The Future of Pediatric Hospital Medicine: Challenges and Opportunities

Abstract

P ediatric hospital medicine (PHM) is in the midst of an exciting period of growth. In 2016, the American Board of Medical Specialties approved the petition for PHM to become the newest pediatric subspecialty, taking PHM on a divergent path from the Focused Practice in Hospital Medicine designation established for adult hospitalists. Establishment as a subspecialty has allowed PHM to defi ne the unique skills and qualifi cations that hospitalists bring to patients and the healthcare system. These skills and qualifi cations are delineated in the PHM core competencies and national fellowship curriculum. 1,2 In order to realize the vision of PHM to improve care for hospitalized children described by Roberts et al., 3 concerted efforts are needed to train and retain a workforce that is equipped with the skills to catalyze improvements in inpatient pediatric care. We discuss challenges and opportunities facing PHM in workforce development, sustainability of clinical work models, and interhospital collaboration. FELLOWSHIP TRAINING AND THE PHM PIPELINEThe development of PHM as a subspecialty was driven by a number of factors. 4 The acuity of hospitalized children has increased signifi cantly, with a population comprised of more children with complex chronic conditions and/or technology dependence, serious complications of acute conditions, and acute mental health problems. At the same time, the medical and behavioral conditions seen by outpatient general pediatricians have become more complex and time intensive, with these practitioners less likely to work in inpatient settings. Hospitalist care has positive impacts on healthcare effi ciency and value, and both parents and primary care pediatricians report high levels of satisfaction with the healthcare delivered by PHM services. 4 A national count of the number of pediatric hospitalists is currently lacking. Conservative estimates suggest that at least 3,000 pediatric hospitalists currently practice in the United States. 5 These hospitalists have highly varied scopes of practice and work across diverse settings-more diverse, perhaps, than any other pediatric subspecialty. Although diffi cult to quantify, we estimate that approximately one-third of pediatric hospitalists in the US work in community hospitals and the remainder practice at children's hospitals. 6 Many of the needs of hospitalized children differ across these settings, and the roles and challenges faced by hospitalists in these settings correspondingly differ. Community hospitalists frequently take active roles in newborn care and emergency department consultation, often without the support of other pediatric subspecialties. 7 In contrast, hospitalists working at children's hospitals more frequently care for highly complex patients, often collaborate across multiple specialties and assume nonclinical roles in quality improvement (QI), research, and medical education.

A Changing Landscape: Exploring Resident Perspectives on Pursuing Pediatric Hospital Medicine Fellowships

“…2,3 PHM fellowships, the first 3 of which were initiated in the United States in 2003, were developed in response to the growing complexity of hospitalized children and the knowledge that hospitalists play a key role in medical education, quality improvement (QI), care coordination, health informatics, scholarly activity, and more, much of which is not formally taught in residency. [4][5][6] The American Board of Pediatrics approved subspecialty status for PHM in December 2015, and the American Board of Medical Specialties later approved it in October 2016. There are now .30 PHM fellowship programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) and .60 total programs in existence.…”

Domains of professional fulfillment for pediatric hospital medicine: A concept mapping study

“…13 Both academic practice and good mentorship may correlate with increased PF among PHM physicians, while high weekend, overnight, and in-house clinical effort may threaten workforce sustainability. 9,13,14 Interventions to promote PHM PF may be most effective when tailored to these concepts. The objective of this study was to describe how PHM physicians at our institution conceptualize PF.…”

“…The state of PHM PF is not well understood, though limited studies have reported high job satisfaction overall 13 . Both academic practice and good mentorship may correlate with increased PF among PHM physicians, while high weekend, overnight, and in‐house clinical effort may threaten workforce sustainability 9,13,14 . Interventions to promote PHM PF may be most effective when tailored to these concepts.…”

“What next?”: Navigating if pediatric hospital medicine fellowship is right for you

“…Many contended that residency training alone was already producing clinicians who meet the American Academy of Pediatrics definition of a pediatric hospitalist—that is, pediatricians working in the hospital providing care in multiple care settings (pediatric ward, labor and delivery, newborn nursery, emergency department, neonatal, and/or pediatric intensive care units) 1 . However, as core competencies for PHM practice were delineated, there was a growing recognition that the children being cared for in the inpatient setting were increasingly complex 2 . There was also the recognition that, to provide the best clinical care, pediatric hospitalists were ideally suited to lead system‐level efforts that would directly translate to enhanced quality of care delivery for children 2 .…”

“…However, as core competencies for PHM practice were delineated, there was a growing recognition that the children being cared for in the inpatient setting were increasingly complex 2 . There was also the recognition that, to provide the best clinical care, pediatric hospitalists were ideally suited to lead system‐level efforts that would directly translate to enhanced quality of care delivery for children 2 . It became clear that additional training would provide incremental benefit for a growing and complex field.…”