The Joint Council of Pediatric Hospital Medicine (JCPHM), successor to the Strategic Planning (STP) Committee, recently recommended submitting a petition for two-year pediatric hospital medicine (PHM) fellowship certification to the American Board of Pediatrics (ABP), which was completed in 2014. In December 2015, the ABP Board of Directors voted to (1) approve the proposal for a two-year PHM fellowship incorporating scholarly activity with the provision that entrustable professional activities (EPAs) be used as the framework for assessing competencies and (2) not require those who achieve and maintain PHM certification to maintain general pediatrics certification. The proposal for certification of a two-year PHM fellowship will now be submitted to the American Board of Medical Specialties (ABMS). Concerns regarding the formal certification of PHM as an ABMS-recognized subspecialty have been raised by many stakeholders, including community pediatric hospitalists, pediatric residency program directors, and med-peds physicians.
We feel that the “first, do no harm” guiding principle seems to have been forgotten by the ABP as it attempts to formalize the training of pediatric hospitalists. In December 2015, the ABP voted in favor of a two-year ACGME-accredited PHM fellowship. The intent was to “assure the best care of hospitalized children,” “assure the public,” “accelerate improvements and innovation in quality improvement,” and “raise the level of care of all hospitalized children by establishing best practices in clinical care.” To be clear, these goals are shared by all of us (although there is no indication that the public is seeking additional assurance). Prior to launching broad-scale, time-intensive, and financially costly initiatives, we should ensure that our efforts would achieve—rather than obstruct—their intended aims. In addition to a lack of evidence supporting that subspecialty certification will advance our path toward achieving these goals, there are numerous reasons a required PHM fellowship is unnecessary and potentially even harmful to the hospitalist workforce. The negative unintended consequences need to be weighed heavily.
We have found no data to support that children would receive inferior inpatient care from pediatric hospitalists due to lack of formal certification. Hospital medicine physicians are paving the way in quality improvement, high-value care, medical education, palliative care, and global health, supported in part through training in various non-accredited hospital medicine fellowships. There is nothing stopping pediatric hospitalists from establishing and disseminating best practices in clinical care. Hospitalists are already making strides in providing high-quality care at low costs, as demonstrated by the abundant PHM scholarly work described in the ABP application to the ABMS. The alleged problem of needing to build trust within the community is yet to be demonstrated, as we have leaders at local, regional, and national levels. The chief medical officer of the Centers for Medicare & Medicaid Services is a hospitalist as is our surgeon general. Hospital medicine is the fastest-growing specialty in the history of medicine,1 and we should seek to propel rather than fetter our future colleagues.
Below are our reasons for opposing this formal certification.
We already have a fellowship system.
As we all know, advanced training opportunities already exist for those interested in pursuing extra research and quality improvement training. Similar to other pediatric subspecialty fellowships, these PHM fellowships are undersubscribed (20% of PHM fellowships did not fill in 2016),2 with the majority of graduating pediatric residents transitioning to hospitalists opting not to pursue fellowship training. We should continue to let graduating pediatric residents vote with their feet without the undue influence of subspecialty certification.
Subspecialization has opportunity costs that may reduce the PHM pipeline.
Even if we assume an adequate number of fellowship programs could be developed and funded, our fear is that the decision to turn PHM into an accredited subspecialty could paradoxically reduce the pipeline of inpatient providers. Residency is already a three- to four-year endeavor (pediatrics and med-peds) that is poorly compensated and time-intensive. In the absence of evidence supporting the value of additional training, tacking on another two years seems unreasonable in the face of the student loan debt crisis, reduced compensation, and lost time for career advancement. These are significant opportunity costs. While most specialties lead to a significant pay raise to compensate for the added training time, pediatrics remains the lowest-paid physician specialty.3 Should PHM follow the trend of most pediatric subspecialties, pursuit of fellowship training would be a negative financial decision for residency graduates.4 For the health system, increasing debt-to-income ratios runs the risk of creating a medical education bubble market.5