Pediatric Hospital Medicine

[starseeker]

Since Pediatric Hospital Medicine was announced as a subspecialty I have heard a lot of chatter around my institution of varying opinions. While speaking with residents who have an interest in becoming a hospitalist many are wondering if it is worth undergoing additional training. Several feel they have spent the majority of their training on the inpatient wards and ICUs and feel prepared for the next step. As someone who trained prior to PHM becoming a subspecialty I know people who chose to pursue fellowship training and those who did not and they have all thrived. I wonder what do you all think are benefits of having hospital medicine as a subspecialty? Do you agree that all pediatric hospitalists should have to undergo additional fellowship training?

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[Step Up]

Disclaimer - I'm a third year resident and have not spoken with many hospitalists about this issue.

I think there are obvious reasons for wanting to pursue the fellowship.

Ask yourself do you want to be in a pure clinician or an academician. If your interest is primarily clinical work then the decision is easy, skip the fellowship and go straight to being a hospitalist attending. On the flip side, if your career goals include the likes of research, having an administrative leadership role such as hospitalist director, or being residency or fellowship director, etc, then personally I would pursue the fellowship. With the fellowship you, ideally, are getting the time and tools to build a foundation for your future career path beyond the clinical aspects. This will help make you more desirable to hire at a major academic center. If you want to be hired at a prestigious academic institution, you very likely need to bring something else, besides clinical skills, to the table.

 

[SurfingDoctor]

Unnecessary to practice community based pediatric hospitalist, maybe necessary for academic based pediatric hospitalist because one needs to have an academic project, and the goal of fellowship is to get one started on that path. The clinical time is irrelevant.

 

[starseeker]

I agree with the both of you completely. I should state since maybe it wasn't clear in my previous post that I personally am not pursuing a career in hospital medicine but instead trying to provide career guidance to my residents. Some of them know they do not want to work at a huge academic center or pursue scholarly activities. Those who do enjoy those things are likely to have completed the fellowship regardless of whether or not PHM was a recognized subspecialty. The residents who see themselves in community settings have stated that it is a difficult decision for them as the benefits of fellowship training are not necessarily adding any skills they desire or that would benefit them throughout their careers. The ABP has stated that they plan to move towards only allowing those who are board certified (of which they have said that only those who completed fellowship would be able to sit for boards) practice hospital medicine. This is expected as that is how subspecialties work. My fear is that some residents will choose to not apply for fellowship training and thus may in the future be prohibited from the career path that they enjoy since we don't know for certain when the cut off will be for allowing non-fellowship trained physicians to sit for PHM boards.

My question wasn't at all meant to be reflective of my personal opinions on the matter but rather asking the opinions of others so that I can offer solid advice to my trainees. Currently I am encouraging all of those interested in hospital medicine to pursue fellowship training for the reasons listed above. Is anyone else having similar discussions with their trainees?

 

[SurfingDoctor]

Well the ABP can't require board certification to practice as a pediatric hospitalist in a community setting, that is up to the employer/hospital. So if that is their motive, it is irrelevant. Additionally, I would actually turn it back on them and say they are setting substandard requirements for residency if someone requires additional years of training to manage pneumonia with hypoxemia.

The only way around this would be what I've seen for general academic medicine fellowships... you get hired as an instructor and get a degree paid for. If that's the case, the 2 year fellowship is probably worth, if not, it is not worth the lost revenue as a fellow to gain no additional clinical skills.

 

[joetrue]

I'm just a medical student hoping to match peds in a few weeks and with a strong interest in hospital medicine.

I actually think it's kind of cool that peds hospital medicine is getting the recognition that having a subspecialty certification brings. That said, I am concerned that there will eventually be pressure on hospitals to hire fellowship trained, board certified hospitalists. Does that kind of thing play in to hospital quality ratings etc? I worry that fellowship training will create an undue burden on trainees. Peds is already under compensated compared to other medical specialties. The amount of debt I and many of my classmates are carrying is mind-numbing. Fellowship is two more years during which our loans will only be growing.

It seems like residents with an interest in academic hospital medicine could build their experience and resume with relevant research and QI projects while in residency, without the additional years and lost income.

But what do I know? I'm not even a doctor yet, so whatever I say comes with a big pile of salt.

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[mvenus929]

The ABP has stated that they plan to move towards only allowing those who are board certified (of which they have said that only those who completed fellowship would be able to sit for boards) practice hospital medicine.

So, there's this thing called a 'pretending' (as one of my attendings affectionately refers to it). These are attendings who practice in a subspecialty, but are not boarded in that specialty (and didn't do a fellowship). I've heard of them at at least two institutions (my home institution, and somewhere in Texas). We currently have them in ED (they serve as a second attending, but they are currently being phased out in favor of board certified PEM attendings) and GI (they see the uncomplicated constipation, functional abdominal pain, and hospital follow-up patients, don't do procedures, and don't see IBD or short gut kids). One of my classmates is going to be an Oncologist Hospitalist, where she is a hospitalist for oncology patients, managing the day-to-day stuffs while the heme-onc attending and fellow are either managing other teams or are seeing patients in clinic, etc. One of my gen peds clinic attendings was a Heme-Onc pretending when she first graduated residency.

So, the ABP can't actually restrict those who are not board certified from practicing a specialty. Which is why hospitalists in the community probably won't need to be fellowship trained, but those at academic centers probably will eventually.

 

[starseeker]

Thank you all for the responses. They were very informative. I haven't been at an institution with "pretendings". I realized that my bias is from the viewpoint of how pediatrics is practiced at large academic setting, specifically where I trained. It's always great to get another perspective!

 

[joetrue]

I wonder how it will play out at places that are in between academic and community. Medium-sized Children's hospitals with community residencies and maybe no fellowships.

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[starseeker]

I'm just a medical student hoping to match peds in a few weeks and with a strong interest in hospital medicine.

I actually think it's kind of cool that peds hospital medicine is getting the recognition that having a subspecialty certification brings. That said, I am concerned that there will eventually be pressure on hospitals to hire fellowship trained, board certified hospitalists. Does that kind of thing play in to hospital quality ratings etc? I worry that fellowship training will create an undue burden on trainees. Peds is already under compensated compared to other medical specialties. The amount of debt I and many of my classmates are carrying is mind-numbing. Fellowship is two more years during which our loans will only be growing.

It seems like residents with an interest in academic hospital medicine could build their experience and resume with relevant research and QI projects while in residency, without the additional years and lost income.

But what do I know? I'm not even a doctor yet, so whatever I say comes with a big pile of salt.

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I think the jury is still out on exactly how the future of hospital medicine will look. In your case I wouldn't worry too much about it at this point. You still have training to complete during which time you will have plenty of exposure to the care of hospitalized patients as well as scholarly pursuits should you so choose. Like I said in one of my previous posts I know several PHM attendings who did not complete fellowship and are practicing at large academic institutions.

 

[Staradmiral]

I am a PGY3 pediatric resident. I personally am unhappy with the news. We already spend 3 years in mostly inpatient pediatric medicine only to be told you are unqualified to be a hospitalist at an academic center (while in the past everyone went in no problem without a fellowship). How many Hospitalist fellowship program directors did a fellowship? This extends the training from 3 to 5 years. How will this motivate medical students to pursue pediatrics? especially those with debt. People have lives, spouses, children to financially support, not everything is about career career career. Many in my class dropped the idea of fellowship once they calculated the finances (mostly those who are married and have children). I personally will be going into outpatient pediatrics.

I don't disagree with Pediatric hospitalist being it's own specialty. They should just make it's own path that you apply to directly after medical school. They already have pediatric global health pathways, pediatric research pathways, etc. Just make a 3 year pediatric hospitalist pathway where the resident spends more time inpatient with more focus on QI. The same should be done with Peds ER, Peds adolescent medicine.. It's absurd Peds ED is 6 years while adult ED is 3.

 

[Staphylococcus Aureus]

A required fellowship after a residency that is already inpatient heavy is a horrific idea. Pediatrics already struggles to get subspecialists because of the time and debt amassed. Will internists be forced to do a hospitalist fellowship after 3 years of IM residency next?

 

[67552931811]

A required fellowship after a residency that is already inpatient heavy is a horrific idea. Pediatrics already struggles to get subspecialists because of the time and debt amassed. Will internists be forced to do a hospitalist fellowship after 3 years of IM residency next?

I agree with you 100% but there is actually is a push to make hospitalist medicine a fellowship after IM.

What the ABP really needs to do it is to give a "clinical" fellowship option for those of us who want to subspec. in peds but have 0 desire to be academic physicians. I mean, is it really necessary for someone in a nicu fellowship, for example, to do 18 months of research when they plan to become a pp neonatologist?

 

[dbeast]

Hospital medicine fellowship is a terrible idea for all of the reasons here yet it seems to be attracting some really great candidates, which means it's unfortunately here to stay. If we could all organize a boycott however...

 

[Andreji]

They'll have to grandfather a bazillion people before instituting restrictions. If we all have some cojones in the peds world and stand up for the worth of our practice, the whole concept of ABP limitations in this specific domain( what's next, a gen peds fellowship for outpatient??) should be DOA.

 

[mvenus929]

They'll have to grandfather a bazillion people before instituting restrictions. If we all have some cojones in the peds world and stand up for the worth of our practice, the whole concept of ABP limitations in this specific domain( what's next, a gen peds fellowship for outpatient??) should be DOA.

There are general academic pediatric fellowships for outpatient Peds

 

[Staphylococcus Aureus]

Why stop at one fellowship? Why not require an adolescent or young child specific fellowship for all pediatric hospitalists? The academics are used to perpetual post-docs, why not parlay that to all of medicine and keep the indentured servitude going...

Meanwhile midlevels can hop into any specialty with no such training (not to open that can of worms).

 

[Andreji]

There are general academic pediatric fellowships for outpatient Peds

Sure enough but the name is quite explicit in what it is (an academic fellowship- in my mind as mandatory as a Master's). And one that can't be set a requirement for practice by a single top hospital for all its outpatient offices. Why should it therefore be so briskly allowed to be one for the inpatient setting, even in the most academic of all? It would be a testament to the decline of pediatric residency if anything (even in their own programs).

Next up we ought to merely have a prelim year and follow suit with this "academic fellowship" shenanigans for many subspecialties then.

 

[Andreji]

Why stop at one fellowship? Why not require an adolescent or young child specific fellowship for all pediatric hospitalists? The academics are used to perpetual post-docs, why not parlay that to all of medicine and keep the indentured servitude going...

Meanwhile midlevels can hop into any specialty with no such training (not to open that can of worms).

Inadvertedly but not untimely (the can of worms, that is). I will always remain impressed at how the US has demoted the attendance of medical school to a mere formality to jump into residency. What is your MD good for? Parallel this to the current state of most bachelor's degrees (now a formality into a Master's). Peds is witnessing a step up not anywhere as apparent in our adult counterparts. This HM fellowship makes peda residency a mere formality in the same sense. I for one think it insulting to think the ABP is ensuring its relevance this way. I respect many dear colleagues I know have undertaken the HM fellowships for their value in research and education but not because it is a step up in knowledge of patient care.

If one's residency program somehow trained one to require an HM fellowship to round in a gen peds ward, you have been quite short-changed.

 

[Staphylococcus Aureus]

To be clear it sounds like a two year HM fellowship will be required for everyone (except those grandfathered in) not sure if they've officially said this. I wouldn't be surprised if this severely damages interest in hospital peds.

 

[NurWollen]

To be clear it sounds like a two year HM fellowship will be required for everyone (except those grandfathered in) not sure if they've officially said this. I wouldn't be surprised if this severely damages interest in hospital peds.

Some people have been saying that hospital fellowships will only be required at academic hospitals, and that you'd still be able to work as a hospitalist at community hospitals with just general peds training. The problem is, more and more, inpatient pediatrics is centered around large academic centers. Even community-based peds residencies are usually at tertiary care centers.

It's not hard to surmise that eventually, pediatrics residencies will be required to have ward attendings be board certified hospitalists, much the way residents must be supervised in the ED by BC PEM people. And this isn't just the white towers, it could potentially be community peds residencies.

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[mvenus929]

Some people have been saying that hospital fellowships will only be required at academic hospitals, and that you'd still be able to work as a hospitalist at community hospitals with just general peds training. The problem is, more and more, inpatient pediatrics is centered around large academic centers. Even community-based peds residencies are usually at tertiary care centers.

It's not hard to surmise that eventually, pediatrics residencies will be required to have ward attendings be board certified hospitalists, much the way residents must be supervised in the ED by BC PEM people. And this isn't just the white towers, it could potentially be community peds residencies.

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There are community hospitals that don't have pediatric residencies, but still are in need of a pediatric hospitalist. They usually have very basic gen Peds cases and usually require some nursery coverage as well, but they exist.

 

[SurfingDoctor]

There are community hospitals that don't have pediatric residencies, but still are in need of a pediatric hospitalist. They usually have very basic gen Peds cases and usually require some nursery coverage as well, but they exist.

It'll be interesting to see this trend. Many community hospitals aren't necessarily profitable and have a hard time competing against larger urban centers, so to maintain business, they join healthcare alliances or networks. This help the community hospital distribute the risk and help the urban hospitals have a constant referral pattern, somewhat of a win-win in the current era of increased costs with lower reimbursements. However, for those community hospitals to be in the network, they typically also have to meet some minimum care standards. It would be interesting to see how this effects positions like hospitalists as more an more community hospitals get engulfed. I suspect that urban centers will require community hospitals to meet the requirement of board certification for employed physicians (I've seen this happen, a community PICU couldn't maintain board certified ICU physicians, so the academic institute cut ties). This then goes either 2 ways, not enough people go through the fellowship training and there is a absence of available hospitalists to employ and the scrap the plan of requiring board certification, or that graduating trainees know that the only way they can get a job (outside of primary care) is by doing additional training and they just do it. It'll be interesting to see which trend wins (my guess is the latter, but I could be wrong).

 

[Staphylococcus Aureus]

Considering how long other fellowship peds specialties have gone underpaid and under supplied, this probably won't end up in our favor.

I personally was torn between inpatient and outpatient, and this made the decision for me.

 

[Perrotfish]

To be clear it sounds like a two year HM fellowship will be required for everyone (except those grandfathered in) not sure if they've officially said this. I wouldn't be surprised if this severely damages interest in hospital peds.

I'm not sure who 'they' are that you think could 'officially' say that a fellowship is required. 'They' meaning the children's hospital association, announcing that they won't hire any more non fellowship trained Pediatricians for hospitalist jobs? Children's hospitals are always in a desperate struggle just to stay staffed by anyone at all. Its a stressful, crappy, high liability, underpaid job and their staffs have incredibly high churn rates as everyone flees the wards for 8-4 clinic jobs in HMOs. They aren't in any position to get picky. 'They' meaning the ABP, announcing that non-fellowship Pediatricians are no longer qualified to see hospitalized children? There has never been any discussion of that, and if there ever was that would be the death knell of the ABP. We would just form a second competitive credentialing group like EM has. Or do you just mean 'they' as in the group of parasitic academic physicians trying to make a hospitalist fellowship a thing? Yes, they will announce that that every hospitalist should have a fellowship. And Ford will announce that everyone should drive a Ford. It doesn't make it true.

The hospitalist fellowship isn't a trend, its just a scam. Maybe a one year fellowship has some real value for someone trying to transition back to inpatient after 5+ years in clinic, but other than that its just someone trying to hire a hospitalist without paying a hospitalist. Its not going to catch on, I doubt even the existing fellowships are filling. There will never be enough hospitalist fellows to staff even a handful of Children's hospitals, let alone all 220 of them.

You don't have to do a fellowship to get a job as a hospitalist and you never will. FWIW none of the three hospitals I rotated through in hyper-desirable southwest costal California had even a single fellowship trained hospitalist on staff.

 

[Perrotfish]

Some people have been saying that hospital fellowships will only be required at academic hospitals, and that you'd still be able to work as a hospitalist at community hospitals with just general peds training. The problem is, more and more, inpatient pediatrics is centered around large academic centers. Even community-based peds residencies are usually at tertiary care centers.

It's not hard to surmise that eventually, pediatrics residencies will be required to have ward attendings be board certified hospitalists, much the way residents must be supervised in the ED by BC PEM people. And this isn't just the white towers, it could potentially be community peds residencies.

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You guys are severely overestimating the actual hiring standards in place out there right now. Community hospitals are hiring family doctors to staff wards unless state law specifically require Pediatricians to be on staff for them to have a nursery and an Ob/Gyn service. In that case they hire absolutely any Pediatrician willing to work there at very high prices. Academic Childrens' hospitals are hiring general Pediatricians to staff their wards, usually directly out of residency (since no one else will take the job), and then they water down even that minimal amount of experience and training by splitting the census between the Pediatrician and an NP who the Pediatrician technically, but not actually, supervises.

 

[SurfingDoctor]

You guys are severely overestimating the actual hiring standards in place out there right now. Community hospitals are hiring family doctors to staff wards unless state law specifically require Pediatricians to be on staff for them to have a nursery and an Ob/Gyn service. In that case they hire absolutely any Pediatrician willing to work there at very high prices. Academic Childrens' hospitals are hiring general Pediatricians to staff their wards, usually directly out of residency (since no one else will take the job), and then they water down even that minimal amount of experience and training by splitting the census between the Pediatrician and an NP who the Pediatrician technically, but not actually, supervises.

I think this speaks to the direness of the community hospital model. These types of hospitals have been closing at record rates for a number of reasons. The scaling back of Medicare and Medicaid is only likely to expedite the dwindling of the community hospital, especially for pediatrics. I wouldn't bank on the willingness of a community-hospital to hire whoever they like as a sure bet for job availability in the future... at least not based on the current trends. There will always be a need for community-based primary care, emergency care and elective surgeries. Outside of that, I don't think its a sure bet.

http://kff.org/report-section/a-loo...ccess-to-care-three-case-studies-issue-brief/

I suspect the US will move more and more toward a UK model, a regional hospital with specialized expertise. I know at least in strokes, it's been shown to improve outcomes. Of course, for that... you need a unified healthcare system... which who knows when will happen in the US.

http://www.bmj.com/content/349/bmj.g4757

 

[SurfingDoctor]

Just FYI...

"Pediatric Hospital Medicine: A Proposed New Subspecialty"

I personally have no stake in the decision for or against a PHM fellowship, but I found this part to be interesting (though very unlikely to be achievable during a PHM fellowship giving the trend of decreasing procedures in PICU fellowships)

"PHM trainees are expected to achieve a level of expertise with expanded breadth and extended depth in certain clinical areas, such as
-serious acute complications of common conditions
-complex conditions and diseases: children with special health care needs, technology-dependent children, and/or children with multiple comorbidities
-comanagement of surgical patients
-sedation and pain management
-palliative care
-selected invasive procedures and technical skills: airway management, venous access, arterial puncture, placement of feeding tubes, needle thoracotomy; and
-other core skills may include (depending on a fellow’s career goals): tracheal intubation, central line and peripherally inserted central catheter placement, bedside sonography, chest tube placement, and transport of the critically ill child."

Also relevant to the topic about community hospitals:

"Credentialing and privileging are local hospital processes that can vary from hospital to hospital. A priori, subspecialty status for PHM does not create inherent limitations to a general pediatrician attaining privileges to care for children, assuming the physician meets that hospital’s standards of competence. That said, as community-based pediatricians increasingly opt to refer their patients to hospitalists for reasons of efficiency, some hospitals could choose to limit a practitioner’s scope of practice in the hospital if he/she does not maintain a sufficient inpatient census or procedure volume. On the other hand, at the present time, there are not enough hospitalists to care for the entire population of hospitalized children. Thus, it is unlikely that hospitals without hospitalists will adopt standards restricting a general pediatrician’s ability to care for his/her own inpatients. Both the AAP and the PHM community are in support of the AAP policy statement “Guiding Principles for Pediatric Hospital Medicine Programs,” which states that general inpatient units should not be closed to general pediatricians."

 

[BigRedBeta]

I think the issue here is that they're trying to create an option that is all things to all people. In a rural state where there's only one children's hospital several hours from everywhere - eg Arkansas, Nebraska, South Dakota, or places where there's no children's hospital at all like Montana or North Dakota - I could see a significant benefit of having a pediatric hospitalist comfortable with the procedural skills listed above. In a major metro area, not so much. But of course the major metro area is the location MOST likely able to hire a full complement of fellowship trained hospitalists. Likewise, the other skills listed are more amenable to a major city location due to demographics and subspecialty support. So who is really going to go into this training program?

I think this speaks to the direness of the community hospital model. These types of hospitals have been closing at record rates for a number of reasons. The scaling back of Medicare and Medicaid is only likely to expedite the dwindling of the community hospital, especially for pediatrics. I wouldn't bank on the willingness of a community-hospital to hire whoever they like as a sure bet for job availability in the future... at least not based on the current trends. There will always be a need for community-based primary care, emergency care and elective surgeries. Outside of that, I don't think its a sure bet.

Depends on what you're discussing in terms of "community hospital". Small rural towns with populations <25k, yeah, those are dying or becoming functional extensions of nursing homes. But there are some large hospital corporations that supposedly view pediatrics as the next great frontier in revenue generation...I'll wait while you clean up after that spit take. I know, I know, we never ever get to hear that places are investing in pediatrics, but I took a job interview last year in Charleston SC at a facility that was doing just that. Already had hired a bunch of PEM folks, built a 6 bed peds ward (beds were licensed ICU beds, and there was space to add additional beds) and were in the process of recruiting intensivists to serve as an anchor for other subspecialists. Were also looking for a neurologist and then planned to recruit GI, Pulm and Endo thereafter. The parent corporation had rolled out this model in several other locations to be in direct competition with academic medical centers. Was definitely not the job for me coming right out of fellowship, and I'm sure they were very carefully choosing markets to go into (Charleston's geography, MUSC's location practically on the ocean, and where the population growth was happening made MUSC seem like a reasonable target from my outsider's POV). The reasoning was that they had invested extensively in NICU's as a draw for OB patients only to see the kids go across the street for their subsequent NICU grad problems. While they could develop birthing destination facilities they weren't able to retain those patients or the parents for other healthcare needs - so the thought process they told me was make it a habit to take your kid to one location from the time they were born and then when choosing a location for Mom's hypothyroidism, you'd choose them over the hospital that might be a little closer to home simply because of prior good experiences. Now I have no idea how successful this model has been, but I will tell you that the investment being made was pretty astounding - just from a salary perspective, they were paying the PEM group like adult EM and the PICU salary was in line with above average adult CCM. I doubt that is sustainable but maybe if you're a hospital employee and your salary is funded more from the associated bed/hospital fees rather than CMS/Insurance billing payments for critical care time it might work out.

 

[SurfingDoctor]

I think the issue here is that they're trying to create an option that is all things to all people. In a rural state where there's only one children's hospital several hours from everywhere - eg Arkansas, Nebraska, South Dakota, or places where there's no children's hospital at all like Montana or North Dakota - I could see a significant benefit of having a pediatric hospitalist comfortable with the procedural skills listed above. In a major metro area, not so much. But of course the major metro area is the location MOST likely able to hire a full complement of fellowship trained hospitalists. Likewise, the other skills listed are more amenable to a major city location due to demographics and subspecialty support. So who is really going to go into this training program?



Depends on what you're discussing in terms of "community hospital". Small rural towns with populations <25k, yeah, those are dying or becoming functional extensions of nursing homes. But there are some large hospital corporations that supposedly view pediatrics as the next great frontier in revenue generation...I'll wait while you clean up after that spit take. I know, I know, we never ever get to hear that places are investing in pediatrics, but I took a job interview last year in Charleston SC at a facility that was doing just that. Already had hired a bunch of PEM folks, built a 6 bed peds ward (beds were licensed ICU beds, and there was space to add additional beds) and were in the process of recruiting intensivists to serve as an anchor for other subspecialists. Were also looking for a neurologist and then planned to recruit GI, Pulm and Endo thereafter. The parent corporation had rolled out this model in several other locations to be in direct competition with academic medical centers. Was definitely not the job for me coming right out of fellowship, and I'm sure they were very carefully choosing markets to go into (Charleston's geography, MUSC's location practically on the ocean, and where the population growth was happening made MUSC seem like a reasonable target from my outsider's POV). The reasoning was that they had invested extensively in NICU's as a draw for OB patients only to see the kids go across the street for their subsequent NICU grad problems. While they could develop birthing destination facilities they weren't able to retain those patients or the parents for other healthcare needs - so the thought process they told me was make it a habit to take your kid to one location from the time they were born and then when choosing a location for Mom's hypothyroidism, you'd choose them over the hospital that might be a little closer to home simply because of prior good experiences. Now I have no idea how successful this model has been, but I will tell you that the investment being made was pretty astounding - just from a salary perspective, they were paying the PEM group like adult EM and the PICU salary was in line with above average adult CCM. I doubt that is sustainable but maybe if you're a hospital employee and your salary is funded more from the associated bed/hospital fees rather than CMS/Insurance billing payments for critical care time it might work out.

Coffee, literally all over my computer screen, thanks for that.

I have also seen this private-community children's hospital model employed. I have no idea if it is paying off like you said. I have heard that the intensivists employed at the private children hospital get paid like their adult counterparts (that part I know is true), but see essentially floor patients due to lack of volume and the inability of more surgical support (no ECMO, no neurosurgeons, etc.). I doubt that model is sustainable considering more than 1/3 of all children are covered by Mediacid (well, they at least are for now), but the companies that manage the private-children's hospital do have a lot of private adult insurees to offset some of the lost revenue for the time being. But like you, I doubt that is a longterm sustainable model. Couple that with the continuation of bundled inpatient care and things like MACRA... who knows how that will influence any of this. In terms of PHM, I foresee it will be that urban hospitals (non-profit or profit) will require PHM fellowship training where the demand for patient-care and desirability are high, and will not be required in places where desirability of living and patient volume are low.

 

[NurWollen]

Update:
Eligibility Criteria for Pediatric Hospital Medicine Now Available

Pediatric hospital medicine marches toward subspecialty recognition

Thoughts?

 

[Staphylococcus Aureus]

2 year hospitalist fellowship (if theoretically was required) still sounds as ludicrous as doing 3 years of IM then needing a 2yr HM fellowship to be an adult hospitalist. With the current debt load I don't know how a current student would have the luxury extending their training years for the same (relatively low) pay.

 

[starseeker]

So essentially they are attempting to phase out non-fellowship trained hospital medicine physicians. It's great that physicians who are already in practice have the opportunity to sit for the exam, but forcing all future graduates to complete a fellowship to become boarded seems excessive to me. Others have already mentioned this but so much of residency is spent learning about the care of hospitalized children. During my training I spent twice as much time inpatient than I did in general pediatrics clinic and as a result felt much more comfortable caring for children in the inpatient setting upon graduation. If my general pediatrics training is good enough to care for patients in the outpatient setting why is it not the same for the inpatient setting?

 

[Staphylococcus Aureus]

If my general pediatrics training is good enough to care for patients in the outpatient setting why is it not the same for the inpatient setting?

Coming soon: two-year primary care fellowship after residency in order to be BC for outpatient peds.

 

[NurWollen]

Coming soon: two-year primary care fellowship after residency in order to be BC for outpatient peds.

Maybe they'll start requiring fellowships in well child checks and fellowships in immunization administration.

In all seriousness, do people here think these fellowships will get more competitive? I could see demand going up much faster than supply.

 

[SurfingDoctor]

Maybe they'll start requiring fellowships in well child checks and fellowships in immunization administration.

In all seriousness, do people here think these fellowships will get more competitive? I could see demand going up much faster than supply.

Depends on what gains by fellowship training and what the market is looking for. Do I think it will be required to practice in an academic setting? That is a likely possibility. Do I think that it will be required to practice pediatric hospitalist medicine in a non-academic, rural or private setting? Well, that is up to the hiring institution, but I doubt it. Thus, the competitiveness depends on the job prospects and supply versus demand of institutes requiring a pediatrician to cover inpatient pediatric patients. The whole healthcare market is so volatile at the moment so it is hard to gauge, but I suspect it will come down to: Want to work as a pediatric hospitalist in a academic setting? You need fellowship training. Want to work as a pediatric hospitalist in a non-academic setting? You don't need fellowship training. Competitiveness only becomes a factor if the former is more in demand than the latter (which seems unlikely, but who knows).

 

[NurWollen]

Depends on what gains by fellowship training and what the market is looking for. Do I think it will be required to practice in an academic setting? That is a likely possibility. Do I think that it will be required to practice pediatric hospitalist medicine in a non-academic, rural or private setting? Well, that is up to the hiring institution, but I doubt it. Thus, the competitiveness depends on the job prospects and supply versus demand of institutes requiring a pediatrician to cover inpatient pediatric patients. The whole healthcare market is so volatile at the moment so it is hard to gauge, but I suspect it will come down to: Want to work as a pediatric hospitalist in a academic setting? You need fellowship training. Want to work as a pediatric hospitalist in a non-academic setting? You don't need fellowship training. Competitiveness only becomes a factor if the former is more in demand than the latter (which seems unlikely, but who knows).

This is a bit of a shameless bump, but when you say these fellowships might be necessary to practice in an academic setting, do you mean high-powered research, upper tier residency programs? Or do you mean any hospital with a peds residency? I realize no one really knows for sure but I think it's a discussion worth having.

I'm interested in hospital medicine, and I think I might like to work in a residency setting. But doing a fellowship would come at an enormous personal cost. It also makes me wonder what exactly I'm being trained to do as a peds resident. My program is very inpatient heavy. If three years of residency is enough to train adult hospitalists, why isn't it enough to train peds hospitalists?

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[SurfingDoctor]

This is a bit of a shameless bump, but when you say these fellowships might be necessary to practice in an academic setting, do you mean high-powered research, upper tier residency programs? Or do you mean any hospital with a peds residency? I realize no one really knows for sure but I think it's a discussion worth having.

I'm interested in hospital medicine, and I think I might like to work in a residency setting. But doing a fellowship would come at an enormous personal cost. It also makes me wonder what exactly I'm being trained to do as a peds resident. My program is very inpatient heavy. If three years of residency is enough to train adult hospitalists, why isn't it enough to train peds hospitalists?

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I don’t know the answer. I will say, I have seen a number undergo fellowship training to become hospitalist in any academic setting, including those with residents but without a strong research focus. However I have also seen people who have not undergone fellowship training and have either been practicing hospital medicine for years or were residents in the program for which they later became a hospitalist. I think the fellowship is still new and so it’s role in the current era is unclear, however, this was true for critical care medicine 25 years ago, and now there is no way you could practice critical care without fellowship training with board certification. I suspect hospital medicine will have the same trend, I just don’t know the time course.

As for the utility of a hospital medicine fellowship, well I have my opinion that I have stated previously, but I don’t make the decisions so I’m not sure my opinion matters.

 

[PTPoeny]

This is a bit of a shameless bump, but when you say these fellowships might be necessary to practice in an academic setting, do you mean high-powered research, upper tier residency programs? Or do you mean any hospital with a peds residency? I realize no one really knows for sure but I think it's a discussion worth having.

I'm interested in hospital medicine, and I think I might like to work in a residency setting. But doing a fellowship would come at an enormous personal cost. It also makes me wonder what exactly I'm being trained to do as a peds resident. My program is very inpatient heavy. If three years of residency is enough to train adult hospitalists, why isn't it enough to train peds hospitalists?

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I was considering hospitalist and had several conversations about this with my program director. In my community residency with no research focus my program director told myself and several other residents that the program only plans to hire fellowship trained hospitalist if the ABP makes it required as part of the residency ACGME faculty requirements. So at this point it is unknown. The ABP can create demand for these fellows by requiring that residency faculty be fellowship trained. I don't know if this will happen or not.

 

[NurWollen]

I don’t know the answer. I will say, I have seen a number undergo fellowship training to become hospitalist in any academic setting, including those with residents but without a strong research focus. However I have also seen people who have not undergone fellowship training and have either been practicing hospital medicine for years or were residents in the program for which they later became a hospitalist. I think the fellowship is still new and so it’s role in the current era is unclear, however, this was true for critical care medicine 25 years ago, and now there is no way you could practice critical care without fellowship training with board certification. I suspect hospital medicine will have the same trend, I just don’t know the time course.

As for the utility of a hospital medicine fellowship, well I have my opinion that I have stated previously, but I don’t make the decisions so I’m not sure my opinion matters.

I keep hearing the PEM comparison, but the critical care one is new to me. It's a good analogy. I guess the difference is that critical care and EM are areas we only get a few months in as peds residents, whereas we spend the majority of our time training in hospital medicine.

I was considering hospitalist and had several conversations about this with my program director. In my community residency with no research focus my program director told myself and several other residents that the program only plans to hire fellowship trained hospitalist if the ABP makes it required as part of the residency ACGME faculty requirements. So at this point it is unknown. The ABP can create demand for these fellows by requiring that residency faculty be fellowship trained. I don't know if this will happen or not.

I kind of worry that with such requirements (and even just the requirements for BC) the demand for these fellowships will skyrocket much faster than supply.

 

[RoboChicken]

I think what many people don't realize is that hospital medicine fellowships (many of them) do NOT place the focus on clinical training. Research is often 70% of the 2 years...so it's really about pursuing academia--many of the programs will pay for you to take courses in other fields (i.e. public health, medical education) or even get master's degrees (including MPH, MBA) and will FUND those degrees. So it's kind of a time apart from residency to build a niche and get more research and other experience. Plus <50% (and often 30%) clinical time is nice despite taking a lower salary for 2 more years, and allows for that space to figure out your place in the world of hospital medicine.

 

[MEN2C]

I think what many people don't realize is that hospital medicine fellowships (many of them) do NOT place the focus on clinical training. Research is often 70% of the 2 years...so it's really about pursuing academia--many of the programs will pay for you to take courses in other fields (i.e. public health, medical education) or even get master's degrees (including MPH, MBA) and will FUND those degrees. So it's kind of a time apart from residency to build a niche and get more research and other experience. Plus <50% (and often 30%) clinical time is nice despite taking a lower salary for 2 more years, and allows for that space to figure out your place in the world of hospital medicine.

Right, but if these were called "QI" fellowships (some places have those, like nationwide), or general research fellowships, no one would have a problem with it. People who are interested would do those. No, they call it a hospitalist fellowship. Which, as people have said, makes no sense because most training program prepare you way better to be a hospitalist than to be an outpatient pediatrician. I know mine did. So you should probably have a fellowship to be a board eligible outpatient pediatrician. At that point, it's just an indictment on poor residency training and if they truly feel that (I don't - would love to see any evidence) - just extend residency.

 

[RoboChicken]

Right, but if these were called "QI" fellowships (some places have those, like nationwide), or general research fellowships, no one would have a problem with it. People who are interested would do those. No, they call it a hospitalist fellowship. Which, as people have said, makes no sense because most training program prepare you way better to be a hospitalist than to be an outpatient pediatrician. I know mine did. So you should probably have a fellowship to be a board eligible outpatient pediatrician. At that point, it's just an indictment on poor residency training and if they truly feel that (I don't - would love to see any evidence) - just extend residency.

I am not arguing that I think Hospital Medicine Fellowships should be made mandatory to become a pediatric hospitalist (and it isn't btw), nor am I saying that peds residency prepares you more for outpatient gen peds (it doesn't). My pediatric residency program is a very large tertiary/quaternary stand alone children's hospital with a huge patient volume, but that being said--we don't get any experience in community hospital medicine (which is VERY different; different resources, priorities, etc.) I think to stay academic, you DO need skills other than what you learn in residency--i.e. sedation, admin, research, QI (not ALL of hospital medicine is QI by the way, so I would hate to have it be labeled a "QI fellowship), education, etc.) and yes, YOU CAN learn those skills on the job, but it takes time. It can take years for people to get to the sort of leadership position by just practicing hospital medicine out of residency vs doing a 2yr fellowship.

 

[MEN2C]

Yeah but you make an attending salary and you can start your life while doing it instead of another match/being a fellow/being cheap labor.

 

[RoboChicken]

Yeah but you make an attending salary and you can start your life while doing it instead of another match/being a fellow/being cheap labor.

Again, at 30-50% clinical time and salaries at many places above that of other fellows (since it isn’t ACGME yet), it’s not really cheap labor. It’s really more like expensive labor....for how little you “work”. But again, it depends on people’s long term goals, what their life situation is etc.

 

[shepardsun]

A little late to this thread but it's a topic that really angers me- I agree with pretty much everything most everyone else has said. The goal of a three year pediatric residency at a high-quality, free standing children's hospital should be to prepare you to care for an appropriate (i.e. non emergency, non-ICU) spectrum of ill children across the inpatient and outpatient environment. Period. If you don't come out being clinically capable to do so, then either your program has failed you or we need to revisit the definition of a pediatrics residency. It's insulting and a slap in the face to be told we need to do a two year fellowship in order to do what these grandfathered attendings have been doing on their own without any formal training for years. If they can turn into competent, even academic hospitalists, then it's hard for me to see this as anything other than a means to secure cheap labor. Considering that most of these attendings are the ones who felt uncomfortable and relied more on us residents when the renal transplant, fontan, or complex special needs patients came in, it's so hypocritical and laughable that it literally makes me sick.

As someone who has transitioned from peds to anesthesia on the way to PICU, peds fellowships are absolutely ridiculous in hindsight and from being immersed in the world of 1-2 year adult fellowships (which all result in you making substantially more). To tell someone interested in infectious disease that they're going to spend three years getting paid like a resident, half of which is research they may or may not have any interest in, all to make less money than an outpatient peds working 8-4 M-Th, then you're going to very quickly run out of infectious disease specialists- not to mention rheum, nephro, and endo. Peds as a whole is in trouble.

 

[Perrotfish]

A little late to this thread but it's a topic that really angers me- I agree with pretty much everything most everyone else has said. The goal of a three year pediatric residency at a high-quality, free standing children's hospital should be to prepare you to care for an appropriate (i.e. non emergency, non-ICU) spectrum of ill children across the inpatient and outpatient environment. Period. If you don't come out being clinically capable to do so, then either your program has failed you or we need to revisit the definition of a pediatrics residency. It's insulting and a slap in the face to be told we need to do a two year fellowship in order to do what these grandfathered attendings have been doing on their own without any formal training for years. If they can turn into competent, even academic hospitalists, then it's hard for me to see this as anything other than a means to secure cheap labor. Considering that most of these attendings are the ones who felt uncomfortable and relied more on us residents when the renal transplant, fontan, or complex special needs patients came in, it's so hypocritical and laughable that it literally makes me sick.

As someone who has transitioned from peds to anesthesia on the way to PICU, peds fellowships are absolutely ridiculous in hindsight and from being immersed in the world of 1-2 year adult fellowships (which all result in you making substantially more). To tell someone interested in infectious disease that they're going to spend three years getting paid like a resident, half of which is research they may or may not have any interest in, all to make less money than an outpatient peds working 8-4 M-Th, then you're going to very quickly run out of infectious disease specialists- not to mention rheum, nephro, and endo. Peds as a whole is in trouble.

I wonder if its time to finally create a new board to compete with the ABP.

 

[Perrotfish]

Again, at 30-50% clinical time and salaries at many places above that of other fellows (since it isn’t ACGME yet), it’s not really cheap labor. It’s really more like expensive labor

50% clinical time in every fellowship I have seen means that you work every other month, and on those months you work 24/28 days. That is what an attending would refer to as a full time job.

 

[RoboChicken]

50% clinical time in every fellowship I have seen means that you work every other month, and on those months you work 24/28 days. That is what an attending would refer to as a full time job.

That's definitely not true for the programs I applied to--I encourage people to actually take a look at the websites for the individual programs. I'm comparing something like 2-3 months on service and a couple electives per year to what our GI, or heme/onc, or cards fellows, etc do. I'm just trying to give a realistic picture of what these fellowship programs actually are. But if people want to continue to bash peds hospital medicine fellowships, I guess maybe it'll keep competition down for people who truly want to do it.

 

[MEN2C]

If you actually look at what the peds hospitalist fellowships application says, it contradicts your point about being an academic hospitalist:

http://www.abms.org/media/114649/abpeds-application-for-pediatric-hospital-medicine.pdf

"Certification will assure the public that the title ‘Board Certified Pediatric Hospitalist’ indicates a proficient level of skill and knowledge has been attained and validated. " (in other words, that non pediatric hospitalist trained person taking care of your child in the hospital may not have that proficient level of skill or knowledge)

" As a new subspecialty, pediatric hospital medicine (PHM) should further accelerate improvements and innovation in quality improvement (QI) science as applied to pediatric inpatient care, create a new and larger cadre of QI experts and mentors, and enhance development of professionals skilled in addressing child health safety issues within the context of health care systems. Certification will raise the level of care of all hospitalized children by establishing best practices in clinical care and disseminating them to all settings caring for hospitalized children." ([citation needed])

"Graduating residents are prepared to care for common problems in the in-patient setting, but it is not the role of categorical training to prepare pediatricians to care for the wider population of hospitalized children with complex disease or to specifically improve the hospital system." (Oh reallly???? What about my rotation in...OH EVERY INPATIENT ROTATION???)

"All residents must have a minimum of 9 months (out of 36 months total training) of experiences in inpatient settings such as inpatient ward, NICU, PICU" (Which residencies only have 9 months total of inpatient experiences including NICU, PICU AND wards?...)

"Without a certification process, patients, families, medical colleagues and hospital administrators have no way of identifying a physician who has the appropriate training and the expert knowledge and skills to provide care to hospitalized patients. " (Boom, right there....residency is not enough to learn the skills in taking care of the hospitalized patient...from their own document)

I encourage people to read that whole application. It's just ridiculous and pretty much an craps all over residency training. It basically implies that we don't train our residents well enough to manage complex inpatient problems, so instead of maybe fixing that (I think most pediatrics programs do just fine in management of complex problems - that's pretty much my entire residency), they are just going to push the buck down. It also talks about "procedures"...like NG tube placement and

I am not going into hospitalist medicine - I am doing a specialty, but this whole document is an absolute insult to all the hard work I've put into being a competent pediatrician and the excellent training that I've received.