What? Why is it the most competitive? Because in their infinite wisdom, the ABP/AAP has essentially set the wheels in motion to make it required to be board certified via fellowship in pediatric hospital medicine to be a hospitalist. And so that created a flood of applicants for fellowship for what used to be just part of residency training and there are simply not enough fellowship spots. Eventually there will be, but essentially you now have to complete a fellowship for what is learned in residency.