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Gender bias and pediatric hospital medicine

Where do we go from here?


 

Autumn is a busy time for pediatric hospitalists, with this autumn being particularly eventful as the first American Board of Pediatrics (ABP) certifying exam for Pediatric Hospital Medicine (PHM) will be offered on Nov. 12, 2019.

Dr. Anika Kumar, Cleveland Clinic Children's

Dr. Anika Kumar

More than 1,600 med/peds and pediatric hospitalists applied to be eligible for the 2019 exam, 71% of whom were women. At least 3.9% of those applicants were denied eligibility for the 2019 exam.1 These denials resulted in discussions on the American Academy of Pediatrics Section on Hospital Medicine (AAP SOHM) email listserv related to unintentional gender bias.

PHM was first recognized as a subspecialty by the American Board of Medical Specialties in December 2015.2 Since that time, the ABP’s PHM sub-board developed eligibility criteria for practicing pediatric and med/peds hospitalists to apply for the exam. The sub-board identified three paths: a training pathway for applicants who had completed a 2-year PHM fellowship, a practice pathway for those satisfying ABP criteria for clinical activity in PHM, and a combined pathway for applicants who had completed PHM fellowships lasting less than 2 years.

Based on these pathways, 1,627 applicants applied for eligibility for the first PHM board certification exam.1 However, many concerns arose with the practice pathway eligibility criteria.

The PHM practice pathway initially included the following eligibility criteria:

• General pediatrics board certification.

• PHM practice “look back” period ends on or before June 30 of the exam year and starts 4 years earlier.

• More than 0.5 FTE professional PHM-related activities (patient-care, research, administration), defined as more than 900 hours/year every year for the preceding 4 years.

• More than 0.25 FTE direct patient care of hospitalized children, defined as more than 450 hours/year every year for the preceding 4 years.

• Practice covers the full range of hospitalized children with regard to age, diagnoses, and complexity.

• Practice interruptions cannot exceed 3 months in the preceding 4 years, or 6 months in the preceding 5 years.

• Practice experience and hours were acquired in the United States and Canada.1,3

The start date and practice interruptions criteria in the practice pathway posed hurdles for many female applicants. Many women voiced concerns about feeling disadvantaged when applying for the PHM certifying exam and some of these women shared their concerns on the AAP SOHM email listserv. In response to these concerns, the PHM community called for increased transparency from the ABP related to denials, specifically related to unintentional gender bias against women applying for the exam.

David Skey, MD, and Jamee Walters, MD, pediatric hospitalists at Arnold Palmer Medical Center in Orlando, heard these concerns and decided to draft a petition with the help of legal counsel. The petition “demand[ed] immediate action,” and “request[ed] a formal response from the ABP regarding the practice pathway criteria.” The petition also stated that there was insufficient data to determine if the practice pathway “disadvantages women.” The petition asked the ABP to “facilitate a timely analysis to determine if gender bias” was present, or to perform an internal analysis and “release the findings publicly.”4

The petition was shared with the PHM community via the AAP SOHM listserv on July 29, 2019. Dr. Walters stated she was pleased by the response she and Dr. Skey received from the PHM community, on and off the AAP SOHM listserv. The petition was submitted to the ABP on Aug. 6, 2019, with 1,479 signatures.

On Aug. 29, 2019, the ABP’s response was shared on the AAP SOHM email listserv1 and was later published in the Journal of Hospital Medicine as a Special Announcement.5 In its response, the ABP stated that the gender bias allegation was “not supported by the facts” as there was “no significant difference between the percentage of women and men who were denied” eligibility.”5 In addressing the gender bias allegations and clarifying the practice pathway eligibility, the ABP removed the practice interruption criteria and modified the practice pathway criteria as follows:

• General pediatrics board certification.

• PHM practice started on or before July 2015 (for board eligibility in 2019).

• Professional PHM-related activities (patient-care, research, administration), defined as more than 900-1000 hours/year every year for the preceding 4 years.

• Direct patient care of hospitalized children, defined as more than 450-500 hours/year every year for the preceding 4 years.

• Practice covers the full range of hospitalized children with regard to age, diagnoses, and complexity.

• Practice experience and hours were acquired in the United States and Canada.1

Following the release of the ABP’s response, many members of the PHM community remain concerned about the ABP’s revised criteria. Arti Desai, MD, pediatric hospitalist at Seattle Children’s and senior author on a “Perspectives in Hospital Medicine” in the Journal of Hospital Medicine,6 was appreciative that the ABP chose to remove the practice interruptions criterion. However, she and her colleagues remain concerned about lingering gender bias in the ABP’s practice pathway eligibility criteria surrounding the “start date” criterion. The authors state that this criterion differentially affects women, as women may take time off during or after residency for maternity or family leave. Dr. Desai states that this criterion alone can affect a woman’s chance for being eligible for the practice pathway.

Other members of the PHM community also expressed concerns about the ABP’s response to the PHM petition. Beth C. Natt, MD, pediatric hospitalist and director of pediatric hospital medicine regional programs at Connecticut Children’s in Hartford, felt that the population may have been self-selected, as the ABP’s data were limited to individuals who applied for exam eligibility. She was concerned that the data excluded pediatric hospitalists who chose not to apply because of uncertainty about meeting eligibility criteria. Klint Schwenk, MD, pediatric hospitalist at Norton Children’s Hospital in Louisville, Ky., stated that he wished the ABP had addressed the number of pediatric hospitalists who elected not to apply based on fear of ineligibility before concluding that there was no bias. He likened the ABP’s response to that of study authors omitting selection bias when discussing the limitations of their study.

Courtney Edgar-Zarate, MD, med/peds hospitalist and associate program director of the internal medicine/pediatrics residency at the University of Arkansas, expressed concerns that the ABP’s stringent clinical patient care hours criterion may unintentionally result in ineligibility for many mid-career or senior med/peds hospitalists. Dr. Edgar-Zarate also voiced concerns that graduating med/peds residents were electing not to pursue careers in hospital medicine because they would be required to complete a PHM fellowship to become a pediatric hospitalist, when a similar fellowship is not required to practice adult hospital medicine.

The Society of Hospital Medicine shared its position in regard to the ABP’s response in a Special Announcement in the Journal of Hospital Medicine.7 In it, SHM’s pediatric leaders recognized physicians for the excellent care they provide to hospitalized children. They stated that SHM would continue to support all hospitalists, independent of board eligibility status, and would continue to offer these hospitalists the merit-based Fellow designation. SHM’s pediatric leaders also proposed future directions for the ABP, including a Focused Practice Pathway in Hospital Medicine (FPHM), such as what the American Board of Internal Medicine and the American Board of Family Medicine have adopted for board recertification in internal medicine and family medicine. This maintenance of certification program that allows physicians primarily practicing in inpatient settings to focus their continuing education on inpatient practice, and is not a subspecialty.7

Dr. Edgar-Zarate fully supports the future directions for pediatric hospitalists outlined in SHM’s Special Announcement. She hopes that the ABP will support the FPHM. She feels the FPHM will encourage more med/peds physicians to practice med/peds hospital medicine. L. Nell Hodo, MD, a family medicine–trained pediatric hospitalist at Icahn School of Medicine at Mount Sinai in New York, joins Dr. Edgar-Zarate in supporting an FPHM for PHM, and feels that it will open the door for hospitalists who are ineligible for the practice pathway to be able to focus their recertification on the inpatient setting.

Dr. Hodo and Dr. Desai hope that rather than excluding those who are not PHM board eligible/certified, institutions and professional organizations will consider all qualifications when hiring, mentoring, and promoting physicians who care for hospitalized children. Dr. Natt, Dr. Schwenk, Dr. Edgar-Zarate, and Dr. Hodo appreciate that SHM is leading the way, and will continue to allow all hospitalists who care for children to receive Fellow designation.

Dr. Kumar is clinical assistant professor of pediatrics at the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University and a pediatric hospitalist at Cleveland Clinic Children’s. She is the pediatric editor of The Hospitalist.

References

1. The American Board of Pediatrics. The American Board of Pediatrics response to the Pediatric Hospital Medicine petition. https://www.abp.org/sites/abp/files/phm-petition-response.pdf. Published 2019.

2. Barrett DJ, McGuinness GA, Cunha CA, et al. Pediatric hospital medicine: A proposed new subspecialty. Pediatrics. 2017;139(3). doi: 10.1542/peds.2016-1823.

3. The American Board of Pediatrics. Pediatric Hospital Medicine Certification. https://www.abp.org/content/pediatric-hospital-medicine-certification. Published 2019.

4. Skey D. Pediatric Hospitalists, It’s time to take a stand on the PHM Boards Application Process! Five Dog Development, LLC.

5. Nichols DG, Woods SZ. The American Board of Pediatrics response to the Pediatric Hospital Medicine petition. J Hosp Med. 2019 Oct;14(10):586-8. doi: 10.12788/jhm.3322.

6. Gold JM et al. Collective action and effective dialogue to address gender bias in medicine. J Hosp Med. 2019 Oct;14(10):630-2. doi: 10.12788/jhm.3331.

7. Chang WW et al. Society of Hospital Medicine position on the American Board of Pediatrics response to the Pediatric Hospital Medicine petition. J Hosp Med. 2019 Oct;14(10):589-90. doi: 10.12788/jhm.3326.

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