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Moving into the Future


The young specialty of hospital medicine has an even younger sibling—pediatric hospital medicine. “Just seven years ago, when I put on my pediatric hospitalist badge, people would ask me, ‘What is that?’” Douglas Carlson, MD, an associate professor at the Washington University School of Medicine in St. Louis, says. “They don’t do that anymore.”

Times certainly are a changing.

With an estimated 1,500 practitioners, pediatric hospitalists make up about 9% of the total hospitalist workforce in the United States. Growth in the pediatric field has been fueled by the need for expertise in treating hospitalized pediatric patients, the increasing complexity of hospitalized cases, mandates to reduce hospital costs and readmission rates, and the curtailment of resident hours.

“The biggest thing is the whole field is blossoming,” says SHM treasurer Jack Percelay, MD.

What Lies Ahead?

Pediatric hospital medicine may be young in years, but the primary focus is on the future. Such was the theme of the Pediatric Hospital Medicine Conference held by SHM, the American Academy of Pediatrics and the Academic Pediatrics Association in July in Denver.

“We are responsible for the future of hospital medicine,” keynote speaker Sanford Melzer, MD, of the University of Washington and Children’s Memorial Hospital and Regional Medical Center of Seattle says in an interview with The Hospitalist. “So what should that future look like?”

Pediatric hospitalists are in an ideal position to improve care, Dr. Melzer said. He outlined six crucial areas for action:

  • Set standards of evidence-based patient care in areas not historically addressed, such as feeding tubes and severe reflux;
  • Implement safety standards for issues such as medical errors, blood infections and hand-offs to other providers;
  • Develop leaders who will work to bring about these changes;
  • Stabilize the workforce by better defining pediatric hospital medicine as a career path;
  • Create value for hospitals;
  • Promote a holistic view of hospital care as a small part of the continuum of care for chronically ill children.

As Dr. Melzer succinctly puts it, “I am here to improve the whole system, not just to give kids meds and get them out.”

“I think our evolution in hospital medicine will follow that of ER physicians very closely,” says Dr. Carlson, who started out as an ER doctor. “Within 30 years, with fellowships and training, their specialty evolved.”

A similar progression is occurring with pediatric hospitalists. Carlson said he remembers when hospitalists would complain that their colleagues in other subspecialties would “treat them like glorified residents.” Not anymore. “We are now seen as equals,” he said.

Pediatric hospitalists bring a lot to the table, Dr. Carlson said, such as broad experience in treating acutely or chronically ill hospitalized children; the ability to coordinate care; knowledge in negotiating hospital routines and protocols; and the capacity to manage family fears.

But to survive and prosper, pediatric hospitalists must create value for their institutions, Dr. Melzer said. And value is exactly what evidence-based medicine can generate, he added. Establishing evidence-based guidelines for the treatment of the 10 most common conditions affecting 80% of patients would be a huge step forward in improving patient care, Melzer explained. It would create value for patients and, ultimately, the hospital.

Lending an Ear

Communication is another key, and can be particularly important in caring for children with life-threatening or terminal illnesses, said another speaker, Margaret Hood, MD, of Orlando Healthcare and Palliative Healthcare. Listening to patients and their families is a critical part of end-of-life care.

“The palliative care offered by pediatric hospitalists becomes a lifeline to patients and their families,” she explained. “Sensitive communications can foster hope, even when the news is bad.”

Dr. Hood told the poignant story of a baby born with a lethal heart problem. “I asked her parents, “What do you want?” she said. “They told me, ‘We want her heart to get better.’”

The doctor—and the family—knew that the baby would never get better. “What else would you like?” she asked. “To hold my little girl,” the mother answered. “I have only held her twice in two months.”

“We can do that.” Dr. Hood quickly replied.

Hope comes in many forms—this time in a mother’s arms, as she finally held her daughter before she died.

Frank Talk on Stress and Career Satisfaction

The 24/7 connection hospitalists have with their institutions is the basis for much of their expertise. Then again, that same 24/7 connection can be a source of extraordinary stress.

“It is variable work, with highs and lows in volume and in unscheduled care,” Dr. Carlson explained. “For hospitalized patients, we always need call coverage. That means odd hours—or being on-call in odd hours. It means night work or evening work. Stress carries risks of unplanned turnover, absenteeism, judgment and action errors, conflicts with colleagues, physical illness and mental fatigue.

“Hospitalists may be burning out even quicker than those in other specialties,” Dr. Carlson added. “Hospitalists love clinical care, they love what they do, but they are working in an environment where they must do more and more. We have to learn how to balance enthusiasm for taking care of patients with the demands of the job.”

One area of concern among hospitals and their pediatric hospitalists is workforce stability. Young women make up the majority of the workforce, and hospitals are “dealing continuously with women who are having families,” Dr. Melzer said.

“I have some people using it as a stepping stone to other specialties,” Dr. Carlson said. “They work as pediatric hospitalists while children are young, for flexibility.”

Both Carlson and Melzer believe a sharper definition of the pediatric hospital medicine career track would make a difference. “How do we get others in the hospital to make this job satisfactory?” Dr. Carlson asked. “Hospitalists enjoy the work, but want to balance it … and make a career out of this.”

Recognition from other medical colleagues is critical to job satisfaction. More and more, pediatric hospitalists are playing key leadership roles. “We are increasingly seen as the experts for hospitalized patients,” Dr. Carlson said. “I believe we can do things better than many specialists and many generalists, because we know how hospitals work—and we are there all the time.”

What’s Next?

Implementing plans for the future of pediatric hospital medicine will require collaboration among the many specialists and groups involved in the care of children. Dr. Melzer suggests convening a “leadership summit” for representatives from all of these associations.

Dr. Percelay agreed.

“It’s exciting,” he says. “The fact that the president of the American Board of Pediatrics came and spoke to our community, along with the presidents of SHM, the American Academy of Pediatrics, and the Academic Pediatric Association, is testimony to the role we are playing in the care of hospitalized children in the United States. We need to take a lot of care to make sure we maintain links between pediatric hospitalists and primary care pediatricians.”

That would be in the best interests of all children. TH

Carol Berczuk’s is a medical journalist based in New York.

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