(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.