Pediatric Hospital Medicine: A Proposed New Subspecialty

Pediatric Hospital Medicine Fellows' Perspectives on Autonomy Through Time

OBJECTIVE

Promoting autonomy is at the core of fellowship education. Pediatric hospital medicine (PHM) fellowship programs are relatively new, and many supervising physicians are not trained on how to promote fellow autonomy. Moreover, no studies have explored fellows' perception of autonomy throughout training. To fill this gap, we explored PHM fellows' perceptions of autonomy throughout training.

METHODS

PHM fellows starting fellowship in July 2021 were recruited to participate in a longitudinal qualitative study. Using self-determination theory as a sensitizing framework, the authors conducted semistructured interviews with 14 fellows throughout fellowship. Incoming data were iteratively analyzed, and codes were created from patterns in the data. Coded data were clustered into themes.

RESULTS

Four themes developed: (1) at the beginning of fellowship, fellows valued direct observation and close supervision from their attending. (2) Initially, fellows felt pressured to make the identical clinical decision as their attending, but over the course of training, they realized their autonomous decisions could coexist with different decisions from their attending physicians. (3) At first, fellows desired attending presence to support and guide their decision making. Over time, fellows desired a coach who could provide valuable formative feedback. (4) Because of the hierarchical nature of medicine, conversations between fellows and attending physicians about autonomy were challenging to initiate.

CONCLUSIONS

Fellows' perceptions of autonomy change throughout fellowship, which should be taken into consideration as provisions of autonomy evolve through training. Our findings can inform PHM fellowship curricula and professional development around the promotion of autonomy in fellowship.

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.

COVID-19 and Its Potential Impact on Achieving Pediatric Hospital Medicine Board Certification for Established Internal Medicine-Pediatrics (Med-Peds) Hospitalists

With the onset of the COVID-19 pandemic and the subsequent rise in adult hospitalized patients, many internal medicine and pediatrics (Med-Peds) hospitalists volunteered or were required by their hospital employers to transition their practice to caring for hospitalized adult patients only. Some Med-Peds hospitalists had a disruption in their practice that may affect their board eligibility for the pediatric hospital medicine (PHM) subspecialty exam in 2024. In this editorial, we review the rise of Med-Peds hospitalist careers, the evolution of PHM becoming a subspecialty, and the effect of the COVID-19 pandemic on some Med-Peds hospitalists in their quest to become board certified in PHM via the practice pathway.

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 Senior Resident-Fellow Dynamic on Pediatric Hospital Medicine Teams: A Qualitative Study

BACKGROUND AND OBJECTIVES

With the Accreditation Council for Graduate Medical Education accreditation in place for pediatric hospital medicine (PHM) fellowships, fellows are playing a larger role in resident education. However, the impact of PHM fellows on pediatric residency training is not well described. We aimed to identify the factors that affect the dynamic between senior residents and fellows working together on PHM teams.

METHODS

In this qualitative study, we used purposive sampling and interviewed 15 senior residents and 8 PHM fellows between April and September 2020. We created a conceptual framework for the senior resident-fellow dynamic to develop the interview guide. Using verbatim transcripts uploaded into Dedoose software, 2 authors coded responses and identified themes using directed content analysis.

RESULTS

Twelve themes emerged as factors that impact the senior resident-fellow dynamic and fell into 6 categories: Team organization, role clarity, teaching, fellow approachability, decision-making, and attending involvement. Both senior residents and PHM fellows described an optimal dynamic in which a hierarchal approach to team structure, teaching, and decision-making is counterbalanced by fellow approachability. Role uncertainty, especially with increased attending involvement, led to conflict between residents and fellows.

CONCLUSIONS

This study demonstrated that a structured hierarchy surrounding supervision, decision-making, and teaching promoted level-appropriate autonomy for both senior residents and fellows. These findings can be used to design an intervention, such as a leadership curriculum for fellows and senior residents, to target behaviors that facilitate a stepwise approach to supervision and patient care.

The Pediatrician Workforce in the United States and China

From 2019 to 2022, the For Our Children project gathered a team of Chinese and American pediatricians to explore the readiness of the pediatric workforce in each country to address pressing child health concerns. The teams compared existing data on child health outcomes, the pediatric workforce, and education and combined qualitative and quantitative comparisons centered on themes of effective health care delivery outlined in the World Health Organization Workforce 2030 Report. This article describes key findings about pediatric workload, career satisfaction, and systems to assure competency. We discuss pediatrician accessibility, including geographic distribution, practice locations, trends in pediatric hospitalizations, and payment mechanisms. Pediatric roles differed in the context of each country's child health systems and varied teams. We identified strengths we could learn from one another, such as the US Medical Home Model with continuity of care and robust numbers of skilled clinicians working alongside pediatricians, as well as China's Maternal Child Health system with broad community accessibility and health workers who provide preventive care.In both countries, notable inequities in child health outcomes, evolving epidemiology, and increasing complexity of care require new approaches to the pediatric workforce and education. Although child health systems in the United States and China have significant differences, in both countries, a way forward is to develop a more inclusive and broad view of the child health team to provide truly integrated care that reaches every child. Training competencies must evolve with changing epidemiology as well as changing health system structures and pediatrician roles.

Trends Following Implementation of an Otolaryngology Hospitalist Model in a Tertiary Care Setting

OBJECTIVES

The otolaryngology hospitalist (OH) model is an emerging paradigm for inpatient and acute patient care. This study presents encounter volume before and after the implementation of an OH service. Postimplementation trends are evaluated.

STUDY DESIGN

Retrospective administrative and clinical database review.

SETTING

Tertiary care university hospital.

METHODS

This review includes 2 distinct time frames (2008-2012, 2014-2018), representing periods before and after OH implementation. The number of billed patient encounters is compared between these 2 periods using the hospital data warehouse. Additional data is evaluated for the postimplementation period, using a clinical database. Encounter type, the reason for consultation, procedures, and requesting service/location are described.

RESULTS

After the OH implementation, there was a 451% increase in evaluation and management encounters submitted for billing. Since the OH model inception, there was an overall increase in encounters (849-910), procedures performed (319-345), and operative cases (46-54) per year. Each inpatient consultation request generates one or more procedures on average. Common reasons for consultation include sinonasal pathology (20.3%), dysphonia/dysphagia (17.5%), and airway evaluation (15%). Critical Care (24%), Emergency Medicine (21%), and Hospital Medicine (21%) requested most of the Otolaryngology consults. Most consults were seen on the inpatient medical/surgical floor (46%), with the ICU (27%) and the Emergency Department (22%) being the next most common locations.

CONCLUSIONS

The OH model is an evolving paradigm that is viable and offers timely, specialized care for patients in a hospital or acute care setting.

The Importance of Subspecialty Pediatricians to the Health and Wellbeing of the Nation's Children

Through this review of published literature, it is clear that children benefit in measurable ways when they receive care from trained pediatric subspecialists. The improved outcomes provided by pediatric subspecialists supports the care provided in the patient's pediatric medical home and emphasizes the importance of care coordination between all components of the pediatric workforce. The AAP highlights this in a recent policy statement by stating the care provided by pediatric clinicians "encompasses diagnosis and treatment of acute and chronic health disorders; management of serious and life-threatening illnesses; and when appropriate, referral of patients with more complex conditions for medical subspecialty or surgical specialty care" Explicit in this statement is the emphasis on the role of complex care coordination between pediatric specialist and primary care pediatricians and that collaboration and guidance by the pediatrician is central to providing optimal care of patients. ⁶⁵ Improving health outcomes early in life is an important public health strategy for modifying the complications from childhood chronic disease and highlights the role of pediatricians in mitigating the long-term consequences of antecedents of adult disease. ⁶⁶ The recent announcement of the National Academies of Science, Engineering, and Medicine (NASEM)'s plan for a Consensus Study on The Pediatric Subspecialty Workforce and Its Impact on Child Health and Well-being is a related and exciting development, on a national scale. ⁶⁷ In response to shortages and geographic maldistributions of pediatric subspecialists, the NASEM committee intends to assess the impact of current pediatric clinical workforce trends on child health and well-being, in order to develop informed strategies to ensure an adequate, high-quality pediatric workforce, with a robust research portfolio that informs those recommendations. While this large, national initiative will surely lead to a better understanding of and strategies to implement across the pediatric subspecialty workforce, more well-designed studies that specifically measure child outcomes related to access to pediatric subspecialty care, would add meaningfully to the body of pediatric literature and to our national pediatric advocacy initiatives.

Factors Associated With Inpatient Subspecialty Consultation Patterns Among Pediatric Hospitalists

IMPORTANCE

Subspecialty consultation is a frequent, consequential practice in the pediatric inpatient setting. Little is known about factors affecting consultation practices.

OBJECTIVES

To identify patient, physician, admission, and systems characteristics that are independently associated with subspecialty consultation among pediatric hospitalists at the patient-day level and to describe variation in consultation utilization among pediatric hospitalist physicians.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study of hospitalized children used electronic health record data from October 1, 2015, through December 31, 2020, combined with a cross-sectional physician survey completed between March 3 and April 11, 2021. The study was conducted at a freestanding quaternary children's hospital. Physician survey participants were active pediatric hospitalists. The patient cohort included children hospitalized with 1 of 15 common conditions, excluding patients with complex chronic conditions, intensive care unit stay, or 30-day readmission for the same condition. Data were analyzed from June 2021 to January 2023.

EXPOSURES

Patient (sex, age, race and ethnicity), admission (condition, insurance, year), physician (experience, anxiety due to uncertainty, gender), and systems (hospitalization day, day of week, inpatient team, and prior consultation) characteristics.

MAIN OUTCOMES AND MEASURES

The primary outcome was receipt of inpatient consultation on each patient-day. Risk-adjusted consultation rates, expressed as number of patient-days consulting per 100, were compared between physicians.

RESULTS

We evaluated 15 922 patient-days attributed to 92 surveyed physicians (68 [74%] women; 74 [80%] with ≥3 years' attending experience) caring for 7283 unique patients (3955 [54%] male patients; 3450 [47%] non-Hispanic Black and 2174 [30%] non-Hispanic White patients; median [IQR] age, 2.5 ([0.9-6.5] years). Odds of consultation were higher among patients with private insurance compared with those with Medicaid (adjusted odds ratio [aOR], 1.19 [95% CI, 1.01-1.42]; P = .04) and physicians with 0 to 2 years of experience vs those with 3 to 10 years of experience (aOR, 1.42 [95% CI, 1.08-1.88]; P = .01). Hospitalist anxiety due to uncertainty was not associated with consultation. Among patient-days with at least 1 consultation, non-Hispanic White race and ethnicity was associated with higher odds of multiple consultations vs non-Hispanic Black race and ethnicity (aOR, 2.23 [95% CI, 1.20-4.13]; P = .01). Risk-adjusted physician consultation rates were 2.1 times higher in the top quartile of consultation use (mean [SD], 9.8 [2.0] patient-days consulting per 100) compared with the bottom quartile (mean [SD], 4.7 [0.8] patient-days consulting per 100; P < .001).

CONCLUSIONS AND RELEVANCE

In this cohort study, consultation use varied widely and was associated with patient, physician, and systems factors. These findings offer specific targets for improving value and equity in pediatric inpatient consultation.

Evaluation of an Education-based Training Orientation for Resident Physicians in an Intensive Care Unit in Hawai'i

The need for multidisciplinary teams to provide complex care has increased as the population ages. As these teams become increasingly integrated, the knowledge, skills, and attitudes of resident physicians to practice safe and effective care in intensive care units (ICUs) evolves. A structured and multidisciplinary orientation day for resident physicians was implemented to assess improvements in physician confidence at Tripler Army Medical Center in Hawai'i from July 2019 to June 2020. ICU residents received an orientation day from a multidisciplinary team, with an emphasis on practical knowledge for common disease processes in a system-based fashion and competency in procedural skills. A total of 30 residents were asked to complete a pre- and post- orientation survey over a 1-year period, with 17 pre and post surveys completed for a response rate of 57%. The survey measured residents' perceived confidence in various tasks. Scores were compared using a paired 2-sampled t-test to assess statistical significance. The majority of resident physicians (76%) had at least 1 month of prior ICU experience. Statistically significant improvement was seen in self-reported abilities in performing 6 of the 10 elements assessed. With the diverse pathophysiology in critical care, it was essential to create a broad orientation with didactic and simulation-based learning, which resulted in observed improvement in more than half of the areas of interest. Adopting an orientation day for resident physicians rotating through the ICU can improve resident physician confidence, review important knowledge and skills, and highlight the role of each contributing multidisciplinary team member.

Med-Peds Residents' Career Plans and the Impact of Pediatric Hospital Medicine Fellowship: A Nationwide Survey

BACKGROUND

The establishment of pediatric hospital medicine (PHM) as a fellowship-trained subspecialty represents a major change in the practice landscape, particularly for combined internal medicine-pediatrics (med-peds) residents. The most recent literature on med-peds residents' career choices predates PHM fellowship and its impact has not been well studied. We aimed characterize med-peds residents' career plans and the factors influencing their choices.

METHODS

We distributed an electronic survey to the 1,505 resident members of the National Med-Peds Resident Association. In addition to sociodemographic data, participants reported their career plans, how well their residency prepared them for various aspects of practice, and their perceptions of PHM fellowship and its effect on their career choices.

RESULTS

Among the 228 participants, the most planned careers were combined hospital medicine (36.8%, 84/228), combined subspecialty practice (32.5%, 74/228), and primary care (31.1%, 71/228). Residents felt well prepared for patient care and significantly more prepared for inpatient practice than for primary care. Participants rated the potential disadvantages of PHM fellowship as major deterrents and did not view the possible advantages as strong incentives. Among those who had considered a hospital medicine careers, 91.2% (186/203) were less likely to pursue PHM after its certification as a subspecialty.

CONCLUSION

Med-peds residents have a wide range of career interests but fellowship has made them less likely to pursue PHM careers. These findings emphasize the importance of addressing the needs of med-peds trained providers as PHM certification pathways and fellowship curricula develop to avoid adverse effects on the workforce.

Patient, Caregiver, and Clinician Participation in Prioritization of Research Questions in Pediatric Hospital Medicine

IMPORTANCE

The research agenda in pediatric hospital medicine has seldom considered the perspectives of young people, parents and caregivers, and health care professionals. Their perspectives may be useful in identifying questions on topics for research.

OBJECTIVE

To prioritize unanswered research questions in pediatric hospital medicine from the perspectives of young people, parents/caregivers, and health care professionals.

DESIGN, SETTING, AND PARTICIPANTS

Between August 4, 2020, and August 19, 2021, two online surveys and a virtual workshop were conducted, using modified Delphi technique and nominal group technique. Young people, parents/caregivers, and health care professionals with experiences in pediatric hospital medicine in Canada were included.

INTERVENTIONS

The established James Lind Alliance Priority Setting Partnership method was used. In phase 1, a survey collected unanswered questions regarding pediatric hospital medicine via 3 open-ended questions. Survey responses were used to develop summary questions that went through an evidence-checking process. Unanswered questions were brought to a phase 2 interim prioritization survey. The top 10 unanswered research questions in pediatric hospital medicine were established at the final priority setting workshop.

MAIN OUTCOMES AND MEASURES

Survey responses, top 10 research questions.

RESULTS

The phase 1 survey was completed by 188 participants (148 of 167 [89%] females; 17 of 167 [10%] males; mean [SD] age, 39.5 [12.4] years) and generated 495 unanswered research questions and comments, of which 58 were deemed out of scope. The remaining 437 responses were grouped into themes (eg, communication, shared decision-making, health service delivery, and health service management) and then refined to 75 unanswered research questions. Of these 75, only 4 questions had sufficient evidence. To make the number of questions in phase 2 manageable, 21 questions submitted by only 1 respondent were eliminated. Fifty unanswered research questions were included in the phase 2 survey, which was completed by 201 participants (165 of 186 [89%] females; 19 of 186 [10%] males; mean [SD] age, 40.0 [11.0] years). A short list of 16 questions-the top 10 questions from patient partners (youths, parents/caregivers) and clinicians-was presented at the final priority setting workshop and the top 10 questions were prioritized. The top 10 questions focused on the care of special inpatient populations (eg, children with medical complexity), communication, shared decision-making, support strategies in the hospital, mental health supports, shortening length of stay, and supporting Indigenous patients, parents/caregivers, and families.

CONCLUSIONS AND RELEVANCE

This patient-oriented pediatric hospital medicine priority setting partnership identified the most important unanswered research questions focused on the care of children in the hospital. These questions provide a possible roadmap for research on areas deemed important to young people, parents/caregivers, and clinicians.

Pediatric Hospital Medicine Resident Elective: A Novel Resident Curriculum for an Evolving Field

Background

Although 8-10% of pediatric residents pursue a career in Pediatric Hospital Medicine (PHM), many report an incomplete understanding of PHM careers and would benefit from a PHM elective.

Methodology

We followed Kern’s six-step curriculum development framework. A general needs assessment via literature review revealed a lack of published PHM elective curricula. A targeted needs assessment was conducted by surveying national PHM fellowship program directors, national PHM fellows, local junior PHM attendings, and local pediatric residents. Content analysis from these surveys was used to develop a PHM resident elective curriculum. The curriculum was implemented and evaluated through an experience log and written reflections.

Results

Needs assessment surveys were completed by fellowship directors (22/61, 36%), fellows (36/103, 35%), attendings (10/26, 38%), and residents (15/98, 15%). Common themes included the importance of academic experiences, mentorship, non-teaching and non-inpatient clinical experiences, community hospital experience, and the desire to address knowledge gaps. Significant variability in survey responses suggested the importance of an individualized curriculum. Goals, objectives, and aligned educational strategies were developed to provide a breadth of clinical experiences, mentorship, and PHM-focused academic activities, with an emphasis on individualization. Implementation of the curriculum began in July 2021 and four residents enrolled in 2021-2022. The curricular evaluation demonstrated the achievement of objectives and improved resident awareness of PHM opportunities, clinical skill development, ancillary shadowing, and academic opportunities.

Conclusions

A PHM resident elective was developed using Kern’s six-step approach with input from national fellows and fellowship program directors to address educational gaps and increase exposure to PHM careers. The next steps include the evaluation of the impact of the PHM elective on career choice and preparedness of residents.

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.

Pediatric Hospital Medicine and Global Health: A Fitting Niche for an Emerging Subspecialty

As North American hospitals serve increasingly diverse patient populations, including recent immigrants, refugees, and returned travelers, all pediatric hospitalists (PHs) require foundational competency in global health, and a subset of PHs are carving out niches focused in global health. Pediatric hospitalists are uniquely positioned to collaborate with low- and middle-income country clinicians and child health advocates to improve the health of hospitalized children worldwide. Using the 2018 WHO standards for improving the quality of care for children and adolescents worldwide, we describe how PHs' skills align closely with what the WHO and others have identified as essential elements to bring high-quality, sustainable care to children in low- and middle-income countries. Furthermore, North American global health hospitalists bring home expertise that reciprocally benefits their home institutions.

Safe transitions from the hospital to home: A review of the pediatric hospitalist's discharge workflow

For children to have safe transitions from the hospital to home, inpatient physicians, nurse practitioners, and physician assistants, should use a standardized discharge process that focuses on thorough discharge planning, multidisciplinary teamwork, communication, and effective hand-offs of care.  Using quality improvement science will help physicians analyze and improve their discharge process and ensure safe discharges.

Differences in Lifetime Earning Potential for Pediatric Subspecialists

OBJECTIVES

Our 2011 report, reflecting data from 2007-2008, demonstrated that, for many pediatric subspecialties, pursuing fellowship training was a negative financial decision when compared with practicing as a general pediatrician. We provide an updated analysis on the financial impact of pediatric fellowship training and model interventions that can influence the results.

METHODS

We estimated the financial returns a graduating pediatric resident might anticipate from fellowship training followed by a career as a pediatric subspecialist and compared them with the returns expected from starting a career as a general pediatrician immediately after residency. We evaluated the potential effects of eliminating medical school debt, shortening the length of fellowship training, and implementing a federal loan repayment program for pediatric subspecialists. We compared the financial returns of subspecialty training in 2018-2019 to those from our previous report.

RESULTS

Pursuing fellowship training generated widely variable financial returns when compared with general pediatrics that ranged from +$852 129 for cardiology to -$1 594 366 for adolescent medicine. Twelve of 15 subspecialties analyzed yielded negative financial returns. The differences have become more pronounced over time: the spread between the highest and lowest earning subspecialties widened from >$1.4 million in 2007-2008 to >$2.3 million in 2018-2019. The negative financial impact of fellowship training could be partially ameliorated by shortening the length of training or by implementing pediatric subspecialist specific loan repayment programs.

CONCLUSIONS

This report can be used to help guide trainees, educators, and policy makers. The interventions discussed could help maintain an adequate and balanced pediatric workforce.

Referral Trends in Two Pioneering Developmental-Behavioral Pediatric Centers in Turkey

OBJECTIVE

To inform professionals pioneering developmental-behavioral pediatrics (DBP) services in low- and middle-income countries (LMICs), we aimed to examine referral trends in 2 pioneering DBP centers at different locations in Turkey and to ascertain whether the official establishment of DBP as a subspecialty affected these trends.

METHOD

This longitudinal observational study included all children referred to Ankara (AUDPD) and Inonu (IUDPD) Universities' Developmental Pediatrics Divisions between 2010 and 2018. We examined the sources of referrals and the independent effects of time and the establishment of DBP as a subspecialty on referral volume using Negative Binomial Regression (NBR) models.

RESULTS

Of 8,051 children, most were boys (58%) and under 24 months of age (72%). Most referrals were from the pediatric and pediatric surgery department clinics (85%); less than 1% were from child and adolescent psychiatry, and none were from family physicians. The NBR models showed that yearly, the referral volume increased significantly, 1.18-fold (95% confidence interval [CI] = 1.09-1.28) and 1.48-fold (95% CI = 1.20-1.82) for AUDPD and IUDPD, respectively. Compared with the trend of referrals before, the trend after the establishment of DBP as a subspecialty increased significantly at AUDPD, but not IUDPD.

CONCLUSION

The increase in referrals to DBP over time is encouraging to professionals working to advance DBP services and training in LMICs even if DBP is not officially established as a subspecialty. Additional efforts may be needed to improve recognition and use of DBP services by community physicians and allied disciplines that provide services to children.

Integrated pediatric urgent care: A perfect fit into patient-centered medical home and meeting the needs of population health and our profession

General Pediatricians have been constrained into a narrower band of primary care practice with the advent of hospitalists, advanced practice professionals and pediatric specific urgent cares. This new patient care structure will require electronic medical records and institutional systems to decrease interfaces and increase integration, thereby allowing a free flow of information that will provide more efficient and safe care. Pediatric specific urgent cares that are integrated will be able to utilize both efficient system level 1 thinking and deeper more thoughtful system level 2 thinking, which will benefit the pediatric patient by decreasing diagnostic errors. If done appropriately, everywhere a pediatric patient contacts the healthcare system, including pediatric specific urgent cares, the patient should be provided a longitudinal, seamless and specific high quality of care that fits the venue they contact.

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.

Ramping Up a Pediatric Hospital Medicine Advanced Practice Provider Team Rapidly

Pediatric Hospital Medicine (PHM) is a growing subspecialty with a broad scope. The Covid-19 pandemic demands flexible staffing models. Advanced practice providers (APPs) can be a valuable addition to hospital medicine teams, although there is no established training program for APPs within PHM. The authors' purpose is to describe how one institution rapidly established a PHM APP team by collaborating with experienced APPs working in other areas of the hospital. This APP team cared for 16% of the average daily census during the pilot period with no significant difference in length of stay compared to traditional teams.

The Intertwined Histories of Resident Education and Pediatric Hospital Medicine in the US

The histories of pediatric resident education and pediatric hospital medicine (PHM) are intertwined. PHM, now a new subspecialty, is generally considered to have emerged from the hospitalist movement in the late 1990s but is actually what some influential pediatricians in the 19th century envisioned for pediatrics in the United States, comparable to the British model. The prime focus of resident education during the 20th century remained hospital care, even during the years of national concern regarding the need for more primary care physicians. Various changes in resident education have contributed to the rise of PHM as a subspecialty. Requirements for subspecialty certification in PHM have implications for general residency training in pediatrics.

Developing Content for Pediatric Hospital Medicine Certification Examination Using Practice Analysis

OBJECTIVES

The American Board of Pediatrics (ABP) and the Pediatric Hospital Medicine (PHM) subboard developed a content outline to serve as a blueprint for the inaugural certification examination through practice analysis. The systematic approach of practice analyses process is described in the study.

METHODS

A diverse, representative panel of 12 pediatric hospitalists developed the draft content outline using multiple resources (publications, textbooks, PHM Core Competencies, PHM fellow's curriculum, etc). The panel categorized practice knowledge into 13 domains and 202 subdomains. By using the ABP database self-defined practicing pediatric hospitalists were identified. Participants rated the frequency and criticality of content domains and subdomains along with providing open-ended comments.

RESULTS

In total, 1449 (12.1%) generalists in the ABP database self-identified as pediatric hospitalists, and 800 full-time pediatric hospitalists responded. The content domains that were rated as highly critical and frequently required in practice were weighted more heavily (ie, the percentage of examination questions associated with a domain) than the less critical and less frequently rated. Both community and noncommunity pediatric hospitalists rated domains similarly (P = .943). Subdomain and preliminary weights were rated with similar means and SDs in the majority of topics.

CONCLUSIONS

There was concordance in the rating of domain and universal tasks among both community and noncommunity hospitalists. The areas of significant differences, although minor, could be explained by difference in practice settings. The practice analysis approach was structured, engaged the PHM community, reflected the breadth and depth of knowledge required for PHM practice, and used an iterative process to refine the final product.

Defining the Essential Components of a Teaching Service

OBJECTIVES

A large portion of residency education occurs in inpatient teaching services without widely accepted consensus regarding the essential components that constitute a teaching service. We sought to generate consensus around this topic, with the goal of developing criteria programs that can be used when creating, redesigning, or evaluating teaching services.

METHODS

A list of potential components of teaching services was developed from a literature search, interviews, and focus groups. Eighteen pediatric medical education experts participated in a modified Delphi method, responding to a series of surveys rating the importance of the proposed components. Each iterative survey was amended on the basis of the results of the previous survey. A final survey evaluating the (1) effort and (2) impact of implementing components that had reached consensus as recommended was distributed.

RESULTS

Each survey had 100% panelist response. Five survey rounds were conducted. Fourteen attending physician characteristics and 7 system characteristics reached consensus as essential components of a teaching service. An additional 25 items reached consensus as recommended. When evaluating the effort and impact of these items, the implementation of attending characteristics was perceived as requiring less effort than system characteristics but as having similar impact.

CONCLUSIONS

Consensus on the essential and recommended components of a resident teaching service was achieved by using the modified Delphi method. Although the items that reached consensus as essential are similar to those proposed by the Accreditation Council for Graduate Medical Education, those that reached consensus as recommended are less commonly discussed and should be strongly considered by institutions.

Preparedness to practice paediatric hospital medicine

Background

The field of paediatric hospital medicine (PHM) is evolving to meet the needs of an increasingly complex paediatric population, lead quality improvement initiatives, and conduct field-specific teaching and research. Over 50 subspecialty PHM fellowship programs exist in the USA and Canada and more are under active development to ensure trainees are prepared to perform competencies specific to the field following transition to independent practice.

Objective

The objective of this study was to assess the perceived preparedness of recently graduated general paediatric residents and recently certified staff paediatricians in Canada with respect to the practice of PHM.

Methods

A survey based on the 'Objectives of Training in Pediatrics' of the Royal College of Physicians and Surgeons of Canada (RCPSC) was distributed to graduating paediatric residents and recently graduated staff paediatricians (2013 to 2017) practicing in the hospital setting. Qualitative comments were also obtained.

Results

Fifty-five surveys were completed (50%). Respondents perceived that, at the on-set of starting practice, they would require assistance or consultation with the majority of representative PHM task competencies. Differences in perception between the two groups were minimal. Our study identified sub-sets of perceived areas of particular strengths (Professional) and deficiencies (Medical Expert, Manager, and Scholar).

Conclusions

Results may help inform future curricula for general paediatric residency programs and provide insight into competencies that may be better targeted for PHM fellowship training programs. This study may also stimulate discussion regarding entrustable professional activities for paediatric curricula as the medical community shifts to a new paradigm of outcome-based assessment.

Pediatric Hospital Medicine: Where We Are, Where We Are Headed: State of the Specialty, Looking Forward

Although pediatric hospital medicine (PHM) is in its adolescence, it is already having a major impact on patient care, quality, safety, and education. Pediatric hospitalists have been front-and-center in the safety and quality movement, driving change as clinicians, applying evidence-based medicine to standardize practice and promulgate evidence-based guidelines, and playing a central role in optimizing the function of inter-professional teams. Pediatric hospitalists have championed the importance of patient-and family-centeredness of care and the need to incorporate principles of health literacy into all aspects of clinical care and research. Beyond delivering care, pediatric hospitalists have prominent roles as hospital leaders, educators, and researchers and have played a critical role in promoting improvements in health and health care outcomes. In its continued evolution, clinical care will undoubtedly remain the major focus, though with subspecialty status, the field will be expected to accelerate innovations in systems-based practice, advance clinical learning environments, and drive further improvements in quality of care.

Process Metrics and Outcomes to Inform Quality Improvement in Pediatric Hospital Medicine

This article provides an overview of the selection, development, and use of process and outcome measures for pediatric hospital medicine quality improvement initiatives. It reviews commonly used categories of process and outcome measures and provides a list of common sources and repositories of previously validated measures. It also provides a blueprint for the development of novel measures. The relative merits of various data collection methods are discussed (eg, medical record abstraction, administrative, surveys), along with guiding principles for disseminating the results of quality improvement evaluations on a local and national level.

Family-Centered Rounds: Past, Present, and Future

Bedside rounds have evolved concurrently with hospitalist medicine and patient-centered care. Family-centered rounds are the foundation of effective communication in the in-patient pediatric setting. Participant perspectives (family members, patients, nurses, faculty, and trainees) on family-centered rounds differ and goals may not always align. Further, the practical components of how rounds are conducted varies and have continued opportunities for improvement. This article summarizes the most recent experience with rounds in an attempt to identify unified and effective strategies moving forward.

Adverse Events and Patient Outcomes Among Hospitalized Children Cared for by General Pediatricians vs Hospitalists

IMPORTANCE

Pediatric hospital medicine is a relatively new and growing specialty. However, research remains inconclusive on outcomes for inpatients cared for by pediatric hospitalists compared with those cared for by general pediatricians.

OBJECTIVE

To analyze outcomes, adverse events (AEs), and types of AEs associated with care provided for pediatric patients by hospitalists vs general pediatricians.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data from the medical records of a US urban academic children's hospital comprising 1423 hospitalizations between January 1, 2009, and August 31, 2015, for 57 diagnoses of patients cared for by either a hospitalist or general pediatrician. General pediatricians worked primarily in the hospital's outpatient clinic, serving a few inpatient weeks per year, and were not the patients' primary care physician. Data analysis was performed from July 1, 2017, to October 10, 2018.

MAIN OUTCOMES AND MEASURES

Outcomes were length of stay, total costs, 30-day readmission rates, and AEs. Adverse events were documented by International Classification of Diseases, Ninth Revision, Clinical Modification codes determined by review of medical records. Adverse event categories were drug events, infections, and device-related AEs. Generalized linear models were used to analyze patient outcomes, with standard errors clustered by physician. Models were adjusted for patient characteristics, including Chronic Condition Indicators. Models were estimated with and without adjustment for physician characteristics.

RESULTS

The data set contained 1423 hospitalizations among 726 female patients and 697 male patients (mean [SD] age, 6.1 [6.3] years). Hospitalists cared for 870 patients, and general pediatricians cared for 553 patients. Among the physicians, there were 57 women and 38 men; physicians were a mean (SD) 11.1 (8.1) years out of medical school. Patients cared for by general pediatricians were younger than those cared for by hospitalists (mean [SD] age, 5.4 [6.0] vs 6.5 [6.4] years; P = .001) but had similar mean (SD) Chronic Condition Indicator scores (1.5 [1.0] vs 1.5 [1.0]). A total of 33 of 56 general pediatricians (58.9%) and 24 of 39 hospitalists (61.5%) were women (P = .006), and general pediatricians were in practice twice as long as hospitalists on average (mean [SD], 16.0 [10.3] vs 7.9 [3.8] years out of medical school; P < .001). In multivariate models adjusting for patient-level features, there were no significant differences between general pediatricians and hospitalists for mean length of stay (4.7 vs 4.6 days), total costs ($14 490 vs $15 200), and estimated 30-day readmission rate (8.9% vs 6.4%), and results were similar with adjustments for physician characteristics. Device-related AEs were higher among hospitalists (3.0% vs 1.1%; odds ratio, 0.34; 95% CI, 0.12-1.00); this association became nonsignificant after adjusting for physician experience.

CONCLUSIONS AND RELEVANCE

General pediatrician and hospitalist inpatient care had similar length of stay, total costs, and readmission rates. However, AEs differed between hospitalists and general pediatricians, with device-related AEs more common among hospitalists, which may be associated with hospitalists' fewer years in practice. Such findings can inform hospitals in planning their inpatient staffing and patient safety oversight.

Staffing and workforce issues in the pediatric intensive care unit

The health care industry is in the midst of incredible change, and unfortunately, change is not easy. The intensive care unit (ICU) plays a critical role in the overall delivery of care to patients in the hospital. Care in the ICU is expensive. One of the best ways of improving the value of care delivered in the ICU is to focus greater attention on the needs of the critical care workforce. Herein, we highlight three major areas of concern-the changing model of care delivery outside of the traditional four walls of the ICU, the need for greater diversity in the pediatric critical care workforce, and the widespread problem of professional burnout and its impact on patient care.

Comparison of Patient Outcome Measures between a Traditional Teaching Hospitalist Service and a Non-Teaching Hospitalist Service at an Academic Children's Hospital

Background and objectives

Inpatient pediatric care is increasingly provided by pediatric hospitalists. This, in addition to changes in resident duty hour restrictions, has led to the creation of new models of care for inpatient pediatric patients. The objective of this study was to compare traditional outcome measures between a pediatric hospitalist-only service and a more traditional academic service in which care was provided by pediatric hospitalists, residents, and medical students. Attending physicians on the hospitalist-only service had an average of 1.7 years of post-residency experience compared to an average 16 years of experience for those working on the traditional academic service.

Methods

This retrospective cohort study (hospitalist-only v. teaching service) used electronic medical records data of patients (n=1,059) admitted to a quaternary care, academic, children’s hospital in Pittsburgh Pennsylvania with diagnoses of bronchiolitis, viral syndrome, and gastroenteritis from July 2011 to June 2014. Primary outcome measures included length of stay, hospital costs, and readmission rates.

Results

Patients with a diagnosis of bronchiolitis admitted to the hospitalist-only service had a significantly higher severity-of-illness-score than those admitted to the teaching service. A decreased length of stay and lower hospital costs were seen for patients admitted to the hospitalist-only service; however, these differences did not reach a level of statistical significance.

Conclusion

There were no statistically significant differences in the outcome measures of patients with common pediatric illnesses admitted to a hospitalist-only versus a teaching hospitalist service. The model of a hospitalist-only service staffed by recent residency graduates may provide an efficient and effective model of care as patients admitted to this service had similar outcome measures to those patients cared for by more-experienced attending physicians.