The Pediatric Hospital Medicine Core Competencies: 2020 Revision

The transition to Pediatric Hospital Medicine fellowship: A national survey-based needs assessment

BACKGROUND

Each year, the number of fellows entering Pediatric Hospital Medicine (PHM) fellowship is increasing. Residency curricula do not always prepare trainees for all aspects of PHM as a specialty and gaps often exist in the transition to fellowship.

OBJECTIVE

To explore the preparedness of PHM fellows for clinical, teaching, and scholarship tasks at the start of fellowship and to identify opportunities for residency and fellowship program development.

DESIGN

Quantitative survey.

SETTING AND PARTICIPANTS

Current and recently graduated PHM fellows (matriculation years 2019-2022).

METHODS

We conducted a national cross-sectional survey from July 2022 to February 2023. We designed survey questions based on PHM fellowship core competencies.

MAIN OUTCOME AND MEASURES

We asked participants to rate preparedness for tasks on a 5-point Likert scale (1 = very unprepared, 5 = very prepared). We analyzed numerical data using descriptive and comparative statistics and free-response data using inductive content analysis.

RESULTS

We received 223 responses to our survey (response rate 74%). Of the respondents, 25% reported no PHM-specific orientation at their program (n = 55). Respondents reported lower median preparedness for research (3, interquartile range [IQR] [2,4]) and teaching tasks (4, IQR [4,4]) compared to clinical tasks (4, IQR [4,5]) at the start of fellowship (p < 0.01, p < 0.01). Content analysis revealed most fellows wished they had received more training around scholarship at the start of fellowship.

CONCLUSIONS

Many PHM fellows enter fellowship feeling inadequately prepared, particularly in scholarship and teaching. Our findings suggest that residency and fellowship programs need to develop more robust curricula to better prepare trainees for successful PHM fellowship. This national survey-based needs assessment should serve as a guide for further program development.

Drawing attention? Going through judgments regarding child and adolescent suicide attempts in emergency rooms from a professional perspective

OBJECTIVE

To understand the perceptions of the multidisciplinary team of an emergency department regarding the care of children and adolescents who have attempted suicide.

METHOD

An exploratory-descriptive, qualitative study, in light of the Symbolic Interactionism theoretical framework. Thirteen professionals from the multidisciplinary team from two emergency rooms (children and adults) of a secondary hospital in São Paulo participated. Data were collected between August and September 2018 using semi-structured interviews, analyzed using thematic content analysis complemented by the IRAMUTEQ® software.

RESULTS

Two central categories emerged: Multidisciplinary team perceptions regarding attempted suicide care; and Multidisciplinary team perceptions regarding the possibilities for improving attempted suicide care. From these, professional perceptions of care, risk factors, emotional reactions, limitations of emergency rooms and strategies for improving practice were observed.

CONCLUSION

Professionals perceived suicide attempt care from a biomedical and reductionist perspective, with an approach marked by stigma, judgment and lack of preparation.

Child Health Needs and the Pediatric Hospital Medicine Workforce: 2020-2040

Pediatric hospital medicine (PHM) established a new model of care for hospitalized children in the United States nearly 3 decades ago. In that time, the field experienced rapid growth while distinguishing itself through contributions to medical education, quality improvement, clinical and health services research, patient safety, and health system leadership. Hospital systems have also invested in using in-house pediatricians to manage various inpatient care settings as patient acuity has accelerated. National PHM leaders advocated for board certification in 2014, and the first certification examination was administered by the American Board of Pediatrics in 2019. In this article, we describe the development of the subspecialty, including evolving definitions and responsibilities of pediatric hospitalists. Although PHM was not included in the model forecasting future pediatric subspecialties through 2040 in this supplement because of limited historical data, in this article, we consider the current and future states of the workforce in relation to children's health needs. Expected challenges include potential alterations to residency curriculum, changes in the number of fellowship positions, expanding professional roles, concerns related to job sustainability and burnout, and closures of pediatric inpatient units in community hospitals. We simultaneously forecast growing demand in the PHM workforce arising from the increasing prevalence of children with medical complexity and increasing comanagement of hospitalized children between pediatric hospitalists and other subspecialists. As such, our forecast incorporates a degree of uncertainty and points to the need for ongoing investments in future research to monitor and evaluate the size, scope, and needs of pediatric hospitalists and the PHM workforce.

Comanagement of Surgical Pediatric Patients in the Acute Care Inpatient Setting

The care of children with primary surgical diagnoses in acute care units often involves a shared surgical and medical model ("comanagement"). There are no formal guidelines for how such programs should be structured or care provided. We used a modified Delphi process, including national experts in pediatrics and pediatric medical subspecialties, pediatric surgical specialties, and pediatric anesthesiology, to develop recommendations for best practices for comanagement programs in community and tertiary care settings.

Pediatric Hospitalists' Performance of Recommended Minor Procedures: A Multicenter Study

BACKGROUND AND OBJECTIVES

Performance of minor procedures is highly variable among pediatric hospitalists. Our objective was to describe procedural frequency and measure self-assessed competence in recommended minor procedures among practicing hospitalists.

METHODS

An electronic survey was administered across 20 US institutions. An individual survey assessed training, frequency, independence, and success in performing 11 minor procedures. The site survey described practice settings at participating study sites. The primary outcome was respondents' self-assessed competence (SAC), derived by averaging self-assessed independence and success scores (each on a 5-point Likert scale) across all 11 minor procedures. Associations between predictor variables and SAC were determined through analysis of variance for categorical variables and fitted regression models for continuous variables.

RESULTS

Of the 360 survey respondents, the majority were female (70%), not fellowship trained (78%), and had 10 years or fewer experience as a hospitalist (72%). Lumbar puncture and bag mask ventilation were most frequently performed. Greater procedural frequency and time since graduation from training were associated with higher SAC scores among respondents. Practice characteristics, including comanagement of patients and reserved time for practicing procedures, were associated with higher SAC scores. The presence of a simulation center and fellowship program was not associated with higher SAC scores.

CONCLUSIONS

Pediatric hospitalists that performed procedures more frequently had higher self-assessed procedural competence. Tailored opportunities with increased hands-on experience in performing minor procedures may be important to develop and maintain procedural skills.

The Core Competencies in Hospital Medicine-Clinical Conditions 2023 Update Methodology

As hospital medicine continues to evolve, the Society of Hospital Medicine (SHM) recognizes the importance of periodic re-evaluation and adaptation of The Core Competencies in Hospital Medicine to reflect and guide the continual expansion of hospitalists' scope of practice. Since its first publication in 2006, the Core Competencies were last revised in 2017 to reflect existing practice. The Core Competencies were initially developed to describe hospitalists' roles and expectations and identify growth opportunities. As hospital medicine has expanded, SHM seeks to maintain the Core Competencies as a framework to guide curricular development, enhance practice assessment, improve the quality of care, and cultivate systems-based practices. Additionally, it helps elucidate the clinical and systems-based aspects central to the field. Thus, the new chapters in the 2023 clinical conditions update focus on enhancing individual hospitalist practice in evaluating and managing common clinical conditions. The accompanying article describes the chapter review and revision process and the criteria for new chapter selection.

Development of an Approach to Assessing Pediatric Fellows' Transport Medical Control Skills

BACKGROUND AND OBJECTIVE

Pediatric interfacility transport teams facilitate access to subspecialty care, and physicians often guide management remotely as transport medical control (TMC). Pediatric subspecialty fellows frequently perform TMC duties, but tools assessing competency are lacking. Our objective was to develop content validity for the items required to assess pediatric subspecialty fellows' TMC skills.

METHODS

We conducted a modified Delphi process among transport and fellow education experts in pediatric critical care medicine, pediatric emergency medicine, neonatal-perinatal medicine, and pediatric hospital medicine. The study team generated an initial list of items on the basis of a literature review and personal experience. A modified Delphi panel of transport experts was recruited to participate in 3 rounds of anonymous, online voting on the importance of the items using a 3-point Likert scale (marginal, important, essential). We defined consensus for inclusion as ≥80% agreement that an item was important/essential and consensus for exclusion as ≥80% agreement that an item was marginal.

RESULTS

The study team of 20 faculty drafted an initial list of items. Ten additional experts in each subspecialty served on the modified Delphi panel. Thirty-six items met the criteria for inclusion, with widespread agreement across subspecialties. Only 1 item, "discussed bed availability," met the criteria for inclusion among some subspecialties but not others. The study team consolidated the final list into 26 items for ease of use.

CONCLUSIONS

Through a consensus-based process among transport experts, we generated content validity for the items required to assess pediatric subspecialty fellows' TMC skills.

Defining Supervision Preferences and Roles Within a New Subspecialty: Pediatric Hospital Medicine

OBJECTIVE

To describe supervision preferences among pediatric hospitalists, Pediatric Hospital Medicine (PHM) fellows, and senior residents (SRs), and to better define the ideal role of a PHM fellow.

METHODS

We conducted a cross-sectional survey study at 6 institutions nationwide. We developed 3 complementary surveys, one for each population (hospitalists, fellows, SRs). We calculated univariate descriptive and bivariate statistics for categorical variables using Chi-square tests with the Rao-Scott correction to account for clustering by institution.

RESULTS

Survey respondents included 106 of 200 hospitalists (53%), all 20 fellows (100%), and 149 of 380 SRs (39%). Most hospitalists and all fellows preferred the supervising hospitalist to have 3+ years of experience or be fellowship-trained. Nearly all fellows preferred the attending round in-person providing progressive independence; while hospitalists and SRs desired greater attending presence on rounds. Hospitalists and fellows wanted more frequent communication when the attending does not round with the team, and more hospitalists desired at least 2 points of contact regardless of attending presence on rounds. Fifty-five percent of SRs reported experiencing much less/less autonomy when on with a fellow than when supervised by a hospitalist only. Regarding the fellow's role, most participants agreed SRs should lead rounds and contact the fellow first with questions. The majority agreed teaching should be a shared responsibility but lacked consensus about how to provide feedback.

CONCLUSIONS

Study results reveal preferences about supervising fellows in this new subspecialty. Hospitalists, fellows, and SRs may have differing opinions regarding workflow, communication, and teaching, impacting team leadership and autonomy.

Late-Career Pediatric Hospitalists: Programmatic Accommodations and Supports

BACKGROUND

As the number of late-career pediatric hospitalists increases, issues regarding aging and retirement will require more attention. Long shifts and overnight clinical responsibilities may be challenging for older physicians. Our study objectives include investigation of the current state of practice regarding work hours, night call responsibilities, productivity requirements, coronavirus disease 2019 (COVID-19) exposure modifications, and division chief knowledge about retirement supports for late-career pediatric hospitalists.

METHODS

This cross-sectional study used a web survey, distributed in spring of 2020 on the American Academy of Pediatrics, Section on Hospital Medicine, Division Chief listserv. The questionnaire asked about (1) program demographics, (2) overnight call responsibilities, (3) clinical schedules, (4) modifications for COVID-19, and (5) retirement benefits and supports. Data were analyzed by using descriptive statistics and the Fisher exact test.

RESULTS

The 47 responding programs employ 982 hospitalists in 728 full-time equivalent positions. Division chiefs estimated 117 (12%) individuals were aged 50 to 64 years and 16 (1.6%) were 65 years or older. Most programs (91%) had at least 1 member 50 to 64 years of age; 13 programs (28%) had a member aged 65 or older. Larger programs were more likely to allow older physicians to opt out of some night call responsibilities. Most programs made some accommodations for COVID-19 exposure. Other than financial counseling and academic benefits, most programs did not provide retirement counseling or other supports for retiring physicians.

CONCLUSION

Although limited by a low response rate, we found most programs had older faculty. Substantial variation exists in how programs make accommodations and offer support for older members.

Preparing for a Career in Pediatric Hospital Medicine: A Needs Assessment and Recommendations for Individualized Curricula

OBJECTIVES

The individualized curriculum within residency programs allows residents to tailor their elective time toward future career goals and interests. Our objective was to identify experiences and activities that would foster resident interest and enhance preparation for a career in pediatric hospital medicine (PHM).

METHODS

Electronic surveys were distributed to pediatric hospitalists, PHM fellowship directors, and graduating PHM fellows. These stakeholders were asked to identify key experiences for residents to explore before entering fellowship or practice. Descriptive statistics and thematic analysis were performed on survey responses.

RESULTS

Forty-six percent of PHM fellows (16 of 35), 42% of pediatric hospitalists (149 of 356), and 58% of fellowship program directors (35 of 60) completed the survey. All 3 groups identified complex care as the most important clinical experience to gain in residency. Other highly valued clinical experiences included pain management, surgical comanagement, and palliative care. Lumbar puncture, electrocardiograph interpretation, and airway management were identified as essential procedural skills. Nonclinical experiences that were deemed important included quality improvement, development of teaching skills, and research methodology. All groups agreed that these recommendations should be supplemented with effective mentorship.

CONCLUSIONS

Identification of key clinical experiences, nonclinical activities, and mentorship for residents interested in PHM may assist with tailoring the individualized curriculum to personal career goals. Incorporating these suggested experiences can improve preparedness of residents entering PHM.

Responsibilities and Interests of Pediatricians Practicing Hospital Medicine in the United States

BACKGROUND AND OBJECTIVES

In 2016, the American Board of Medical Specialties (ABMS) approved pediatric hospital medicine (PHM) as the newest pediatric subspecialty. To characterize development of the field, this article aims to: (1) describe the responsibilities and practice settings of US pediatricians self-identifying as hospitalists; and (2) determine how exclusive PHM practice, compared with PHM practice in combination with general or subspecialty care, was associated with professional development interests.

METHODS

Pediatricians enrolling in the 2017-2018 American Board of Pediatrics (ABP) Maintenance of Certification program were offered a voluntary survey about their responsibilities, interests, and practice settings. Logistic regression was employed to characterize associations between exclusive PHM practice and: (1) interest in quality improvement (QI) leadership; (2) intention to take the PHM certifying exam; (3) satisfaction with allocation of professional time; and (4) intention to maintain more than one ABP certification.

RESULTS

The survey response rate was 70.0%; 1662 (13.1%) self-reported PHM practice. Four-hundred ninety-one (29.5%) practiced PHM exclusively, 518 (31.1%) practiced PHM and general pediatrics, and 653 (39.3%) practiced PHM and one or more subspecialties. Respondents reporting exclusive PHM practice were significantly more likely to report interest in QI leadership or consultation (adjusted odds ratio [OR], 1.39; 95% CI, 1.09-1.79), PHM exam certification (adjusted OR, 7.10; 95% CI, 5.45-9.25), and maintenance of more than one ABP certification (adjusted OR, 2.64; 95% CI, 1.89-3.68).

CONCLUSIONS

Hospitalists reported diverse clinical and nonclinical responsibilities. Those practicing PHM exclusively expressed high levels of interest in board certification and QI leadership. Ongoing monitoring of PHM responsibilities and practice settings will be important to support the professional development of the PHM workforce.

Research and Career Outcomes for Pediatric Hospital Medicine Fellowship Graduates

OBJECTIVES

Pediatric hospital medicine (PHM) fellowships have rapidly developed to meet established needs. The purpose of this research was to describe the research and career outcomes of PHM fellowship graduates. We hypothesized that graduates would report significant research and academic productivity.

METHODS

This was an institutional review board-approved, cross-sectional survey of PHM fellowship graduates in 2018. The 88-item survey was modified from an existing survey, developed by experts to address study objectives and pilot tested, and it included quantitative and qualitative items to assess characteristics of fellowship training and research and career outcomes.

RESULTS

A total of 63% of PHM fellowship graduates (143 of 228) completed the survey (graduation dates, 2000-2018). In total, 89% graduated from dedicated PHM fellowship programs, with 59% completing a 2-year fellowship and 78% now practicing primarily at a university or children's hospital. Fellows conducted research in clinical research (53%), quality improvement (41%), health services (24%), and medical education (19%). A total of 77% of graduates continued to do research after graduation, with 63% publishing and 25% obtaining grant funding. Graduates of 2- and 3-year fellowships and those with a master's degree were significantly more productive. Graduates now hold important roles in academic and health systems leadership. Graduates are highly satisfied with their decision to do PHM fellowship and identified 5 themes regarding how fellowship impacted their career outcomes.

CONCLUSIONS

In this study, we document robust research activity and leadership positions among PHM fellowship graduates and can serve as a benchmark for metrics that PHM educational leaders can use to assess outcomes and improve training regarding research and career development.

Identifying and Supporting the Needs of Internal Medicine and Pediatrics Residents Interested in Pediatric Hospital Medicine Fellowship

BACKGROUND

Pediatric hospital medicine (PHM) became a subspecialty of the American Board of Pediatrics (ABP) in 2016. Starting in 2019, residency graduates are required to complete fellowship training to qualify for PHM board eligibility. These requirements pose unique challenges to internal medicine-pediatrics (med-peds) residents interested in practicing combined adult hospital medicine (HM) and PHM.

OBJECTIVE

To describe the needs of med-peds residents interested in PHM fellowship training and how the current PHM training environment can meet these needs.

METHODS

We conducted two cross-sectional electronic survey studies: one of med-peds residents and one of PHM fellowship program directors (FDs). Surveys were distributed to resident and FD listservs. Questions were designed using an iterative consensus process among authors. Responses were analyzed with descriptive statistics.

RESULTS

Four hundred sixty-six residents responded to the resident survey. Ninety-six percent (n = 446) had considered a career in HM. Almost all (n = 456, 97.9%) respondents indicated a preference for a fellowship with both adult HM and PHM clinical training. Subspecialty designation decreased desire to pursue a career including PHM for 90.1% of respondents. Twenty-eight (58.3%) FDs responded to the FD survey. Fifteen (53.6%) programs reported being able to accommodate adult HM and PHM clinical time.

CONCLUSION

The majority of resident respondents reported a desire for a PHM fellowship with clinical time in both PHM and adult HM. Approximately 30% of current US PHM fellowship programs can accommodate adult HM practice for med-peds fellows, and many other programs would be willing to explore such opportunities.