A powerful tool, subspecialty certification should be adopted—and soon
There are many different ways for pediatric hospital medicine to evolve and gain recognition. Board certification with required fellowship training is the most well-known method. For adult hospitalists, recognition of Focused Practice in Hospital Medicine (FPHM) has been established. Residency programs are becoming more innovative, creating additional tracks to provide accelerated fellowship education. What path should be chosen for the future of pediatric hospital medicine?
The decision could be compared to purchasing a cellphone. Simple flip phones are sufficient for making phone calls, just as a graduating pediatrics resident might care for routine inpatients. But the smartphone, like the fellowship/subspecialty certification route, provides advantages that could be worth the additional costs.
You can tell a lot about a person by looking at their cellphone. It often reveals personality traits, professions, and behavioral tendencies. Similarly, administrators, colleagues, and other payors might make assumptions based on fellowship/subspecialty certification status. Pediatric hospitalists should be considered experts in the field of clinical HM, hospital-based research, quality improvement (QI), inpatient procedures, and administrative leadership. Fellowship directors have begun discussing how to standardize these content areas. Subspecialty certification after such training will provide a powerful tool for hospitalists to navigate potentially complex clinical scenarios, hospital bureaucracies and/or academic hierarchies. Fellowship training will add a more concrete identity and standards of quality to our subspecialty.
Smartphones are “smart” because they bring convenience and efficiency. The same can be said about fellowship training. Residency training no longer addresses all the needs of a practicing hospitalist. Although one can attend workshops on QI or research and learn hospital administration, all while on the job, many young hospitalists struggle to adapt quickly early in their career; they might fail to thrive. Fellowship programs would provide a learner-centered environment and protected time to accomplish these goals. Certification would help ensure that trainees have the knowledge and competencies needed for the job. This process, designed to create a well-prepared hospitalist work force, should lead to better advancement within the field, which would mean more hospitalists in meaningful leadership roles and improved quality of hospital care.
The cost of a cellphone and its monthly plan must be taken into account when choosing what purchase. Similarly, the benefits of additional education and recognition must be measured against the costs of additional training. For most, the benefits of well-trained hospitalists outweigh the costs in the long run. Concerns of alienating those without board certification or limiting the work force likely are unfounded. The majority of EDs are staffed by general emergency medicine physicians who do not have pediatric emergency medicine certification—and they all see children, and provide referrals to dedicated children’s facilities when needed. Similarly, community hospital wards can choose to follow suit, depending on their needs.
Fellowship training and subspecialty board certification offer numerous benefits that likely outweigh the costs of a new “plan.” We don’t want just anyone on call; we want a future full of smart hospitalists who are leading practitioners of QI, education, and scholarship.
Dr. Chen is assistant professor in the department of pediatrics at the University of Texas Southwestern in Dallas.
One-size-fits-all approach is not what pediatric hospitalists need
According to Freed et al in the Journal of Hospital Medicine, the central goals of a fellowship in pediatric HM include “advanced training in the clinical care of hospitalized patients, quality improvement (QI), and hospital administration.”1 To determine if certification within pediatric hospital medicine should require a fellowship, it is necessary to decide if there are additional skills beyond those obtained during a pediatric residency that are required for practice as a pediatric hospitalist.
Pediatric residencies are designed to provide residents with the skills to practice in the field of general pediatrics. According to Accreditation Council for Graduate Medical Education (ACGME) standards, just 40% of a resident’s training is required to be in the outpatient setting. There is the expectation that at the end of three years, a resident is capable of spending 95% of their practice in the primary-care setting despite spending less than half of their training in outpatient medicine.
Having a greater focus on inpatient medicine during residency provides a knowledge base that is adequate to start an HM career. As intended, the amount of training dedicated to inpatient and outpatient care in a pediatric residency program is adequate to achieve the skills that make them capable of practicing both inpatient and outpatient care.
Although Freed stated the goal of advanced training, it is unclear what specialized body of knowledge would be gained during a fellowship. The need for advanced clinical training is a concept that is a careerlong, neverending endeavor. Even if this were the reason to require a fellowship, how long is long enough to have mastered clinical care?
One year? Two years? 35 years? If more than half of a three-year residency is not enough time to provide residents the education and training to care for hospitalized inpatients, we should not require more training; we should fix our current training system.
Administrative experience and training in QI and research are important skills that can help advance a hospitalist’s career. It is important to recognize that because these skills are not required for all pediatric hospitalist positions, it would be unnecessary for all hospitalists to attain these skills in a fellowship. In addition, for those interested in administration or research, there are many other ways to attain those skills, including the APA educational scholars program or obtaining a master’s degree in medical education. The added benefit of these avenues for additional skills is that they can be completed throughout a career as a pediatric hospitalist.
As pediatric hospital medicine is a field in its early stages, it is important to consider all options for certification. While fellowship training has been the path for many subspecialties within pediatrics, HM will be better served by recognizing the need to remain inclusive. The positions within HM are broad, and the training should be individualized for the skills each physician requires.
Dr. Eagle is a hospitalist in the general medicine service at The Joseph M. Sanzari Children’s Hospital at Hackensack University Medical Center in New Jersey.
- Freed G, Dunham K. Characteristics of pediatric hospital medicine fellowships and training programs. J Hosp Med. 2009;4(3):157-163.