Recommendations for Minimum Residency Training Requirements in Pediatric Hospital Medicine.

Abstract

Pediatric hospital medicine (PHM) has grown tremendously over the past 2 decades and was approved in 2016 by the American Board of Medical Specialties as the most recent pediatric subspecialty. The designation as a specialty has increased discussion about if and when future employers may require PHM board certification. With the practice pathway closing, fellowship will be the only avenue to obtain pediatric hospital medicine board certification. At least 10% of recent graduates from general pediatric residencies have chosen PHM as their career, with around two-thirds planning to remain hospitalists long-term.1 The demand for pediatric hospitalists currently far exceeds the fellowship spots available. In the last 2 matches, PHM was the most competitive specialty, matching at 100%, with a third of applicants unmatched.2 For a sense of perspective, in 2021 there were 96 fellowship positions in the United States and an estimated 4000 or more pediatric hospitalists practicing across the United States.3 As such, the vast majority of physicians caring for inpatient children in the United States do not, and will not, have fellowship training, as the demand for practicing hospitalists and training spots are far from equal. Despite the reality that most pediatric hospitalists will not be fellowship-trained for the foreseeable future, there are no current requirements to prepare non-fellowship-trained physicians for independent practice. It is critical for the safety of children who will be admitted to hospitals for inpatient care that minimum residency training requirements for pediatric hospital medicine are established.Medical training is constantly evolving. Several fields of medicine that now require a 3-year fellowship were previously practiced without additional training. Yet even after the introduction of additional fellowship training requirements for critical care and emergency medicine, residents continue to have required rotations in these fields as part of their general pediatrics training. The Accreditation Council for Graduate Medical Education (ACGME) requires 10 blocks of inpatient care experiences, which include 2 units of NICU, 2 units of PICU, and 1 unit of newborn medicine.4 This leaves 5 units for inpatient pediatrics, of which no more than 1 should be devoted to a single subspecialty. However, without specific requirements for general inpatient pediatric units, the remaining 4 units may be allocated to the care of patients on a combined service run by multiple subspecialists. This leaves residents without significant time dedicated to learning the “bread and butter” of general inpatient pediatrics.Whether residents are planning for a career in primary care or a 3-year ICU fellowship, the ACGME has deemed exposure to these fields of medicine an integral part of general pediatrics training. Hospital medicine should not be any different. Although PHM fellowship allows for the opportunity to gain further clinical and research expertise,5 hospital medicine still deserves a spot in the residency curriculum with a minimum requirement for clinical exposure to general inpatient pediatrics. This is particularly important when considering that not every pediatric hospitalist will be able to pursue fellowship training. Many factors will affect a physician’s ability to pursue fellowship training beyond the availability of fellowship positions. Recent evidence has shown that since the introduction of PHM fellowship requirements, residents are now less likely to pursue a career in PHM, citing personal financial and opportunity costs.6Inpatient general pediatrics forms the core of pediatric residency education. The skills acquired during rotations on general medicine are foundational to the education of future pediatricians. Residents learn critical thinking skills, common pediatric diagnoses, how to triage patients by acuity, and how to lead a team. Much of the learning gained during general medicine rotations also prepares residents who seek other subspecialty fellowship training in the future, as trainees are exposed to diverse pathology during their inpatient general pediatric rotations. Physicians in nearly every field of pediatrics will interface with pediatric hospitalists, whether it is to admit a patient from an outpatient office or an emergency department, to consult on a general pediatrics patient, or to co-manage a complex patient. It is important and useful for trainees going into all fields to understand the workflow of a service that is essential to hospital functioning. In addition, hospital medicine encompasses a wide range of clinical experiences as every hospital has a different level of acuity and skills required of its providers. This is particularly true in community hospitals.One third of pediatric hospitalists practice in community hospitals, and the remainder within children’s hospitals.7 Seventy percent of American children are cared for in these community sites. The top 3 services covered by pediatric hospitalists are pediatric inpatient or observation admissions (97%), emergency department consults (89%), and general newborn care (67%).7 PHM programs also provided coverage for other services, including newborn deliveries (43%), Special Care Nursery or Level II NICU (41%), step-down units (20%), and mental health units (13%).7 Given the wide range of responsibilities required and varying resources and onsite support, applicants to community hospitalist positions would benefit from established minimum training requirements in hospital medicine to ensure exposure to a breadth of clinical scenarios.There are currently no ACGME guidelines for the minimum amount of time required rotating on an inpatient general pediatrics service. We acknowledge that not every trainee needs the same amount of time to gain competency in a skill. There is no current consensus, however, on what defines competency in pediatric inpatient medicine, and we feel it is critical that the ACGME set these new guidelines in a timely manner. Thus, our recommendations are time-based rather than competency-based, in accordance with current ACGME time-based requirements for other subspecialties.In August 2021, a concerned group of 80 members of the American Academy of Pediatrics Section on Hospital Medicine listserv from across the country from both academic and community sites convened virtually for a 90-minute open discussion forum. In this meeting, members of the listserv were given the opportunity to offer suggestions and solutions to this issue. Afterward, a committee of 8 hospitalists representing community and academic sites from 3 regions of the country developed the following recommendations which were sent to the ACGME and are presented here. We recommend that pediatric residents complete a minimum of 4 blocks of general inpatient pediatrics, with at least 1 block occurring as a senior resident leading a team. We define general inpatient pediatrics as any rotation that admits nonspecialty patients, and includes a variety of pediatric diagnoses, led by a pediatric hospital medicine attending physician. A general pediatric block may also be defined as a rotation with experiences in a variety of settings, including but not limited to newborn nursery, sedation, transport, etc. In addition, trainees may seek to bolster particular skills, such as neonatal resuscitation, procedural skills, sedation, pain management, research, or quality improvement, based on personal interest or requirements for future employment through additional rotations using an individualized curriculum. Given the varied skill sets required of hospitalists depending on their institution and location, certain skills will need to be sharpened during onboarding to ensure proficiency for independent practice.The majority of our hospitalized children are treated in community hospitals, staffed almost exclusively by non-fellowship trained pediatric hospitalists. Without established residency requirements for training in PHM, programs may begin to decrease their focus on general inpatient hospital medicine, as trainees now have the opportunity to complete an additional 2 years of training in this field. Though new fellowships are being created rapidly in an attempt to keep up with demand, for at least the next several years many new pediatric hospitalists will be neither fellowship-trained nor board-certified. Thus, it is possible that some trainees may graduate residency unable to manage common pediatric diagnoses because of lack of exposure. If we do not advocate for a guaranteed minimum exposure to PHM in residency now, when our field is still relatively young and rapidly evolving, we will miss this critical opportunity to ensure that future generations of physicians and patients will not suffer the consequences.