More than 25% of med-peds graduates pursue careers in hospital medicine, a percentage that continues to grow, accounting for more than 100 new hospitalists per year.6 As a result, med-peds-trained hospitalists constitute more than 10% of the pediatric hospitalist workforce.6 Requiring PHM fellowship training may reduce this crucial pipeline of practitioners. In a 2014 unpublished survey of 225 med-peds practitioners, 78% of residents and 96% of attendings responded that they would not consider pursuing an ACGME-accredited PHM fellowship.7 This is compounded by a lack of parity with the practice of adult hospital medicine both in compensation and required training and is heightened by the fact that the training in question does not incorporate care for adult patients. There is clear consensus by 96% of med-peds hospitalists that the creation of an ACGME-certified PHM subspecialty will negatively affect the likelihood of med-peds providers pursuing PHM.7
Certification will pose a potential risk to specific patient populations.
We are also concerned that a reduced PHM workforce could disproportionately impact young adults with special healthcare needs and those children cared for in rural or community-based hospitals. Med-peds training equips providers to care for children with chronic diseases that then transition into adulthood; more than 25% provide care for young adults with special healthcare needs.6 With the increasing number of children with chronic health conditions surviving into adulthood,8 med-peds hospitalists serve essential roles in providing care and coordination for this vulnerable population. Furthermore, hospital medicine groups in medical systems that cannot support a full-time categorical pediatric hospitalist tend to employ med-peds physicians or family practitioners. Concerns with PHM certification are thus extended to those family medicine physicians who practice PHM.
Pediatric residency trains pediatricians in inpatient care.
We feel that the decision to move forward on PHM subspecialty certification calls into question the value of pediatric residency training. There is no evidence that clinical inpatient training in pediatrics residency is inadequate. If one leaves residency trained to do anything, it is practicing hospital medicine. A significant portion of residency takes place inpatient, both on wards and in the intensive care units. The 2009 ABP Foundation–funded study of PHM reported that 94% of pediatric hospitalist respondents rated their training in general clinical skills during residency as fully adequate, 85% rated their training in communication skills as fully adequate, and 73% did not believe any additional training beyond residency should be required.9 With respect to med-peds graduates, more than 90% feel equipped to care for children and adults upon residency completion.10 If the ABMS carries forward with this decision, the only clinical work one would be “certified” to do after residency is primary care. However, after completion of residency training, most of us feel at least as comfortable, if not more comfortable, caring for children in the inpatient setting.
Primary care should require subspecialty certification as well.
Furthermore, the decision to create a certified subspecialty begs the question as to why fellowship should not be mandated for those entering the field of primary care. Does the field of primary care not require research to move it forward? Does the field of primary care not require providers who can adeptly apply quality improvement methodologies to improve primary-care delivery? Does the public not require the same type of assurance? By these measures, primary care should require subspecialty certification as well. These arguments could easily be construed as an indictment of residency training.
The target should be residency training.
The PHM ABMS application describes a clinical curriculum consisting of eight core clinical rotations in various settings. That small number emphasizes the fact that extra clinical training is really not needed and that we do not require a complete overhaul of the current training system. The skills in question for the accredited PHM fellowship include communication, negotiation, leadership, quality improvement, pain management, sedation, procedures, transport, billing/coding, autonomous decision making, and scholarly practice. Are most of these not skills that we should foster in all practicing pediatricians? If graduating pediatric residents lack competence in core pediatric skills (e.g., communication, pain management, autonomous decision making), we should target improvements in residency education rather than require years of further training. Pediatrics residency training already requires training in quality improvement and is incorporating “tracks” that target areas of perceived deficiency. Those physicians who actually require specialized hospital-based skills (e.g., sedation, procedures, and transport) could receive core training during residency (e.g., through PHM tracks or electives) and further hone these skills through faculty development efforts. While non-PhD researchers may benefit from additional training in research methodologies, this training comes at the expense of time spent caring for patients on the wards and should not be required training for the majority of pediatric hospitalists pursuing purely clinical roles.