Thank you for inviting comments on the American Board of Pediatrics (ABP) application for a subspecialty certificate for Pediatric Hospital Medicine (PHM). The National Med-Peds Residents’ Association (NMPRA) represents Internal Medicine and Pediatrics (Med-Peds) residents across the country and, among other missions, seeks to advocate for the specialty and its trainees.

Change must be welcomed in the world of medicine, however, it must be measured and with appropriate consideration given to its consequences and costs. We would like to highlight both the unintended consequences of PHM accreditation and oversights of the submitted application. We will also submit alternatives that may be more reasonably pursued.

 
Access to and Quality of Care

Ultimately, the single most important consideration is whether PHM accreditation will improve the health of our patients, either via improved quality of care or improved access to care. Regardless of how efficient hospitals become or how advanced guidelines become, without the ability to access providers, these efforts are largely moot. Surveys indicate that Med-Peds physicians will be less inclined to pursue PHM if it requires a two year fellowship and there are obvious disincentives for pediatric residency graduates in having to pursue even more training. It seems that PHM accreditation would actually negatively impact growth in the number of pediatric hospitalists rather than bolster it.

Further, the application trivializes the contribution of Med-Peds hospitalists to the care of inpatient children. Med-Peds hospitalists are being increasingly utilized by hospitals to better staff hospitalist services given their comfort in treating acutely ill pediatric and adult patients. More than 80% of Med-Peds hospitalists see children and adults and comprise over 10% of the PHM workforce. An unpublished survey of Med-Peds residents and attendings showed that the majority of participants would not consider pursuing an accredited PHM fellowship if it were in strongly encouraged.

Advancement in inpatient pediatric care, as well as standardization of hospital medicine curricula, can proceed without a two-year long fellowship. Dedicating resources to any area of medicine will aid in its advancement, and PHM is no exception. However, while it is evident that pediatric hospitalists have had a positive impact (demonstrated by metrics of care), this has occurred without an accredited fellowship. Prior to implementing an increase in length of training by 2-years to achieve the same level of employment, it would be prudent to have data showing differences in outcomes of fellowship vs. non-fellowship trained hospitalists. There is a single recent study that suggests differences in perceived competence, but there is a severe lack of evidence proving an actual distinction.
 

Effect on residency training

The ABMS should consider the implications of the statements made in the ABP application such as, “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.” Rather than attempting to address what seems to be a failure of pediatric residency by improving residency curricula, the PHM community wants to develop fellowships that would cost tens of millions of dollars over time and disenfranchise thousands of future pediatrics graduates. Advanced training in quality improvement, leadership, and research are relevant to all fields of pediatric medicine. It would be wiser to reevaluate and add focuses to pediatric residency training than to require a two year fellowship in these areas. Resigning to the notion that current pediatric residency training may not adequately prepare graduates for management of hospitalized children and creating fellowships to address the perceived issue is a very myopic solution.

Relegating graduates of pediatric residency to outpatient care and very basic inpatient care is a disservice to not only pediatric residents, but also our patients. The most obvious example is in the rural setting where community pediatricians round on hospitalized patients due to a lack of pediatric hospitalists. While there are merits to the argument that increased training is required to manage increasingly complex patients in the inpatient setting, these are fleeting when viewed through a practical lens.

 
Alternatives

There are two main alternatives that we would like to propose that would not lengthen the duration of training as drastically as a separate two-year fellowship.

The first is pursuing targeted concentrations during pediatric residency training which include increased focus on pediatric hospital medicine, quality improvement, and research. The need for evolution of pediatric residency training has become more apparent than ever. Addressing the needs of PHM would be a good starting point to improving the preparedness of graduating residents.

The second is to pursue a model similar to that of adult hospital medicine. This would involve Focused Practice in Hospital Medicine Maintenance of Certification rather than a separate two-year fellowship. Graduates would be free to choose their involvement in research and leadership but would still be required to prove their proficiency in hospital medicine.

Both of these alternatives preserve the current length of training, would save substantial costs, and would provide few disincentives for pursuing a career in PHM. Finally, research in PHM, as with any other field, is a product of funding and personal interests in the subject matter. Protected time for research will likely be a function of practice setting and institution specific goals.

 
Conclusion

NMPRA agrees with the AAP Med-Peds section and the Med-Peds Program Directors Association’s well-documented stances in recommending against approval of Pediatric Hospital Medicine as an accredited fellowship. We believe improvements in access and quality of care would best be achieved with innovation and improvements to the current frameworks of pediatric residency and hospital medicine.

References

O’Toole JK, Friedland A, et al. The practice patterns of recently graduated internal medicine-pediatric hospitalists. Hosp Pediatr 2015;5:309-14.

Librizzi, J., Winer, J. C., Banach, L. and Davis, A. (2015), Perceived core competency achievements of fellowship and non-fellowship-trained early career pediatric hospitalists. J. Hosp. Med., 10: 373–379.

ACGME Program Requirements for Graduate Medical Education in Pediatrics. Available at: http://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/320_pediatrics_07012015.pdf

Donnelly MJ, Lubrano L, Radabaugh CL, Lukela MP, Friedland AR, Ruch-Ross HS. The Med-Peds Hospitalist Workforce: Results from the American Academy of Pediatrics Workforce Survey. Hospital Pediatrics. Nov. 2015; 5(11):574-579. P