I am decidedly anti-politics. The entire process seems fatally flawed. The vast majority of the public votes based on one or two emotional interests, such as religion or personal finances. The candidates’ responses are calculated, based on the millions of dollars they receive from competing interest groups and evidence-based analysis of what will garner the most votes. So for me at this time of year, watching debates and TV coverage of primaries is akin to watching an MTV reality show—lots of drama, little substance.
But there is one election (of sorts) this year that gives me hope: Our input has been solicited by the Strategic Planning (STP) Committee to help sort through the issue of certification in pediatric hospital medicine. What is potentially at stake here is how we define ourselves as a field. At one end is the traditional, three-year fellowship with certification as a subspecialty. At the other end is no change, or the status quo. In between are myriad options, each with unique pros and cons. It is all summarized at the STP blog (http://stpcommittee.blogspot.com), which allows for input.
This is a unique opportunity, as pediatric HM is at a crossroads. The STP Committee states that this solicitation of public comment is different from processes that other fields (pediatric emergency medicine, child abuse, adult hospital medicine) have used, and it will allow for more engagement of the pediatric hospitalist community at large. I agree. And I heartily endorse an open forum for this process.
What happens after this is somewhat less clear, but it involves synthesis of all of the input and presentation to the Joint Council of Pediatric Hospital Medicine (JCPHM). In addition, the American Pediatric Association (APA), the American Academy of Pediatrics (AAP), and SHM representatives will solicit feedback from their leadership and membership. A minor drawback of this process is the fact that the JCPHM remains a somewhat mythical body to date, as it has not been publicly defined to my knowledge. But this will be the body that makes the final decision.
OK, enough of the sausage-making (“laws are like sausages: It is best not to see them being made”) and on to the actual candidates. I suppose we should begin with the “incumbent”—the status quo. I will not rehash the pros and cons that have been meticulously laid out by the STP Committee on the website. But I will add that this candidate has the benefit of being well-known and is the least complicated option. Unfortunately, it’s also the least sexy option, which I’m told is actually a factor in elections. Given the number of alternatives that the committee has laid out, I’m not going with this one, simply because there has to be a better one out there.
I also immediately discount the option on the other end of the spectrum: a full three-year fellowship (the current standard for subspecialists). We’re all familiar with the details of this option, but the year of research is, on average, a bigger waste of time than college calculus. I remember a lot of fellows who didn’t care about research; they were sleeping next to me in the clinical research classes, ones that I was taking in my spare time. They completed projects to get through the fellowship, and that was it for “research” in their careers. Now, I can’t exclude the fact that they learned something from those projects, but the American Board of Pediatrics (ABP) clearly states that the “rationale for including a requirement for participation in scholarly activity flows from the belief that the principal goal of fellowship training should be the development of future academic pediatricians.”1 Practice in a community hospital is quite different from that of an academic pediatrician.
(This is not to say that we do not need a pipeline of future academic leaders, an absolute necessity for our young field. However, if we are to decide certification options for everyone, I think we should focus on a set of minimum requirements and have additional options, or tracks, for academicians. Thus, I would reframe the debate to focus on what every hospitalist needs.)
What is really needed to train effective pediatric hospitalists? I think we begin by acknowledging that additional clinical training is a priority for several reasons:
- Pediatric residents are receiving less and less inpatient training;
- Our patients are increasingly complex; and
- The hospital is a unique and complicated system within which to practice.
I was trained in the good ol’ days, before duty hours, and I was still pretty dumb when I started as an attending. While I don’t think it’s difficult for new grads to learn on the job, once you pay someone a full salary and give them billing as a full-fledged attending, you lose a lot of leeway—on both sides—to structure their education.
Some standard of quality and safety training should be included in this minimum requirement. One byproduct of the quality movement in medicine is that we now clearly understand that hospitals are complex systems with many moving parts. Interacting in that system, and providing safe and effective care within those confines, requires a certain set of knowledge, attitudes, and skills—particularly if we are to be leaders in hospital practice. It is no longer sufficient to be just a hospital-based doctor with no extramural involvement in improving the system. Strategically, this would be of value to both hospital administrators and academic institutions, our primary funding streams.
So I vote for some set of minimum requirements. And I think that has to be the focus of our initial discussion. Once those are decided, the immediate next issue should be whether this is implemented as a fellowship or through focused practice. Here, I lean towards the former, as I think that a fellowship allows us to better control the quality of that training. The final issue is which option to choose, but I think that becomes a formality once minimum requirements are decided; in many instances, there may be more than one option that works.
So do your part, and contribute to the discussion. But don’t just pick an option. Describe what you think hospitalists of tomorrow need when they start their careers. And enjoy this refreshing process, one without the irrationalities of politics and something that we can all buy into for the future of pediatric HM.
Dr. Shen is pediatric editor of The Hospitalist and medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas.