From the Society

Pediatric hospital medicine marches toward subspecialty recognition


 

Pediatric hospital medicine is moving quickly toward recognition as a board-certified, fellowship-trained medical subspecialty, joining 14 other pediatric subspecialties now certified by the American Board of Pediatrics (ABP).

It was approved as a subspecialty by the American Board of Medical Specialties (ABMS) at its October 2016 board meeting in Chicago in response to a petition from the ABP. Following years of discussion within the field,1 it will take 2 more years to describe pediatric hospital medicine’s specialized knowledge base and write test questions for biannual board exams that are projected to commence in the fall of 2019.

Dr. Daniel Rauch, associate director of pediatrics at Elmhurst Hospital Center, Queens, N.Y.

Dr. Daniel Rauch

“Now begins the work of an ABP sub-board on pediatric hospital medicine, which I chair, to establish the criteria that would allow one to sit for board certification and to define the core content specific to this field, which will provide the basis for the certifying exam,” said Daniel Rauch, MD, FHM, associate director of pediatrics at Elmhurst Hospital Center, Queens, N.Y. Although passing the exam is a necessary requirement for achieving board certification in the subspecialty, qualifying to sit for the exam will be possible through an experiential or practice pathway the first three times the exam is offered – in 2019, 2021 and 2023.

Eventually, starting in 2025, pediatric hospitalists will need to complete a fellowship of 2 years or more if they wish to sit for the exam and become board-certified in the field. But for the next 7 years, hospitalists in current practice will be able to qualify based on their work experience. Maintenance of certification requirements likely will be similar to those in other subspecialties, and doctors certified in pediatric hospital medicine won’t be required to maintain general pediatric certification, Dr. Rauch said.

Formal eligibility criteria have not been set, but likely will include working half-time overall in pediatric-related activities, and quarter-time in clinical practice in pediatric hospital medicine for 4 years prior to qualifying for the exam. How the hours might break down between clinical and other hospital responsibilities, and between pediatric or adult patients, still needs to be determined, Dr. Rauch said. He added that the experiential pathway is likely to be defined broadly, with latitude for determinations based on percentages of time worked, rather than absolute number of hours worked. Local pediatric institutions will be granted latitude to determine how that “plays out” in real world situations, he said, “and an ABP credentialing committee will be available to hear appeals for people who have complicated life circumstances.”

Dr. Ricardo Quinonez, past chair of AAP's Section on Hospital Medicine, chief of the division of pediatric hospital medicine at Texas Children's Hospital--Baylor College of Medicine, Houston.

Dr. Ricardo Quinonez

The Society of Hospital Medicine (SHM) didn’t have any formal role in developing subspecialty certification, although it includes members who work in pediatrics and led the development of Pediatric Hospital Medicine Core Competencies,2 a cornerstone of the field’s development, said Ricardo Quinonez, MD, FAAP, FHM, past chair of the AAP’s Section on Hospital Medicine and chief of the division of pediatric hospital medicine at Texas Children’s Hospital, Baylor College of Medicine, Houston.

“I was part of a committee that explored these issues. We were an independent group of hospitalists who decided that board certification was a good way to advance the field,” Dr. Quinonez said. “We’ve seen what subspecialty certification has done, for example, for pediatric emergency medicine and pediatric critical care medicine – advancing them tremendously from a research standpoint and helping to develop a distinct body of knowledge reflecting increased severity of illness in hospitalized children.”

Discrepancy between practicing hospitalists, fellowships

An estimated 4,000 pediatric hospitalists now practice in the United States, and 2,100 of those belong to the American Academy of Pediatrics’ Section on Hospital Medicine. There are 40 pediatric hospital medicine fellowship programs listed on the website of AAP’s Section on Hospital Medicine (http://phmfellows.org/phm-programs/), although formal training assessment criteria will be needed for the American College of Graduate Medical Education to recognize programs that qualify their fellows to sit for the PHM exam. A wide gap is anticipated between the demand for pediatric hospitalists and currently available fellowship training slots to generate new candidates for board certification, although Dr. Rauch projects that fellowship slots will double in coming years.

“My message to the field is that historically, board certification has been the launching point for further development of the field,” Dr. Rauch said. “It leads to standardization of who is a subspecialist. Right now, who is a pediatric hospitalist is subject to wide variation. We need to standardize training and to create for this field the same distinction and stature as other medical subspecialties,” he said, noting that subspecialty status also has ramifications for academic settings, and for career advancement and career satisfaction for the individuals who choose to pursue it.

“I know there has been some hue and cry about this in the field, but in most cases certification will not change a pediatric hospitalist’s ability to obtain a job,” he said. “Already, you can’t become a division leader at a children’s hospital without additional training. This isn’t going to change that reality. But for people who don’t want to follow an academic career path, there will never be enough board-certified or fellowship-trained pediatric hospitalists to fill all of the pediatric positions in all the hospitals in the country. Community hospitals aren’t going to say: We won’t hire you unless you are board certified.”

Is the fellowship good for the field?

The subspecialty development process clearly is moving forward. Those in favor believe it will increase scholarship, research, and recognition for the subspecialty by the public for its specialized body of knowledge. But not everyone in the field agrees. Last fall The Hospitalist published3 an opinion piece questioning the need for fellowship-based board certification in pediatric hospital medicine. The author recommended instead retaining the current voluntary approach to fellowships and establishing a pediatric “focused practice” incorporated into residency training, much as the American Board of Internal Medicine and the American Board of Family Medicine have done for hospitalists in adult medicine.

Dr. Weijen W. Chang, pediatric editor of The Hospitalist News, and  chief of the division of pediatric hospital medicine at Baystate Children's Hospital, Springfield, Mass.

Dr. Weijen W. Chang

Weijen Chang, MD, SFHM, chief of the division of pediatric hospital medicine at Baystate Children’s Hospital in Springfield, Mass., wrote an introduction for that article. He wonders if board certification will eventually become necessary to continue seeing pediatric patients in the hospital. “This process leaves that question to local hospitals as the decision makers. But we can’t know what your local hospital credentialing committee will do,” he said.

“Will it lead to uncertainty among those currently in residency programs? If you are a pediatric resident and you want to become a board-certified pediatric hospitalist, you’ll need at least 2 years more of training. Is that going to deter qualified individuals?” Dr. Chang said. “The people this decision will impact the most are med-peds doctors – who complete a combined internal medicine and pediatrics residency – and part-timers. They may find themselves in a difficult position if the number of hours don’t add up for them to sit for the boards. For the most part, we’ll have to wait and see for answers to these questions.”

Brian Alverson, MD, FAAP, current chair of the AAP’s Section on Hospital Medicine and associate professor of pediatrics at Brown University, Providence, R.I., says he can see both sides of the debate.

Dr. Brian Alverson, chair of AAP's Section on Hospital Medicine and associate professor of pediatrics at Brown University, Providence, R.I

Dr. Brian Alverson

“I think for the field of pediatric hospital medicine, as far as advancing our knowledge and the care of children in the hospital, this is a very good thing,” he said. “It will push academic children’s hospitals that don’t have a division of hospital medicine to invest in one. All of the really sick children are in the hospital, and if we’re going to attend to those children at their most vulnerable time, we need to address the existing knowledge gap in pediatric hospital medicine.”

But at the same time, there is a significant opportunity cost for doing 2 more years of fellowship training, Dr. Alverson said.

“We don’t know how much the board certification test will improve actual care,” he noted. “Does it truly identify higher quality doctors, or just doctors who are good at taking multiple choice exams? There are a number of people in pediatrics who do a lot of different things in their jobs, and it’s important that they not lose their ability to practice in the field. Two-thirds of our work force is in community hospitals, not academic medical centers. They work hard to provide the backbone of hospital care for young patients, and many of them are unlikely to ever do a fellowship.”

Nonetheless, Dr. Alverson believes pediatric hospitalists needn’t worry. “You still have plenty of time to figure out what’s going to happen in your hospital,” he said.

References

1. Section on Hospital Medicine. Guiding principles for pediatric hospital medicine program. Pediatrics; 2013; 132:782-786.

2. Stucky E. The Pediatric Hospital Medicine Core Competencies. Wiley-Blackwell; 2010.

3. Feldman LS, Monash B, Eniasivam A. Why required pediatric hospital medicine fellowships are unnecessary. The Hospitalist Magazine, October 8, 2016.

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