PHM Board preparation- Pediatric Hospital Medicine Board exam- what question banks, exam prep resources are you using?

[modocdo]

Hi everyone,
A few colleagues and I are planning on sitting for the Pediatric Hospital Medicine board exam for 2021 and 2023 cycles. What exam prep resources are you using? PREP has questions banks since 2018- those of you who took the 2019 exam, were they useful and accurate? Anyone using other resources other than general review books from the general pediatric board exam? Thanks!

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[SurfingDoctor]

I’ll be fascinated to hear how different the test questions will be from the general peds boards. Are there like examples posted somewhere, just for curiosity sake?

 

[Goneril]

I’ll be fascinated to hear how different the test questions will be from the general peds boards. Are there like examples posted somewhere, just for curiosity sake?

I doubt you’d get a lot of questions on developmental milestones. But it would be nice to see how different it is from the Peds exam.

 

[NurWollen]

I doubt you’d get a lot of questions on developmental milestones. But it would be nice to see how different it is from the Peds exam.

I wonder if I could pass it if I took it today. As a fellow in a different subspecialty who just took and passed the gen peds boards.


Wouldn't that be a scandal?

 

[SurfingDoctor]

I wonder if I could pass it if I took it today. As a fellow in a different subspecialty who just took and passed the gen peds boards.


Wouldn't that be a scandal?

I'm not trying to throw stones... but the practice questions I saw could easily be answered by any pediatric intensivist. Then one has to wonder... what is the advantage? And I don't mean that in a derogatory stance... more of a practical testing sense. Like what is trying to be achieved? I actually don't know the answer.

That being said... I don't find the chronically ill, complex children terribly rewarding... so if the point is to off load my burden... I'm okay with that. However, the issues in doing so were always nursing and not physician based. It is very interesting to me that the US healthcare system has enabled a version of healthcare that is "too sick for the pediatric floor, but too well for home care" where families get better care at home than in the hospital. I'm not sure how to address that, but maybe that is a different discussion. Oh well...

 

[WheezyBaby]

I'm not trying to throw stones... but the practice questions I saw could easily be answered by any pediatric intensivist. Then one has to wonder... what is the advantage? And I don't mean that in a derogatory stance... more of a practical testing sense. Like what is trying to be achieved? I actually don't know the answer.

That being said... I don't find the chronically ill, complex children terribly rewarding... so if the point is to off load my burden... I'm okay with that. However, the issues in doing so were always nursing and not physician based. It is very interesting to me that the US healthcare system has enabled a version of healthcare that is "too sick for the pediatric floor, but too well for home care" where families get better care at home than in the hospital. I'm not sure how to address that, but maybe that is a different discussion. Oh well...

Department chairs aren't even majority in favor of the fellowship. It's a mess. And as much as I would love it I don't think the goal is to offload the chronically ill technology dependent child from the PICU service

 

[sliceofbread136]

Department chairs aren't even majority in favor of the fellowship. It's a mess. And as much as I would love it I don't think the goal is to offload the chronically ill technology dependent child from the PICU service

I’m assuming this is mainly referring to trach vent kids. IMO pulm would be a better candidate for this (like they do in cinci). I would not trust a hospitalist to take care of these children...

 

[WheezyBaby]

I’m assuming this is mainly referring to trach vent kids. IMO pulm would be a better candidate for this (like they do in cinci). I would not trust a hospitalist to take care of these children...

Agreed. Hospitalists would need a lot of prep that isn't part of the fellowship to be prepared to take care of home ventilated kids and pulm is a much more natural group to do so. Our pulm group is allowed to admit home vent but it's fairly narrow scope (limited in number based on nursing availability, and also can't be a primary pulmonary process and need to be on home vent settings). I've seen other places care for this group in a stepdown setting, but with maybe one exception it's still intensivists rounding

 

[FlowLimited]

Agreed. Hospitalists would need a lot of prep that isn't part of the fellowship to be prepared to take care of home ventilated kids and pulm is a much more natural group to do so. Our pulm group is allowed to admit home vent but it's fairly narrow scope (limited in number based on nursing availability, and also can't be a primary pulmonary process and need to be on home vent settings). I've seen other places care for this group in a stepdown setting, but with maybe one exception it's still intensivists rounding

You've hit on some of the major issues here. A trach/vent kid often needs a level of care during an acute respiratory illness beyond what a regular floor ward can safely provide. That's why these kids end up admitted to the PICU. It's not that the pulmonologist doesn't know how to manage a home vent. They may need changes to their home ventilator settings and/or supplemental O2 and often need frequent adjustments. They commonly have an increased demand for airway clearance/suctioning that would overwhelm a floor nurse/RT team taking care of multiple other patients.

The question of hospitalist vs. pulmonologist comes up a lot for the more stable trach/vent kid on the floor on their home vent settings. As we all know, these kids come with a lot of other medical issues that the hospitalist is much more knowledgeable about. All these things tend to flare up during an acute illness. You certainly don't want the pulmonologist managing increasing seizures, neurostorming, tube feed related issues, etc.

For these more stable kids, I disagree that it would take a lot of prep for a hospitalist to learn the important aspects of inpatient trach/vent management. Most of the issues that come up are related to airway clearance and the vent is typically untouched. Knowing how/when to change a trach and utilize airway clearance would be 90%+ of the job. The hospitalist could always consult the pulmonologist automatically or as needed.

Does anyone know if hospitalist fellowships are teaching this stuff?

 

[WheezyBaby]

You've hit on some of the major issues here. A trach/vent kid often needs a level of care during an acute respiratory illness beyond what a regular floor ward can safely provide. That's why these kids end up admitted to the PICU. It's not that the pulmonologist doesn't know how to manage a home vent. They may need changes to their home ventilator settings and/or supplemental O2 and often need frequent adjustments. They commonly have an increased demand for airway clearance/suctioning that would overwhelm a floor nurse/RT team taking care of multiple other patients.

The question of hospitalist vs. pulmonologist comes up a lot for the more stable trach/vent kid on the floor on their home vent settings. As we all know, these kids come with a lot of other medical issues that the hospitalist is much more knowledgeable about. All these things tend to flare up during an acute illness. You certainly don't want the pulmonologist managing increasing seizures, neurostorming, tube feed related issues, etc.

For these more stable kids, I disagree that it would take a lot of prep for a hospitalist to learn the important aspects of inpatient trach/vent management. Most of the issues that come up are related to airway clearance and the vent is typically untouched. Knowing how/when to change a trach and utilize airway clearance would be 90%+ of the job. The hospitalist could always consult the pulmonologist automatically or as needed.

Does anyone know if hospitalist fellowships are teaching this stuff?

It's a fair question. I agree I don't see pulm being on top of those areas. Honestly developmental peds / complex care service to me seems like the best middle ground, as they're already commonly caring for trach / gtube patients and are familiar with the comorbidities many trach/vent patients commonly have. Then the patient could be taken care of on a pulmonary floor to maintain nurse / RT familiarity. The other issue would be overnight coverage and which staff if any are available in house to trouble shoot the ventilator if needed, which isn't easily done remotely if it's a resident in house and staff / fellow home coverage for a given service. I hate mandatory/automatic consults, but certainly at least having a zero resistance pathway to pulm consult would be reasonable. At any rate, it's not something our fellowship is teaching as it isn't something our hospitalists care for or are currently comfortable managing (at least in my discussions with them). I also agree that the basics of trach/vent management aren't insurmountable my any means, but the stakes of those things being mismanaged I think is a barrier to people approaching it

 

[FlowLimited]

It's a fair question. I agree I don't see pulm being on top of those areas. Honestly developmental peds / complex care service to me seems like the best middle ground, as they're already commonly caring for trach / gtube patients and are familiar with the comorbidities many trach/vent patients commonly have. Then the patient could be taken care of on a pulmonary floor to maintain nurse / RT familiarity. The other issue would be overnight coverage and which staff if any are available in house to trouble shoot the ventilator if needed, which isn't easily done remotely if it's a resident in house and staff / fellow home coverage for a given service. I hate mandatory/automatic consults, but certainly at least having a zero resistance pathway to pulm consult would be reasonable. At any rate, it's not something our fellowship is teaching as it isn't something our hospitalists care for or are currently comfortable managing (at least in my discussions with them). I also agree that the basics of trach/vent management aren't insurmountable my any means, but the stakes of those things being mismanaged I think is a barrier to people approaching it

I certainly share your feelings on the auto-consult. At my children's hospital the trach/vent kinds who are admitted for non-respiratory reasons or those with a lot of "other stuff" go to the hospitalist service. The protocol is for an auto-consult to pulm so they're made aware of the patient, but it frequently falls through the cracks. If the consult does happen, pulm usually gives their blessing and says call us if you need us.

It's interesting to hear the different opinions of hospitalists at different institutions in terms of managing this stuff. Our hospitalists have made it known that they want these patients (and many others) that in the past have been admitted to a specialty service. Pulmonology at our hospital still admits patients for now, but I don't know how long that's going to last.

 

[SurfingDoctor]

Most of the trach/vent management can be handled by nurses (and RTs). They are when they are at home. If there is a trach/vent kid with cellulitis and difficulty tolerating feeds who is on their home respiratory therapy and requirements, there is no role for a pulmonologist. Likewise, it's overkill to be in the ICU. But, the nursing ratio has to be higher (as it is at home) and that's the hang up. The "training" is irrelevant. Is the chest moving and the SaO2 >90% on baseline oxygen settings? Cool, don't touch anything. If those criteria aren't met 1) did you change the trach? 2) did you call a rapid response? That's it.

 

[WheezyBaby]

Most of the trach/vent management can be handled by nurses (and RTs). They are when they are at home. If there is a trach/vent kid with cellulitis and difficulty tolerating feeds who is on their home respiratory therapy and requirements, there is no role for a pulmonologist. Likewise, it's overkill to be in the ICU. But, the nursing ratio has to be higher (as it is at home) and that's the hang up. The "training" is irrelevant. Is the chest moving and the SaO2 >90% on baseline oxygen settings? Cool, don't touch anything. If those criteria aren't met 1) did you change the trach? 2) did you call a rapid response? That's it.

It still seems resource wasteful to me to have anyone who needs to remotely deviate from home vent to immediately need PICU. It's just an easy conservative cut off to be able to keep some of these kids out the picu

 

[SurfingDoctor]

It still seems resource wasteful to me to have anyone who needs to remotely deviate from home vent to immediately need PICU. It's just an easy conservative cut off to be able to keep some of these kids out the picu

Well, besides oxygen titration, many newer "home vents" need to be changed through the supplier. When you have to start mucking around with the vent it is 1) nearly impossible to do inpatient (again minus oxygen flow) and 2) typically a harbinger of things getting worse. I have no issue with those kids coming to the ICU.

We do however, have a good number of kids who sit on their home vents at their home settings to get antibiotics or manage their feeds or the worst... await home health nurse availability OR await foster care placement. It's especially those latter kids who are ready for discharge but literally can't be that is the biggest waste of resources... and it's become more common, not less.

 

[thetubes]

I certainly wouldn't want cystic fibrosis patients admitted for pulmonary exacerbation managed by a pediatric hospitalist. Regarding the issue of patients on chronic mechanical home ventilation managed by pediatric hospitalists I am of the opinion that pediatric pulmonary should always at least be consulted to review ventilator settings and acid/base status and that they should have the final say on when the patient is ready to be discharged from a respiratory standpoint. The biggest problem that I have with any strictly hospital-based service (Hospitalist, PICU, ED; NICU is an exception) managing patients followed by other subspecialists is that no matter how hard they try, they just cannot see the longitudinal ramifications of what is or isn't done for the patient. The reason quite frankly is that they don't follow these patients outside of the hospital. They don't know what the "baseline" is for the patient or are quick to interpret the patient as being "good enough" for home but the problem with that logic is that if you continue doing this, in a few years patients will lose lung function that they will never get back. Any increase in support or clinical decline (even a small degree) shouldn't be just accepted, not without a good justification and certainly not without an earnest effort to reverse the course.

 

[sliceofbread136]

You've hit on some of the major issues here. A trach/vent kid often needs a level of care during an acute respiratory illness beyond what a regular floor ward can safely provide. That's why these kids end up admitted to the PICU. It's not that the pulmonologist doesn't know how to manage a home vent. They may need changes to their home ventilator settings and/or supplemental O2 and often need frequent adjustments. They commonly have an increased demand for airway clearance/suctioning that would overwhelm a floor nurse/RT team taking care of multiple other patients.

The question of hospitalist vs. pulmonologist comes up a lot for the more stable trach/vent kid on the floor on their home vent settings. As we all know, these kids come with a lot of other medical issues that the hospitalist is much more knowledgeable about. All these things tend to flare up during an acute illness. You certainly don't want the pulmonologist managing increasing seizures, neurostorming, tube feed related issues, etc.

For these more stable kids, I disagree that it would take a lot of prep for a hospitalist to learn the important aspects of inpatient trach/vent management. Most of the issues that come up are related to airway clearance and the vent is typically untouched. Knowing how/when to change a trach and utilize airway clearance would be 90%+ of the job. The hospitalist could always consult the pulmonologist automatically or as needed.

Does anyone know if hospitalist fellowships are teaching this stuff?

You make some good points. I guess a hospitalist would be good for the scenarios you mentioned. In my head the patient population I was more thinking was the 6 m/o bpd kid waiting until he is ready to transition to a home vent. I think the chronic respiratory failure component would be better managed under pulm. But perhaps a hospitalist could be primary with pulm as a consultant.

Most pulm people I know are very comfortable with tube feeds. Seizures and other Neuro stuff not as much. Oddly enough at my institution pulm is trying to steal complex care kids from phm because our outpatient billing is down. Maybe the best way could even some sort of qi project

 

[hmockingbird]

I can comment on my experiences at two hospitals. At both my residency and current job, there was some type of step down situation primarily managed by pulm. Unless there was a reason for the kid to be in the ICU (significantly increased settings, unstable BPs, status epilepticus, etc) they would be on the pulm team. Like others have said a lot of them were just kids waiting to get home nursing set up and have parents complete teaching, or finishing a course of IV abx, so basically rocks. I do think this would be a waste of ICU space. At both places, pulm is/was really familiar with stuff like tube feeds, but usually kids would have nutrition, GI and neuro consulted liberally. I felt like this was a really valuable experience in residency and it contributed to my confidence in taking care of complicated kids — and also my comfort with consulting for them! At my current job, the hospitalists cover overnight and we mostly only call pulm if they need a vent change (and usually that means they’re going to the ICU anyway).

 

[mvenus929]

I don't know all the details for my current institution, but in residency, if a kid was acutely admitted and had a vent/trach, they went to the PICU mostly for nursing ratio purposes (suctioning every hour is challenging when you're managing 3-5 other patients). If they needed a prolonged admission, there was a long-term care unit that they could be transferred to (managed by pulm) once stable until they were ready for discharge home. Otherwise, those were basically the only kids we discharged directly from the PICU. I think my current institution is similar (though I don't know if there's a long-term care unit), as I see the vent/trach kids sit in the PICU for ages.

It really does come down to nursing and not physicians, though. We manage DKA on the floor at my institution (provided they aren't high risk for cerebral edema), but that's because the care assistants (or whatever you call them) are permitted to check blood sugars and do neurological checks here. They have to report those values to the nurse, but the nurse isn't going in every hour to do cares usually.