Current Roles and Perceived Needs of Pediatric Hospital Medicine Fellowship Graduates

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.

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.

Development of Scholarship Core Competencies for Pediatric Hospital Medicine Fellowship Programs

The Pediatric Hospital Medicine (PHM) Fellowship Directors, recent fellowship graduates, and senior leaders in PHM have long identified training in scholarly activities as a key educational priority for fellowship training programs. We led a 2-day conference funded by the Agency for Healthcare Research and Quality to develop scholarship core competencies for PHM fellows. Participants included fellowship directors, national experts in PHM research, and representatives from key stakeholder organizations. Through engagement in large group presentations and small group iterative feedback and editing, participants created and refined a set of scholarship core competencies. After the conference, goals and objectives were edited and harmonized by conference leaders incorporating feedback from conference participants. Core competency development included 7 domains: (1) study design and execution, (2) data management, (3) principles of analytics, (4) critical appraisal of the medical literature, (5) ethics and responsible conduct of research, (6) peer review, dissemination, and funding, and (7) professionalism and leadership. Specific objectives for each goal were further organized into 3 levels to indicate core skills for all fellowship trainees (level 1), specialized and specific skills determined by fellow scholarly focus (level 2), and advanced skills for fellows interested in a clinical investigator career path (level 3). These newly developed scholarship core competencies provide a foundation for curricular development and implementation to ensure that the field continues to expand academically, given the 2-year training period and variable infrastructure across programs.

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.

Advanced fellowship training for cardiology fellows in acute care cardiology

Hospitalised children have become more medically complex and increasingly require specialised teams and units properly equipped to care for them. Within paediatric cardiology, this trend, which is well demonstrated by the expansion of cardiology-specific ICUs, has more recently led to the development of acute care cardiology units to deliver team-based and condition-focused inpatient care. These care teams are now led by paediatric cardiologists with particular investment in the acute care cardiology environment. Herein, we describe the foundation and development of an Acute Care Cardiology Advanced Training Fellowship to meet the clinical, scholarly, and leadership training needs of this emerging care environment.

A Novel Hospital Medicine Training Track for Internal Medicine Residents: Description and Program Evaluation of the First 15 Years

BACKGROUND

The growth of hospital medicine has resulted in a parallel growth of hospital medicine training within internal medicine residency programs (IMRPs), but the experience and outcomes of these training offerings have not yet been described.

OBJECTIVE

To describe the first dedicated hospitalist track and the program evaluation data.

METHODS

The University of Colorado Hospitalist Training Track (HTT) is a 3-year track within the IMRP with robust inpatient clinical training, specialized didactics, experiential improvement work, and career mentorship. We collected data on graduates' current practices and board certification pass rates. To further evaluate the track, we electronically sent a cross-sectional survey to 124 graduates from 2005 to 2019 to identify current practice settings, graduate roles, and assessment of the training track.

RESULTS

Among 124 graduates, 97 (78.2%) practice hospital medicine, and the board certification pass rate was slightly higher than the overall IMRP pass rate for those graduating classes. Sixty-two (50%) graduates responded to the survey. Among respondents, 50 (80.6%) currently practice hospital medicine and 34 (54.8%) practice in an academic setting. The majority (50, 80.6%) hold leadership roles and are involved in a variety of scholarship, educational, and operational projects. Dedicated clinical training, didactics, and mentorship were valued by respondents.

CONCLUSIONS

This represents the first description and program evaluation of a HTT for IM residents. A dedicated HTT produces graduates who choose hospital medicine careers at high rates and participate in a wide variety of leadership and nonclinical roles.

The current state of general paediatric fellowships in Canada

Introduction

The field of Paediatric Medicine has grown tremendously over the last two decades. Several niche areas of practice have emerged, and opportunities for focused training in these areas have grown in parallel. The landscape of 'General Paediatric Fellowship' (GPF) Programs in Canada is not well described; this knowledge is needed to promote standardization and high-quality training across Canada. This study explores the structure and components of existing GPFs in Canada and identifies the interest and barriers to providing such programs.

Methods

A questionnaire was created to explore the landscape of GPF Programs in Canada. Invitations to participate were sent to leaders of General Paediatric Divisions across Canada, with a request to forward the survey to the most appropriate individual to respond within their local context.

Results

A total of 19 responses (95%) representing 17 different Canadian universities were obtained. Eight universities offered a total of 13 GPF Programs in 2019, with one additional university planning to start a program in the coming year. Existing programs were variable in size, structure and curriculum. Most programs identified as Academic Paediatric Programs, with an overlap in content and structure between Academic Paediatrics and Paediatric Hospital Medicine programs. The majority of respondents felt there was a need for GPF Programs in Canada but cited funding as the most common perceived barrier.

Conclusion

A growing number of GPF Programs exist in Canada. Current fellowship programs are variable in structure and content. Collaboration between programs is required to advance GPF training in Canada.

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.

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

BACKGROUND

Pediatric Hospital Medicine (PHM) was approved as a subspecialty in 2016. Perspectives of pediatric and combined pediatric residents regarding barriers and facilitators to pursuing PHM fellowships have not previously been assessed.

METHODS

A survey to explore residents' perspectives on PHM fellowships, with questions regarding demographics, likelihood of pursuing PHM after fellowship introduction, and influencing factors was distributed to pediatric and combined pediatric residents via program directors.

RESULTS

The survey was distributed to an estimated 2657 residents. A total of 855 (32.2%) residents completed the survey; 89% of respondents had at least considered a career in PHM, and 79.4% reported that the introduction of the PHM fellowship requirement for subspecialty certification made them less likely to pursue PHM. Intent to practice in a community setting or only temporarily practice PHM, Combined Internal Medicine and Pediatric trainee status, and high student loan burden were associated with decreased likelihood of pursuing PHM (P < .05). Most respondents reported that forfeited earnings during fellowship, family and student loan obligations, and perceived sufficiency of residency training discouraged them from pursuing PHM fellowship. Half of respondents valued additional training in medical education, quality improvement, hospital administration, research, and clinical medicine.

CONCLUSIONS

Many survey respondents expressed interest in the opportunity to acquire new skills through PHM fellowship. However, the majority of respondents reported being less likely to pursue PHM after the introduction of fellowship requirement for board certification, citing financial and personal opportunity costs. Understanding factors that residents value and those that discourage residents from pursuing PHM fellowship training may help guide future iterations of fellowship design.

Learning by Doing: Design and Evaluation of a Quality Improvement Curriculum for Pediatric Hospitalists

Quality improvement (QI) is a core competency for Pediatric Hospital Medicine (PHM) and required for maintenance of certification, but many hospitalists lack QI training. This project set out to increase a PHM faculty’s QI knowledge and comfort participating in QI projects, while concurrently applying the skills learned to a QI project in the hospital.

How Do Pediatric Hospital Medicine Fellowships Prepare Graduates as Educators? A Survey of Program Directors and Graduates in the United States

Pediatric hospital medicine (PHM) is the newest recognized subspecialty in pediatrics within the United States. While fellowships in PHM have been available for several years, completion of a 2-year fellowship has become a requirement for subspecialty certification. Pediatric hospitalists provide substantial teaching to trainees, and therefore, PHM fellowships must include dedicated training around teaching and medical education. The purpose of this study was to determine how current PHM fellowships prepare graduates for their roles as medical educators. Two surveys were developed from the published PHM core competencies and Entrustable Professional Activities for pediatric subspecialties. One survey was disseminated to all active PHM program directors and the second was disseminated to all PHM fellowship graduates who completed training between 2012 and 2016. Items included those related to program structure and training/assessment in medical education. A total of 21 program directors (response rate = 58%) and 46 fellowship graduates (response rate = 46%) participated in the survey. All graduates (100%) reported teaching learners in their current setting. Many (67%) fellowship programs offered formal training in medical education, and this is greater than the 50% that was previously described. Direct observation (71%) was the most common method of assessment. Most graduates reported their fellowship provided optimal training in feedback and teaching during family centered rounds but suboptimal training in other skills such as curriculum development. The results of this study highlight areas for improvement in fellowship curriculum and assessment to better prepare fellows for their roles as educators.

Tools for Medical Education Scholarship: From Curricular Development to Educational Research

The development of successful educational scholarship, either curricula or medical education research, is vital in ensuring that the field of medical education continues to evolve. Fostering the skills of medical educators in conducting high-quality educational research is essential to this process because publishing such research helps to disseminate best educational practices to the medical community at large. Unfortunately, developing rigorous medical education research can be challenging for pediatric hospitalists within busy clinical settings. In this article, we aim to discuss key principles and frameworks for curricular development as well as offer guidance in transforming a curriculum into a scholarly medical education research product for pediatric hospital medicine providers.

Career Motivators for Community Pediatric Hospitalists

BACKGROUND AND OBJECTIVES

Within the field of pediatric hospital medicine, physicians can choose to work at community-based or university-based centers. The factors that motivate pediatric hospitalists to work specifically at community sites have not yet been fully explored. Our objective with this study was to elucidate the motivators for pediatric hospitalists to begin and continue work at community sites.

METHODS

A qualitative study was performed via phone-based focus groups. Physicians were included if they were able to attend 1 of the offered group sessions and they self-identified as spending the majority of their time working as community-based pediatric hospitalists. Data were analyzed through a constant comparative analysis.

RESULTS

Five themes emerged regarding factors that motivate pediatricians to begin and continue their careers as hospitalists in the community. The themes were (1) professional impact, (2) scope of practice, (3) personal and professional satisfaction, (4) community involvement, and (5) job availability.

CONCLUSIONS

This study reveals the key factors that motivate community pediatric hospitalists to begin and continue working in the community.

Current Perspectives on Transport Medicine in Pediatric Hospital Medicine Fellowships

Transport medicine (TM) is a Pediatric Hospital Medicine (PHM) Core Competency and part of the proposed PHM fellowship curricular framework. No published TM curricula are available. This cross-sectional study was designed to determine attitudes toward TM training among PHM fellowship stakeholders and conduct a TM curriculum needs assessment. Unique, web-based, anonymous surveys for PHM fellows, graduates, and program directors (PDs) were administered, with response rates of 57%, 37%, and 44%, respectively. Fellows' interest in completing a TM rotation is greater than their perceived interest by PDs (P = .06). Graduates who completed a TM rotation were more likely to recommend a TM rotation than those who did not (P = .001). Perceived barriers included lack of a formal TM curriculum and time constraints. Stabilizing patients and triage of referrals were deemed important learning objectives, and active learning strategies were prioritized. Curriculum design should focus on topics specific to the transport process and environment.

Graduating Pediatric Residents Entering the Hospital Medicine Workforce, 2006-2015

OBJECTIVE

In October 2016, the American Board of Medical Specialties approved the petition for pediatric hospital medicine (PHM) to become the newest pediatric subspecialty. Knowledge about residents entering the PHM workforce is needed to inform certification and fellowship accreditation. This study describes the characteristics of graduating pediatric residents with PHM positions and identifies factors associated with postresidency position choices.

METHODS

We analyzed data from the American Academy of Pediatrics Annual Survey of Graduating Residents, 2006-2015. Chi-square tests were used to compare responses between residents entering PHM to those entering subspecialty fellowships, and to compare residents entering PHM at community and tertiary-care hospitals. We used multivariable logistic regression to identify associations between resident and training characteristics and position choices.

RESULTS

A total of 5969 respondents completed the survey (60.6% response rate); 593 (10.3%) reported that they were entering PHM and 1954 (33.9%) reported subspecialty fellowships. Of residents entering PHM, 345 (60.7%) reported positions at tertiary-care hospitals and 194 (34.2%) reported positions at community hospitals. Seventy percent of residents entering PHM envisioned long-term PHM careers, with PHM career goals more frequently reported among residents entering community hospitalist positions (P < .01). In multivariable analysis, residents entering PHM were significantly more likely to be female, to have children, to report that family factors limited their job selection, and to have higher levels of educational debt than residents entering fellowships.

CONCLUSIONS

Factors associated with postresidency PHM positions, including substantial educational debt and sociodemographic characteristics, may influence the development of the field as the specialty pursues fellowship accreditation.

Development of a Curricular Framework for Pediatric Hospital Medicine Fellowships

Pediatric Hospital Medicine (PHM) is an emerging field in pediatrics and one that has experienced immense growth and maturation in a short period of time. Evolution and rapid expansion of the field invigorated the goal of standardizing PHM fellowship curricula, which naturally aligned with the field's evolving pursuit of a defined identity and consideration of certification options. The national group of PHM fellowship program directors sought to establish curricular standards that would more accurately reflect the competencies needed to practice pediatric hospital medicine and meet future board certification needs. In this manuscript, we describe the method by which we reached consensus on a 2-year curricular framework for PHM fellowship programs, detail the current model for this framework, and provide examples of how this curricular framework may be applied to meet the needs of a variety of fellows and fellowship programs. The 2-year PHM fellowship curricular framework was developed over a number of years through an iterative process and with the input of PHM fellowship program directors (PDs), PHM fellowship graduates, PHM leaders, pediatric hospitalists practicing in a variety of clinical settings, and other educators outside the field. We have developed a curricular framework for PHM Fellowships that consists of 8 education units (defined as 4 weeks each) in 3 areas: clinical care, systems and scholarship, and individualized curriculum.