducted with IBM SPSS Statistics version 25 (IBM SPSS Statistics, IBM Corporation Armonk, NY), and P ≤ .05 was used to define statistically significant differences.

Of 1804 respondents, 206 (11.4%) self-identified as hospitalists in 2012. A total of 180 of these 206 hospitalists responded again in 2016, encompassing the final analytic sample; 122 (68%) of these individuals remained hospitalists in 2016. Cohort development and career choices of those not remaining in PHM at the time of this second survey are shown in Fig 1. Of note, a total of 156 of 1530 survey respondents in 2016 self-identified as hospitalists (10.2%); we have not included 34 individuals who newly identified as hospitalists on the 2016 survey in our analyses.

The characteristics of respondents who remained hospitalists over the 5-year study period relative to those who left the field are indicated in Table 1. Among the demographic factors we examined, country of medical school graduation and concerns surrounding educational debt were significantly associated with retention. Among position-related factors, income was significantly associated with longevity in PHM, with those earning ≥$175 000 in 2012 more likely than those earning less to remain in PHM. Among factors related to stress and satisfaction, only timing of schedule availability and job satisfaction were significantly associated with retention. Participants who knew their work schedule ≥2 months in advance were more likely to remain hospitalists than those with less notice. Those who expressed overall satisfaction with their job were more likely to remain hospitalists than those less satisfied. Of note, nearly 85% of respondents reported satisfaction with their jobs.

In the multivariable analysis (Table 2), respondents who earned higher salaries were more likely to remain in PHM than those earning less (adjusted odds ratio [aOR] = 3.93; 95% confidence interval [CI]: 1.26–12.25), and those very or somewhat concerned with educational debt were significantly less likely to remain in PHM than those not concerned (aOR = 0.42; 95% CI: 0.20–0.90). Respondents who reported higher levels of job satisfaction were more likely to remain in PHM than those who were less satisfied (aOR = 3.28; 95% CI: 1.22–8.80).

Among a national sample of pediatricians, nearly 70% of respondents self-identifying as pediatric hospitalists in 2012 remained hospitalists after 5 years. This exceeds some previous estimates of intended retention in PHM, suggesting that some individuals intending to enter PHM for only the short-term may in fact remain in the field.²  Individuals leaving PHM pursued general pediatrics at approximately equal rates as other subspecialties, suggesting that PHM is not a consistent stepping stone to any other particular professional role.

Financial factors appear to play an important role in PHM retention. Half of the study participants reported that they were somewhat or very concerned about their educational debt, and those with more concern were significantly less likely to be hospitalists after 5 years. Compensation also played a role in retention, with those earning ≥$175 000 demonstrating little attrition. Finances may impact decisions surrounding both the choice of PHM as a career and whether to pursue PHM fellowship training. As noted in previous studies, those concerned with loan debt may forego additional training to try to improve their financial situations quickly.^3,7 

Overall job satisfaction also appears to play an important role in retention in PHM. A majority of this cohort reported positive job satisfaction, supporting findings of previous studies revealing high levels of job satisfaction among both pediatric and adult hospitalists.^8–11  In previous studies in adult hospital medicine, researchers have aimed to synthesize factors contributing to job satisfaction into measures of provider morale and “job fit” and have associated these measures with retention; improvement in these areas has correlated with decreased intent to leave current positions.^12,13  Both morale and job fit appear to improve as longevity in hospital medicine increases,^12,13  suggesting that attrition may also decrease after the early years of one’s career in hospital medicine. Further efforts to identify and promote professional factors that improve satisfaction may help to increase longevity in PHM.

Although study limitations include potential for bias in self-reported responses, small cell sizes for some groups, and inability to explore career aspects not assessed in PLACES, results of this study have implications for PHM training program development and future workforce planning. Our finding that the proportion of hospitalists remaining in PHM over time was higher than some previous estimates is promising. Although the number of training programs for PHM has increased,¹⁴  if a majority of individuals anticipating a PHM career opt to pursue fellowship, this growth may need to continue in the coming years to accommodate continued growth in the field. Conversely, little is known about what factors might promote or deter individuals from pursuing PHM fellowship; this is an important area for future study.

As PHM evolves as an ABP subspecialty, continued workforce research will be critical. An increase in PHM retention might be anticipated among fellowship-trained hospitalists given their educational investment. Efforts to characterize PHM salary benchmarks among hospitalists with and without fellowship training will be particularly important. Further research focused on factors impacting job satisfaction may also contribute to positive programmatic changes facilitating retention.

In this national sample of pediatricians, 11% reported working as pediatric hospitalists, and nearly 70% of these remained hospitalists over a 5-year period. These findings inform national estimates about the size of the PHM workforce and have implications for the number of fellowship spots that may be needed to support trainees wishing to pursue PHM subspecialty certification. Financial factors and overall job satisfaction appear to be the most important drivers of PHM retention. Careful assessment of the financial impacts of choosing and remaining in PHM are critical, particularly as the field evolves as an ABP-certified subspecialty.