Child Health Needs and the Pediatric Hospital Medicine Workforce: 2020–2040

There were ∼5.2 million inpatient pediatric hospitalizations in the United States in 2019, divided into birth (3.7 million) and nonbirth (1.5 million) hospitalizations.⁴  Of the 20 most common diagnoses associated with US pediatric admissions, 19 are listed in the American Board of Pediatrics (ABP) content outline for PHM certification, reflecting the diversity of conditions managed by pediatric hospitalists.^5,6 

PHM as a field is differentiated not by a specific organ system or set of conditions but rather by patient acuity and setting. To that end, the simplest description of pediatric hospitalists is: “pediatricians who work primarily in hospitals.”⁷  Although accurate, this definition lacks specificity. In general, pediatric hospitalists routinely care for children hospitalized in general inpatient units, intermediate care units, observation units, or the newborn nursery. Typical pediatric hospitalists’ practice excludes children receiving care in other areas of the hospital (eg, intensive care units and emergency departments [EDs], with the exception of ED consults) are relatively common in community hospitals.⁸  Although the pediatric hospitalist’s fundamental role is to assume primary responsibility for acutely ill children during hospitalization and facilitate their transitions home, additional roles may include newborn resuscitation, sedation services, and comanagement with other subspecialists (eg, surgeons).

Describing a pediatric hospitalist’s scope of practice is challenging because there is no single model, with responsibilities varying according to local hospitals’ specific needs and structures, in addition to the interests and skills of individual hospitalists in those settings.⁹  An early attempt came in 2010 (updated in 2020) with the publication of The Pediatric Hospital Medicine Core Competencies by the Society of Hospital Medicine with support from the American Academy of Pediatrics (AAP) and the Academic Pediatric Association (APA).^1,10,11  These competencies were organized into common diagnoses, core skills, specialized services (eg, palliative care, transport), and health care systems (eg, QI, medical education). Building on the Core Competencies, the Accreditation Council for Graduate Medical Education (ACGME) and the ABP defined a PHM subspecialist’s scope of practice through fellowship training requirements, board certification, and the development of entrustable professional activities.^12,13  These emphasize comprehensive medical care across the full spectrum of hospitalized children in addition to research, education, QI, and hospital administration. In practice, PHM subspecialists assume diverse clinical and professional roles ranging from general inpatient care to more specialized responsibilities or hospital and health system leadership.

Three parent organizations (AAP, APA, and the Society of Hospital Medicine) supported PHM’s development over the past 30 years alongside the contributions of individual hospitalists who carved out distinct areas of clinical practice, scholarship, and professional leadership.¹  During that time, PHM evolved from an emerging model of care to the newest board-certified pediatric subspecialty.

After a formal request from the pediatric hospitalist community in 2014 and approval from the ABP and the American Board of Medical Specialties in 2016, the first PHM board certification examination was offered in 2019. Pediatric hospitalists seeking board certification currently achieve eligibility via 3 pathways: (1) training: general pediatrics or an internal medicine–pediatrics (Med–Peds) residency followed by a PHM fellowship, (2) practice: 4 years of ABP criteria-based PHM practice starting no later than July 2019, or (3) combined: 1 year of fellowship and 2 years of practice. After 2024, only those completing the training pathway will be able to apply to sit for the PHM certification examination. PHM is also the first ACGME-accredited pediatric subspecialty to allow 2-year as opposed to 3-year fellowships.¹ 

Pediatric hospitalists function in a variety of diverse roles, which may impact an individual’s decision to pursue board certification.^14–16  For hospitalists primarily caring for a medically diverse and potentially complex cadre of patients and who take on research, QI, safety, and hospital administrative roles, PHM board certification may be desirable. This contrasts with hospitalists assuming narrower career roles, such as in-house coverage of the newborn nursery, co-management with surgeons or specific pediatric subspecialties, and Med–Peds hospitalists caring primarily for adults that may not meet ABP eligibility criteria. In assessing the overall PHM workforce for this article (Fig 1), both groups of pediatric hospitalists are considered as part of the supply of pediatric hospitalists if their clinical responsibilities contribute meaningfully to the care of hospitalized children, including newborns but excluding neonatal and pediatric ICU-level care and other subspecialty inpatient services. Although we do not consider pediatricians exclusively practicing surgical and medical subspecialty comanagement as contributing to the supply of pediatric hospitalists in this analysis, comanagement is considered in relation to PHM workforce demands.

As a new subspecialty, data on the overall number of pediatric hospitalists are limited. The ABP, however, maintains data on board-certified PHM subspecialists. As of June 2023, nearly 3000 individuals had applied to sit for the initial certification examination, 2542 had passed the examination and were board-certified, and almost all (2538) were enrolled in Maintenance of Certification (MOC).¹⁷  However, this most likely undercounts the current PHM workforce. First, it is nearly identical to a 2009 estimate from the Association of American Medical Colleges, and the number of pediatric hospitalists has grown in the past decade.¹⁸  Second, it does not include current hospitalists intending to pursue board certification in 2024, the final year of practice pathway eligibility. Third, ABP MOC survey data from 2017 and 2018 revealed that 31% of those practicing exclusively as pediatric hospitalists did not intend to sit for PHM boards.⁸  Based on these surveys, the total PHM workforce was estimated to range from ∼3000 to 3500 hospitalists when considering only those who exclusively practice PHM (regardless of intention to pursue board certification). There were an additional 7000 to 8000 survey respondents who reported that they were hospitalists combined with general or another subspecialty practice,⁸  ∼20% of whom intended to pursue board certification, conservatively translating to an additional 1400 PHM board-certified hospitalists. Therefore, 4400 represents a lower estimate of the current PHM workforce, depending on the assumptions and definitions of PHM.

Two groups, Med–Peds and short-term hospitalists, are worth noting given their importance to the PHM workforce. Up to one-third of the almost 6000 active US Med–Peds physicians spend a portion of their time caring for hospitalized children and are less likely to pursue PHM board certification.^19–22  Short-term hospitalists typically represent individuals planning to match into PHM or other subspecialty fellowships or are exploring their career direction. Data suggest that approximately one-third of pediatric hospitalists in 2012 no longer practiced PHM in 2016;²³  another study revealed that between one-third and one-half of graduating pediatric residents taking hospitalist positions did not intend to practice PHM long-term.²⁴  These statistics on short-term hospitalists are dated and may no longer be accurate. In particular, their numbers may have dwindled in recent years because programs preferentially hired PHM board-certified candidates.

The ABP collects demographic and practice data through its census surveys at various time points, including initial certification and MOC enrollment.¹⁷  Compared with other pediatric subspecialties, those certified in PHM are younger and more frequently women (Table 1). An estimated 11.0% of board-certified pediatric hospitalists identify as underrepresented in medicine (URiM; includes Black or African American, Hispanic, Latin, or Spanish, American Indian or Native Alaskan, or Native Hawaiian or Pacific Islander origin) compared with 13.0% of all pediatric subspecialists, 15.8% of general pediatricians, and 16.8% of pediatric fellows.^25,26  The disproportionately low number of board-certified pediatric hospitalists identifying as URiM compared with general pediatricians is particularly troublesome when viewed in the context of the PHM workforce’s youthfulness and points to gaps in training and retention along the path from residency to PHM board certification for individuals from URiM backgrounds. Regarding medical training, 80.2% were American medical school graduates (AMGs) with a Doctor of Medicine (MD) degree and 7.4% were AMGs with a Doctor of Osteopathy (DO) degree. Unlike other subspecialties, <20% of trainees were international medical graduates (IMGs), with 6.9% holding an MD degree and 5.5% holding an international degree.

Data on the work characteristics of current ABP-certified PHM subspecialists were collected through the ABP’s MOC enrollment surveys from 2019 to 2022.²⁷  Nearly all pediatric hospitalists reported working in urban or suburban settings. Most pediatric hospitalists work full-time, which varies by sex (women: 85.1% vs men: 97.0%), and 44.0% work ≥50 hours per week. Nonclinical responsibilities are common because approximately one-half (51.9%) of pediatric hospitalists spend <75% of their professional time in direct patient care, mostly medical education, administration, and QI. Nearly one-third (31.0%) of pediatric hospitalists have dedicated time for research, although <4% report spending ≥25% of their time conducting research. Professional time for research is notably less when compared with other pediatric subspecialists (any: 52.6% and ≥25%: 12.9%). Time spent on medical education, administration, and QI was broadly proportional with other subspecialists. According to MOC data from 2017 and 2018, the majority of pediatric hospitalists work at children’s hospitals, particularly those exclusively practicing PHM (75.4%), as compared with those practicing both PHM and general outpatient pediatrics (46.9%).⁸ 

When the sample is limited to the United States in 2023, there is an average of 48.5 currently certified PHM subspecialists per US state (range 0–353), which translates to 3.4 PHM board-certified subspecialists per 100 000 children 0 to 17 years of age (range 0.0–19.1) across the United States (Fig 2).

With respect to fellowship training programs, ACGME data reveal an increase of 106.1% (from 33 to 68) in the number of accredited US programs between academic years 2019 to 2020 (when ACGME first accredited PHM fellowships) and 2022 to 2023.²⁸  A combination of ABP and ACGME data reveal an increase of 71 to 192 (+170%) total PHM fellows during that same period.^26,28 

Of the 192 fellows in the academic year 2022 to 2023, 73.1% identified as female, 26.9% identified as male, and 16.5% identified as URiM. A total of 77% were AMGs with an MD degree, 14.0% were AMGs with a DO degree, 0.5% were AMGs with an unknown degree, 5.7% were IMGs with an MD degree, and 2.1% were IMGs with an international degree. Fellows commonly take a first position post-training near their training location;²⁶ Fig 2 reveals PHM fellowship locations in 2021 to 2022 compared with the geographic distribution of board-certified pediatric hospitalists in January 2023.

Pursuing a career in PHM typically entails a substantial financial loss compared with general pediatrics and an even greater loss compared with procedurally oriented or adult specialties.^29,30  Older survey data suggest that financial considerations are of limited importance to pediatric residents in choosing a subspecialty career.^31,32  However, higher lifetime earnings are positively associated with fellowship fill rates across pediatric subspecialties,³³  suggesting that financial considerations may be more salient than reported in surveys. In the preboard-certification era, increasing educational debt was associated with working as a hospitalist as opposed to pursuing a subspecialty fellowship after residency,³⁴  whereas higher compensation was associated with long-term PHM practice.²³  On the ABP’s 2022 Subspecialty In-Training Exam Survey, 39.9% of current PHM fellows owe $200 000 or more compared with 39.5% for all pediatric subspecialty fellows (personal communication, ABP, February 20, 2023). Therefore, financial considerations ranging from educational debt to deferred compensation associated with fellowship and anticipated lifetime earnings are likely to impact the size and composition of the PHM workforce.

This article is written as part of an ABP Foundation-sponsored Pediatrics supplement focused on the pediatric subspecialist workforce and its relationship to the anticipated health care needs of US children in the coming decades. The supplement includes all 15 ABP-certified subspecialties.³  However, PHM lacks the longitudinal data used to forecast other subspecialties, so PHM workforce projections were not modeled. Instead, we present a review of PHM-specific workforce data from a variety of sources interpreted using an adapted version of the conceptual framework used to model the other subspecialties (Fig 3).

Historically, an estimated 300 graduating pediatric residents enter the PHM workforce annually,^17,34  with two-thirds pursuing PHM long-term.^23,24  In addition, around 65 graduating Med–Peds residents each year take hospitalist positions, which include caring for hospitalized children.^17,20  National Resident Matching Program (NRMP) data suggest that more pediatricians are interested in PHM training than current training programs can accommodate (103 first-year fellows in 2022), with 19% to 35% of PHM fellowship applicants not finding positions in the Match each of the past 5 years (23–51 applicants), the highest rate among pediatric subspecialties.³⁵  Although the number of fellowship programs and positions has doubled since 2018,³⁵  it is unclear whether this growth is sustainable or a short-term boost associated with the implementation of subspecialty board-certification. For example, PHM fellowship directors note challenges to expansion, including institutional support and difficulties identifying community hospital training sites (Sarah Varghese, PHM Fellowship Directors Listserv, January 17, 2023). It is not known how the needs of hospitalized children, market demand for fellowship-trained PHMs, and fellowship availability will interact over the next 2 decades. This requires close monitoring to ensure hospitalized children receive highly skilled care.

Non-fellowship-trained, noncertified hospitalists may remain a substantial portion of the PHM workforce well into the next 2 decades, particularly in under-resourced areas. As such, general pediatrics and Med–Peds residencies must continue to prepare new graduates to independently care for hospitalized children. If formally adopted, proposed changes to pediatric residency requirements by the ACGME place a greater emphasis on outpatient and elective experiences.³⁶  The impact of these or future curriculum changes remains to be seen but may reduce readiness to join the PHM workforce without additional training. In addition, Med–Peds graduates report relatively low interest in PHM fellowship training and pursuing board certification, which may reduce their likelihood of joining the PHM workforce.^22,37  Combined with financial incentives that favor caring for adult patients, these trends could contribute to future shortfalls in the PHM workforce.²⁹ 

Compared with other subspecialties, pediatric hospitalists, on average, spend a greater proportion of their time providing direct patient care. However, surveys of recent PHM fellowship graduates suggest their percent clinical time (PCT) may be lower than the overall PHM workforce. For example, more than three-quarters report conducting research after fellowship, whereas nearly one-half report protected time and one-quarter report research grant funding.^38,39  Additionally, formal education and hospital leadership positions are common among fellowship graduates and further reduce PCT.^38,39  This is not surprising because preparing graduates for nonclinical roles represents a major focus of fellowship training.¹²  These trends toward nonclinical work will help advance important research priorities in the field, improve quality, safety, and patient outcomes, and create academic leadership and hospital administrative opportunities for hospitalists but may decrease PCT. Additionally, trends in the total hours worked by physicians in all specialties reveal consistent decreases over the past 20 years, which are likely to continue.⁴⁰ 

Changes in patient needs and care models are expected to drive demand for pediatric hospitalists in the coming decades. Although pediatric inpatient admissions have declined over the past 15 years,⁴¹  this may reflect the increasing use of observation status hospitalizations such that the total number of children requiring hospital care may remain unchanged.^42–44  In addition, the number of children with complex chronic conditions, who are more likely to require hospitalization and experience longer lengths of stay, continues to increase.^45–47  The exponential increase in ED and inpatient boarding of patients with behavioral or mental health needs shows no sign of abating and must be taken into account in planning for the future workforce.^48,49  PHM’s clinical footprint is expected to continue expanding as other subspecialties shift to primarily consultative services⁵⁰  because of improved outcomes associated with hospitalist co-management of medically complex children,^51,52  hospitalist availability to provide 24/7 in-house coverage,⁵³  and additional subspecialist time demands for procedures and outpatient clinic.

Two aspects related to the geographic distribution of pediatric hospitalists warrant consideration: (1) regional alignment between expected population growth and the PHM workforce, and (2) whether children requiring hospitalization can access care close to home. The Pacific, Mountain, West South Central, and South Atlantic US census divisions are forecast to experience double-digit child population growth from 2020 to 2040. In contrast, the East South Central, West North Central, East North Central, Middle Atlantic, and New England census divisions are all forecast to experience single-digit or negative growth.⁵⁴  Notably, these latter 3 census divisions currently contain a relatively high concentration of board-certified pediatric hospitalists and fellowship programs (Fig 2).

In addition, hospitals providing pediatric care exist on a spectrum across 4 models: (1) large freestanding children’s hospitals (FCHs), (2) children’s hospitals within hospitals, (3) community hospitals with pediatric units, and (4) community hospitals without dedicated pediatric beds.⁵⁵  Historically, most pediatric hospitalizations occurred outside of FCHs.⁵⁶  However, pediatric inpatient care has shifted away from community hospitals with nearly one-fifth of pediatric units reported to have closed between 2008 and 2018, coinciding with a 12% increase in beds at FCHs.⁵⁷  The distance between where children live and the nearest pediatric hospital bed continues to increase, particularly for children in rural communities, such that accessing inpatient care often requires interfacility transfer even for common pediatric conditions.^57,58  The opening of community-based “satellite” branches of children’s hospitals partially mitigates this, but these are typically located in suburban settings within reasonable proximity to the affiliated existing children’s hospital.^59–62  Financial concerns represent a major driver of regionalization and speak to the need for creative and cost-effective solutions for increasing access to pediatric inpatient care at community hospitals. Two-thirds of community hospital programs provide newborn services ranging from delivery attendance to nursery coverage to Level 2 and 3 NICU care;^53,63  adding these to general inpatient responsibilities can improve financial performance and physician productivity.⁶⁴  Additionally, telehealth may represent a novel care model to address the needs of children in rural and community settings.⁶⁵ 

Career longevity will also impact the future supply of pediatric hospitalists. The relative youthfulness of the workforce suggests that PHM is less likely than other pediatric subspecialties to experience significant contraction due to retirements in the coming decades. Still, more than one-third of community and one-half of university-based PHM division directors reported concerns regarding program sustainability related to hospitalist burnout, clinical effort, or intent to remain in their current position.^53,63  In a 2020 study, nearly one-fifth of pediatric hospitalists reported symptoms of burnout and 11% were considering leaving their current position.⁶⁶  It is unclear how this compares to other pediatric subspecialties, but even if pediatric hospitalists experience less burnout than their peers, it still represents a significant challenge. Drivers of physician burnout are complex and multifactorial. However, PHM’s workforce is heavily clinical (averaging >1800 hours per year) and shift-based (typically requiring 24/7 in-house coverage including nights, weekends, and holidays), both of which have been associated with burnout and job dissatisfaction.^53,67 

Ensuring an adequate PHM workforce is essential for meeting the health care needs of all US hospitalized children. Although PHM has demonstrated remarkable growth since its inception 3 decades ago, deliberate efforts are needed to sustain and accelerate further workforce development (Table 2).

Expanding PHM fellowships requires additional investments ranging from fellow, program director, and program coordinator salaries to resources supporting fellows’ scholarly activities.⁶⁸  Pediatric departments affiliated with large children’s hospitals can grow existing PHM fellowships by increasing total institutional or Children’s Hospital Graduate Medical Education funding or reallocating positions from historically underfilled fellowships. A National Academy of Medicine proposal to target governmental graduate medical education funding toward subspecialty and geographic workforce disparities may facilitate the creation of new programs at smaller, less well-resourced institutions while simultaneously addressing regional variation in the PHM workforce.⁶⁹  Professional societies (eg, AAP, APA) can coordinate learning and research networks to support smaller fellowships with program logistics and scholarly activities. Pediatric unit closures present an additional challenge to expanding PHM fellowship programs of all sizes by reducing available community training sites.

Non-board-certified, non-fellowship-trained pediatric hospitalists will continue to represent an important portion of the PHM workforce, and it is important to support, recognize, and mentor their unique career paths. The ACGME and Association of Pediatric Program Directors could help residencies develop PHM tracks within residency training based on the PHM core competencies to prepare residents for independent practice as hospitalists.¹¹ 

A well-supported community hospital infrastructure and workforce are essential to ensure that children can access hospital care close to home, particularly those in rural areas. Successful telehealth programs for both PHM and subspecialty consultative services should be studied and expanded, requiring a combination of health services research, regulatory changes, and new payment models. Affiliated networks or other formal operating agreements with academic children’s hospitals may help catalyze the necessary infrastructure to sustain PHM in community settings. Other options include locally developed, clinically focused “mini-fellowships” or intensive MOC QI activities, particularly for the community hospitalist workforce that requires a distinct set of skills.⁷⁰  This pathway would not supplant board certification for these members of the PHM workforce but would provide opportunities for professional advancement throughout their careers to ensure an inclusive and sustainable PHM workforce across the United States.¹⁴ 

Medicaid covers up to 50% of US children and reimburses at lower rates than other payers.^41,71  This disparity results in large financial losses from inpatient pediatric care and helps explain pediatric unit closures, suggesting that Medicaid parity with Medicare will be important to pursue to maintain accessible, high-quality care for children.^72,73  Reimbursement parity for nonprocedural and pediatric services is also needed to ensure an adequate future PHM workforce.^22,23,34 

PHM is in a transition period, highlighting the need for research to understand trends in the supply, distribution, and need for pediatric hospitalists. Projections regarding the future PHM workforce assume a similar growth trajectory as in the past decade. However, this rapid expansion may be an anomaly associated with establishing the subspecialty and could level off. Ongoing surveys of both board-certified and non-board-certified hospitalists could address this uncertainty and aid future planning. Focused efforts are also needed to address disparities in the proportion of PHM fellows identifying as URiM. Regarding training, a recent needs assessment was performed to assist residency programs in advising trainees interested in PHM, but community hospitalist perspectives were underrepresented,⁷⁴  highlighting a target for further study. Finally, given the substantial proportion of PHM division directors concerned about program sustainability, research into the drivers and solutions to address burnout and career satisfaction is needed.

As the newest board-certified subspecialty, PHM stands at an exciting but uncertain juncture. The demand for pediatric hospitalists is expected to increase in coming years, owing to the rising prevalence of children with complex chronic conditions and a shift toward hospitalist comanagement. The most prominent challenges to ensuring that the future PHM workforce meets anticipated population needs include appropriate fellowship positions to meet child needs, further diversification of the workforce, and countering regional and economic trends that threaten reduced hospital access for children.

The authors thank Virginia A. Moyer and Patience Leino for their editorial support. We also thank the pediatricians who shared their information with the ABP Foundation and made this supplement possible.

AAP

American Academy of Pediatrics

ABP

American Board of Pediatrics

ACGME

Accreditation Council for Graduate Medical Education

AMG

American medical school graduates

APA

Academic Pediatric Association

DO

Doctor of Osteopathy

ED

emergency department

FCH

freestanding children’s hospital

IMG

international medical graduate

MD

Doctor of Medicine

Med–Peds

internal medicine–pediatrics

MOC

Maintenance of Certification

PCT

percent clinical time

PHM

pediatric hospital medicine

QI

quality improvement

URiM

underrepresented in medicine