Why Required Pediatric Hospital Medicine Fellowships Are Unnecessary

Broad-based support for a PHM subspecialty has not been demonstrated.

While approximately 40 pediatric hospitalists originated the PHM certification petition, we have not seen clear support for subspecialty certification from the community. PHM certification runs the risk of alienating the general pediatrics community, as many outpatient pediatricians continue to care for their patients in the inpatient setting. Furthermore, at tertiary-care medical centers, pediatric subspecialists often serve as hospitalists, yet this stakeholder group has not entered into this conversation. Importantly, the Association of Pediatric Program Directors (APPD) did not endorse this proposal. Many of the APPD members were quite concerned about the harm this certification could cause. While the APA Board and the AAP Board of Directors support PHM subspecialty certification, it is not clear that the rank-and-file members do. The Society of Hospital Medicine did not support or oppose certification. In an era of controversy surrounding certification requirements, prior to making a decision that will alter the direction of an entire field and impact all future residency graduates interested in entering that field, we should ensure there is broad-based support for this decision.

An alternative path has already been established and validated.

A more prudent, cost-effective, and universally acceptable approach would be to follow in the footsteps of the American Board of Internal Medicine (ABIM) and American Board of Family Medicine (ABFM) in establishing a Focused Practice in Pediatric Hospital Medicine program. This approach respects the unique body of knowledge required of those who care for hospitalized children while maintaining the required flexibility to nurture and help to mature existing training pipelines. Core hospital medicine skills should be further honed through residency curricular changes and faculty development efforts, while hospital-based physicians interested in developing niche skills could still do so via already existing fellowships.

When it comes to pediatric hospital medicine, first, do no harm.

Pediatric hospitalists are inpatient generalists by training and clinical approach. Our practices vary from large academic medical centers with every imaginable subspecialty consult service available to remote rural settings that require hospitalists to possess unique and specific skills. Some pediatric hospitalists participate in newborn care, some perform sedations, and some perform a variety of diagnostic and therapeutic procedures. The current system is meeting the needs of the vast majority of our PHM community. Changes to the residency curriculum that are already under way can address any clinical and quality improvement gaps. More than enough PHM fellowships are available to those who choose to pursue them. The public is not requesting reassurance, and the field is already advancing at a rapid rate both clinically and scholarly. Subspecialty recognition is not necessary and will likely lead to negative unintended consequences. Given the financial constraints on our current system and the need for pediatric hospitalists to be stewards of high-value care, we should make collective decisions that will clearly benefit our patients and health system. As medical professionals, our priority should always be first, do no harm.

Weijen W. Chang, MD, is chief of the Division of Pediatric Hospital Medicine at Baystate Children’s Hospital and associate professor of pediatrics at the University of Massachusetts Medical School.

Leonard Samuel Feldman, MD, is director of the Medicine-Pediatrics Urban Health Residency Program and associate professor of medicine and pediatrics at Johns Hopkins School of Medicine.

Bradley Monash, MD, is associate chief of medicine at University of California, San Francisco and assistant clinical professor of medicine and pediatrics at UCSF School of Medicine.

Archna Eniasivam, MD, is assistant clinical professor of medicine at UCSF School of Medicine.

References

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