A year and a half ago, I found myself seated in a crowded hall at the national Pediatric Hospital Medicine (PHM) conference. Throughout the conference, trainees like me were warmly welcomed into small groups and lunch tables. I tried to keep my cool while PHM “celebrities” chatted with me in the elevator. Most sessions were prepared with plenty of chairs, and those that were not encouraged latecomers to grab a spot on the floor or the back wall – the more the merrier.
Dr. Catherine Ezzio
The intention of this “advice for applicants” meeting was to inspire and guide our next steps toward fellowship, but a discomforting reality loomed over us. It was the first year graduating pediatricians could not choose PHM board certification via the practice pathway – we needed an invitation in the form of a fellowship match.
The “hidden curriculum” was not subtle: People who scored a seat would keep their options open within the field of PHM, and those who did not had a murkier future. This message stood in stark contrast to the PHM inclusivity I had experienced all conference, and planted seeds of doubt: Was I welcome here? Did I “deserve” a seat?
I found the experience as a PHM fellowship applicant to be uncomfortable, and my all-too familiar friend “imposter syndrome” set up camp in my brain and made herself at home. I had no way of knowing how many programs to apply to, how many to interview at, or the chances of my matching at all. Once on the interview trail, I realized I was not alone in my discomfort – most applicants harbored some trepidation, and no one truly knew how the chips would fall on Match Day.
I am thrilled and relieved to have come out the other end in a great position. The team I work with and learn from is phenomenal. I am grateful that ACGME accreditation ensures structures are in place for fellows to be supported in their academic and educational efforts and have full confidence that the skills I gain in fellowship will help me contribute to progression of the field of PHM and improve my performance as a clinician-educator.
Sadly, each year PHM match day celebrations are dampened by the knowledge that a large portion of our colleagues are being left out in the cold with an “unmatched” notification in their inboxes. Approximately 200 graduating pediatricians become pediatric hospitalists each year,1 but only 68 fellowship positions were available in the United States for matriculation in 2020.2 In 2019, PHM fellowship candidates navigated the 6-month application journey with aspirations to further their training in the profession they love. Of the candidates who submitted a rank list committing to 2 or more years in PHM fellowship, 35% were denied.
Unfortunately, despite expansion of PHM fellowship programs and fifteen seats added from last year, we learned this December that there still are not enough positions to welcome qualified applicants with open arms: Thirty-three percent of candidates ranked PHM programs first in the NRMP but did not match – the highest unmatched percentage out of all pediatric subspecialties.3
The NRMP report shared a glimpse of our colleagues who received interview invitations and submitted a rank list, but this is likely an underestimation of pediatric graduates who wanted to obtain PHM board certification and wound up on a different path. Some residents anticipated the stiff competition and delayed their plans to apply for fellowship, while others matched into another subspecialty that was able to accommodate them. Many pediatric graduates joined the workforce directly as pediatric hospitalists knowing the practice pathway to certification is not available to them. Along with other physicians without board certification in PHM, they shoulder concerns of being withheld from professional advancement opportunities.
For the foreseeable future it is clear that pediatric hospitalists without board certification will be a large part of our community, and are crucial to providing high-quality care to hospitalized children nationally. In 2019, a national survey of pediatric hospital medicine groups revealed that 50% of pediatric hospitalist hires came directly out of residency, and only 8% of hires were fellowship trained.4 The same report revealed that 26% of physicians were board-certified.These percentages are likely to change over the next 5 years as the window of practice pathway certification closes and fellowship programs continue to expand. Only time will tell what the national prevalence of board-certified pediatric hospitalists settles out to be.
Historically, PHM fellowship graduates have assumed roles that include teaching and research responsibilities, and ACGME fellowship requirements have ensured that trainees graduate with skills in medical education and scholarship, and need only 4 weeks of training to be done in a community hospital.5 Pediatric hospitalists who do not pursue board certification are seeing the growing pool of PHM fellowship graduates prepared for positions in academic institutions. It is reasonable that they harbor concerns about being siloed toward primarily community hospital roles, and for community hospitalists to feel that this structure undervalues their role within the field of PHM.
At a time when inclusivity and community in medicine are receiving much-needed recognition, the current fellowship application climate has potential to create division within the PHM community. Newly graduating pediatric residents are among the populations disproportionately affected by the practice pathway cutoff. Like other subspecialties with ever-climbing steps up the “ivory tower” of academia and specialization within medicine, the inherent structure of the training pathway makes navigating it more difficult for pediatricians with professional, geographic, and economic diversity or constraints.
Med-Peds–trained colleagues have the added challenge of finding a fellowship position that is willing and able to support their concurrent internal medicine goals. International medical graduates make up about 20% of graduating residents each year, and just 11% of matched PHM fellows.3,6 Similarly, while DO medical graduates make up 20% of pediatric residents in the United States, only 10% of matched PHM fellows were DOs.3,6 New pediatricians with families or financial insecurity may be unable to invest in an expensive application process, move to a new city, and accept less than half of the average starting salary of a pediatric hospitalist for 2-3 years.7
The prevalence of implicit bias in medicine is well documented, and there is growing evidence that it negatively impacts candidate selection in medical education and contributes to minorities being underrepresented in the physician workforce.8 We must recognize the ways that adding a competitive costly hurdle may risk conflict with our mission to encourage diversity of representation within PHM leadership positions.
We have not yet successfully bridged the gap between qualified PHM fellowship candidates and available fellowship positions. I worry that this gap and the lack of transparency surrounding it is resulting in one portion of new pediatricians being welcomed by the subspecialty, and others feeling unsupported and alienated by the larger PHM community as early career physicians.
Right now, the only solution available is expansion of fellowship programs. We see progress with the new addition of fellowship positions every year, but finding funding for each position is often a lengthy endeavor, and the COVID-19 pandemic has tightened the purse strings of many children’s hospitals. It may be many years before the number of available fellowship positions more closely approximates the 200 pediatricians that become hospitalists each year.
The most equitable solution would be offering other avenues to board certification while this gap is being bridged, either by extending the practice pathway option, or making a third pathway that requires less institutional funding per fellow, but still incentivizes institutional investment in fellowship positions and resources (e.g., a pathway requiring some number of years in practice, plus 1 year in fellowship centered around a nonclinical academic curriculum).
In the absence of the solutions above, we collectively hold the responsibility of maintaining inclusivity and support of our PHM colleagues with and without board certification. One important strategy provided by Dr. Gregory Welsh9 is to incorporate community hospital medicine rotations into residency training. Sharing this side of PHM with residents may help some graduates avoid a training pathway they may not want or need. More importantly, it would raise trainee exposure and interest toward a service that is both expansive – approximately 70% of pediatric hospitalists practice in a community hospital – and crucial to children’s health nationally.
Pediatric hospitalists who are not eligible for board certification are vital and valued members of the PHM community, and as such need to maintain representation within PHM leadership. Professional development opportunities need to remain accessible outside of fellowship. The blossoming of virtual conferences and Zoom meet-ups in the face of the COVID-19 pandemic have shown us that with innovation (and a good Internet connection), networking and mentorship can be accomplished across thousands of miles.
While there’s great diversity within PHM, this subspecialty has a history of attracting pediatricians with some common core qualities: Grit, creativity, and the belief that a strong team is far greater than the sum of its parts. I have confidence that if we approach this PHM transition period with transparency about our goals and challenges, this community can emerge from it strong and united.
Dr. Ezzio is a first-year pediatric hospital medicine fellow at Helen DeVos Children’s Hospital in Grand Rapids, Mich. Her interests include medical education and advocacy. Dr. Ezzio would like to thank Dr. Jeri Kessenich and Dr. Rachel “Danielle” Fisher for their assistance in revising the article. To submit to, or for inquiries about, our PHM Fellows Column, please contact our Pediatrics Editor, Dr. Anika Kumar ([email protected]).
References
1. Leyenaar JK and Fritner MP. Graduating pediatric residents entering the hospital medicine workforce, 2006-2015. Acad Pediatr. 2018 Mar;18(2):200-7.
2. National Resident Matching Program. Results and data: Specialties matching service 2020 appointment year. Washington, DC 2020.
3. National Resident Matching Program. Results and data: Specialties matching service 2021 appointment year. Washington, DC 2021.
4. 2020 State of Hospital Medicine report. Society of Hospital Medicine. 2020.
5. Oshimura JM et al. Current roles and perceived needs of pediatric hospital medicine fellowship graduates. Hosp Pediatr. 2016;6(10):633-7.
6. National Resident Matching Program. Results and data: 2020 main residency match. Washington, DC 2020.
7. American Academy of Pediatrics Annual Survey of graduating residents 2003-2020.
8. Quinn Capers IV. How clinicians and educators can mitigate implicit bias in patient care and candidate selection in medical education. American Thoracic Society Scholar. 2020 Jun;1(3):211-17.
9. Welsh G. The importance of community pediatric hospital medicine. The Hospitalist. 2021 Jan;25(1):27.