Question and Response from July 2013 PHM Group Email

QUESTION:

PREFACE

Weighing the many advantages and disadvantages of the various long-term strategies for pediatric hospital medicine certification is a monumental task. Kudos to all who have participated. When approaching such a complex task, the process employed will significantly impact the resulting decision.  At the April 2013 meeting, the participants decided to focus on two laudable goals - improving the care of hospitalized children and ensuring public trust. Both goals are highly desirable and widely shared, arguably the top two ideals for advancing the field of PHM. Now the larger community needs to assess if this process has been effective in producing the wisest possible strategy.  In a system which is neither a corporate hierarchy nor a popular democracy, vetting the strategy is an unclear process. The true validation will be demonstrated by the judgments of medical students and residents over the next 5-10 years.

FIRST CONCERN

Focusing on two goals was an understandable tactic.  It simplified a very complex process. This tactic is used in mediation to foster win-win decision-making when there are many stakeholders with competing interests.  Using the tactic, the April conference was effective in producing near unanimity. Does this indicate clear superiority of one strategy? Or does the unanimity indicate that the two chosen goals were too similar to each other and/or that competing interests were inadequately represented?  Both chosen goals are susceptible to similar biases, particularly the appearance (possibly illusory) that each goal will be furthered by increased education and training. That formulation of the issue – with two dependent variables which are highly confounded – lacks a term which represents the negative consequences of prolonging training. With career goals that include income, prestige, and credentialing, will the best and brightest residents choose a 3 year fellowship in pediatric critical care or neonatology rather than two years in hospital medicine?

SECOND CONCERN

The wrong strategic plans will hamper the growth of the field and the quality of care for children. Given the stakes, would a second iteration of this stage 2 planning meeting, but with different stated goals, improve the accuracy of, and confidence in, the current recommendations? Suggested goals:  1) improving hospital care of children, and 2) promoting a positive response to the question “Would I recommend this career pathway to my best three residents?” An alternative second goal: “Will this strategy strengthen and promote the impact of pediatric hospital medicine?” One of the strengths of hospital medicine has been the large numbers of people going into it. If we expect only a small fraction of hospitalists to go through a 2 year fellowship program, with much smaller numbers than neonatology, it may significantly reduce the influence of our PHM organizations on the direction health care. Strategic planning is partly political and needs those elements explicitly represented.

THIRD CONCERN

Once the vision and goals of strategic planning are in place, a good chief executive would ask whether his/her company has the correct resources to fulfill those plans. A common theme in corporate planning is to avoid reinventing the wheel. So far this strategic planning has looked at four different ways of training and credentialing hospitalists. The proposed strategy has morphed into a focus on developing a large set of competencies for the future leaders of pediatric hospital medicine. These competencies include budgeting, management of personnel, and expertise in quality improvement processes. This set of competencies is a package already taught in MBA programs, particularly those with operations management emphasis. Many MBAs can be obtained in two years of part-time work. A halftime pediatrician can earn the salary of a PL-4 and have enough left over for tuition. How would a two-year fellowship in PHM, as envisioned in this proposal, compare to an MD-MBA in terms of salary, marketability, verifiable competency, and potential for career advancement to a much higher salary?

FOURTH CONCERN

This strategy’s purpose is to develop leaders in pediatric hospital medicine through a two-year fellowship. Are there any plans to enable the larger community of pediatric hospitalists to distinguish themselves from board-certified general pediatricians?

FIFTH CONCERN

As the assemblies at PHM, AAP, APA, and SHM national meetings review and discuss the Joint Council’s initial recommendations, it would be helpful to know to what degree the choice of developing a two year fellowship was influenced by current restrictive thinking at the American Board of Pediatrics. Is two years of fellowship training, rather than utilizing faculty development, necessary to achieve the envisioned set of competencies, or is that length fixed by the benefit of board certification? Is the goal of ensuring public trust a proxy for seeking a board certification from the ABMS? Is working with the ABPS an alternative?

PROCESS

The webinar in late May in which I intended to participate was later labeled for community hospitalists, so I did not participate at that time. My understanding of the current process is that questions and concerns should be submitted to the Joint Council so that they would have an opportunity to post a reply on the website before these matters are discussed at the August meeting in New Orleans. Thank you for your consideration of my concerns.

RESPONSE:

Thank you for sharing your concerns both at PHM and to this email.  You will see our response to your points below.  This response reflects the consensus of the group that met with the ABP.  It is our opinion only, and not fact.  As you point out in your preface, the ultimate validation of any course chosen will be many years in the future.

To your first concern: We do believe that our two goals for the conference were separate even if the ultimate best solution for both was the same.  We believe PHM is distinct from PICU and NICU so we are not concerned about 'losing' trainees who see the current pathway as 'easier' instead of fellowship training.  We would not consider those currently choosing PHM predominantly for the lack of further training as our 'best and brightest' (although we agree to some overlap).  In fact, some of our ‘best and brightest’ are already choosing PHM fellowship training despite the lack of ABP recognition.  Fellowships in NICU and PICU as well as the more analogous field of PEM have not deterred applicants, nor some of the organ-based specialties where ultimate financial remuneration is poor (Heme/Onc as a prime example).

To your second concern: We can't predict the future but we can look to past experiences for guidance.  PEM and ID have both advised us that board certification was a huge help to their fields, especially in academic settings.  ABP certification won't have any impact on the workforce for at least 10 years, and then it will likely acutely increase the number of individuals who try to get in the grandparenting timeframe before the fall-off created by limiting certification to only those fellowship trained.  The number of the PHM workforce are significantly higher than that of PEM prior to PEM certification and please remember that ABP certification will not limit anyone from practicing PHM without fellowship training, similar to being able to work in an emergency setting without PEM training.

To your third concern: The question of resource availability is somewhat out of our control and particularly difficult to forecast.  However, we can look to the growth of fellowships over the last five years without ABP standing and predict that ACGME reimbursement will only help solidify resources for future fellowships.  We fundamentally believe that PHM training is different from an MBA.  While there are overlapping leadership and business management skills the two paths are different.

To your fourth concern: We are in full agreement that ongoing meaningful CME for PHM is necessary.  It is a separate issue from ABP certification.  The JCPHM as well as the three organizations are all looking at developing more PHM content.

To your fifth concern: The two year time frame was chosen by the group and not the ABP.  No ABP representative participated in those discussions at the April meeting.  Additionally, several of us have had in-depth discussions with leaders from other specialties regarding their opinion of length of training.  We looked in to ABPS.  Their HM certificate is currently for adult medicine only and has had poor uptake in the adult HM community.  ABP did acknowledge ABPS but informed us that ABPS does not have the universal acceptance across all 50 states that ABMS has.  We decided that the extra value of ABP/ABMS approval was worth the cost differential from ABPS.

Thank you again for sharing your concerns.  We hope you will see that we’ve given these and other issues a great deal of thought.  We acknowledge that we will not achieve universal agreement with our conclusions and we welcome ongoing dialogue to ensure that all sides are heard.

The PHM Certification Leadership Group

PHM 2013 Presentation

PHM 2013 Slide Presentation for Informational Session on Sunday, August 4, 2013

Please follow this link above (it will open in a new window) to see the slides from the Informational Session at PHM 2013.

If you have comments, please log in and leave them on the blog site or email phmstrategicplanning@gmail.com and we can post these either with your name or anonymously.

Q&A from the April 4-5, 2013 Certification Meeting Summary Posting

In an effort to share information, the National PHM Certification Group will post questions received andresponses given to queries regarding the recent April Certification Meeting Summary posting. This Q&A will be posted on all PHM listservs and the STP committee blog site available at (http://stpcommittee.blogspot.com/). The names of those sending in questions are redacted for privacy reasons.

QUESTION:
I am a pediatric hospitalist, and I was quite interested to read the notes/minutes from the PHM Leaders Conference. This, in particular, caught my interest:

"There was overwhelming consensus that a standardized training program resulting in certification was the best option to assure adequate training in the PHM Core Competencies and provide the public with a meaningful definition of a pediatric hospitalist (17 for, 1 abstain). "

"There was overwhelming consensus that the duration of such training should be 2 years, recognizing that there may be trainees who will seek additional training to attain expertise in selected areas (16 for, 2 abstain)."

"There was overwhelming consensus that a 2 year accredited fellowship track was optimal path to provide the best patient care for hospitalized children and assure the public the qualifications of physicians practicing Pediatric Hospital Medicine."

I only finished residency 8 years ago. At that time, many of my colleagues and I felt that the ONLY place that we were prepared to practice medicine was in an in-patient setting. So I wonder why it is so different now? Is there a more fundamental problem that needs to be addressed, that speaks to the erosion of residency training in general (I believe largely due to restrictions imposed by the RRC)?

I am involved in teaching pediatric residents. It has been striking to me that over the last 5 years, I find a huge shift: such that it is now rare to find a resident who plans to stay in GEN PEDS. I find that they are more frequently seeking fellowship training of some sort (and perhaps, under your proposed model, this will include hospital medicine). Is this because they are all fervently seeking to become subspecialists, or because they feel that at the end of their GEN PEDS training, that they are not competent to be a practicing physician?

It would seem to me that we should be considering a few other very important questions, such as:

1. If the current RRC restrictions are to remain, should GEN PEDS become a 4 year residency?

2. If you believe that PHM should require an additional 2 years of fellowship training, what is the fundamental difference between this and pursuing a fellowship in Critical Care?

I would be curious to hear some thoughts/responses from some of your committee members.
Thank you for your time & consideration.

RESPONSE:
Dear Dr XX,

Thank you for your email. We really appreciate your taking the time to write, and you bring up some excellent points, many of which were discussed at our meeting and discussed again after reading through your concerns.


During the meeting, there were extensive discussions from multiple viewpoints as to which were the best training and certification options to ensure the best care of hospitalized children. Here are thoughts from many of the members of the group, pulled together here as one response.


To address your two questions:


1. If the current RRC restrictions are to remain, should GEN PEDS become a 4 year residency?

Discussing the length of residency education was out of the scope of this meeting, as the duration of the General Pediatrics residency is determined by a different organization, the ACGME. However, this issue has been discussed by Pediatric residency program directors in the past, and at this point, it is not going to be increased to four years. Some specific areas of deficiencies after residency training were noted in autonomous decision-making, communication, care coordination of complex cases, sedation, delivery room resuscitations, and leading in difficult situations.


We also discussed whether the new ACGME recommendation for 6 units of individualized curriculum for each resident would meet the training needs for pediatric hospitalists and would provide for the best care of hospitalized children. However, this was not felt to be sufficient, particularly given the changes in residency training over the past several years. Also, the units chosen will lack standardization between residents and residency programs and would not serve to ensure public trust in our profession.


The PHM leadership group also discussed at length whether or not residency plus one year of additional training (4 total years) could be sufficient. Ultimately, we decided that even though there might be further development of necessary clinical skills, it would be hard to fully develop the QI, leadership, and scholarship abilities needed to move the field forward. This experiment has been done through the use of chief residents, and though we think they add incredible value to the institution and do develop in some of these same areas, one year is not sufficient for all educational elements (clinical, QI, teaching, leadership, and scholarship) in a way that would significantly improve the field of pediatric hospital medicine or the care of children.


A defined residency track + 1 year of PHM fellowship was offered as a possible option and discussed. But there were issues with standardization of residency tracks and whether these would be available at each residency program. There was also concern regarding the need for an early career decision. A 1-year fellowship would also not provide enough time for QI, research, and other skills training such as management of pain, sedation, transport, and procedures.



2. If you believe that PHM should require an additional 2 years of fellowship training, what is the fundamental difference between this and pursuing a fellowship in Critical Care?

Excellent question. We all agree that there are certainly areas in which the fields overlap, but there are also defined knowledge, skills, and attitudes that define PHM as a specialty unique from Pediatric Critical Care as well as Pediatric Emergency Medicine. While a Pediatric Critical Care or Pediatric Emergency Medicine fellowship would certainly meet many of the PHM core competencies, there are others that a PHM-specific fellowship would need to address.


The skills acquired in an ideal PHM fellowship training would also include all, or nearly all, the skills needed to succeed at a community or university center.


With our recent meeting with ABP, it is clear that the bar for pediatric hospital medicine is being raised, be it within the clinical arena, research, education, or quality. To advance the PHM field and improve the quality of hospital care provided, scholarship is necessary. One could do a MPH, Graduate Certificate, a QI course in 2 years, and for those choosing to do a research track, an additional year of PHM fellowship may be available.


Resident debt at the end of residency was also considered. While 3 years would be necessary for complete scholarship, we concluded that 2 years would provide the necessary skills needed for most pediatric hospitalists.


The chronic nature of care and care coordination are very different. The PICU gets all of the resources they need and care for acute problems very well. Hospitalists can manage acute problems yet concentrate on the complexity of patients and longitudinal health. I feel, and have confirmed with several of my colleagues, that additional training for a hospitalist, although can contain some PICU concepts, requires a different skill set concentrating on complex management in a less resourced environment with a longitudinal perspective. The research components could be similar

Thank you again for your time,


National PHM Certification Group




2nd round QUESTION:
Thank you for your timely and thoughtful response. A few additional thoughts/responses from my side:"Some specific areas of deficiencies after residency training were noted in autonomous decision-making, communication, care coordination of complex cases, sedation, delivery room resuscitations, and leading in difficult situations."


I think that if residents are graduating any ACMGE accredited program with deficiencies in "autonomous decision making, communication, care coordination of complex cases.... and leading in difficult situations" then we have a very big problem, indeed. These should be basic core competencies for any resident to master, for any specialty. It makes me sad to think that we are all, apparently, knowingly graduating residents from any program who might lack these very important skills. I personally believe that if these deficiencies are present, they need to be addressed at the level of residency training rather than requiring fellowship training to learn these skills.


As for the specific skills of both sedation as well as delivery room resuscitations: I believe that these are skills that can/should be learned by all pediatric residents. If they are not being taught, then (again): these are very important gaps that have apparently been identified that need to be addressed. I cannot imagine graduating from a pediatric residency program, for example, without having attended at least 100 deliveries....

Ultimately, we decided that even though there might be further development of necessary clinical skills, it would be hard to fully develop the QI, leadership, and scholarship abilities needed to move the field forward. This experiment has been done through the use of chief residents, and though we think they add incredible value to the institution and do develop in some of these same areas, one year is not sufficient for all educational elements (clinical, QI, teaching, leadership, and scholarship) in a way that would significantly improve the field of pediatric hospital medicine or the care of children.

As for specific QI, research, and "scholarship" abilities: I would think that a PHM fellowship, particularly for those interested in remaining in academics, would be a wonderful opportunity. However, my suspicion is that the majority of children in this country are cared for by pediatricians in non-academic settings (even when they are cared for by pediatric hospitalists). As a non-academic/"community" pediatric hospitalist, although I have done QI projects, I will never pursue any research/publication. Since my goals have always been 100% clinical (which I think pertain to the majority of practicing physicians), I would think that requiring all pediatric hospitalists to have training/experience in research, etc., would be adding to the time/expense required to train any individual clinician, without adding to their ultimate ability to provide excellent care to children at the bedside.

RESPONSE:
Thank you for your very insightful comments and continued dialogue. You have hit upon a real issue that we are all (larger “all” of medicine) struggling with : the changes in residency training and what that means for practicing clinicians everywhere. It is difficult to compare past to present, but the “10,000 hours” that is cited as needed for any training to be an expert (Malcolm Gladwell, based on Ericcson's work) is indeed at risk with current residency models. While residents are graduating with experiences, it is less often that they are graduating with expertise. I think the Milestones are a statement of this as well – the concept that after residency, there is still learning needed to become an expert.


We anticipate that the ACGME has looked at the training models in Canada and the UK and other countries and has weighed the needs of the trainee with the needs of the patients. As patients are more acutely ill and have more complex issues both in and outpatient, the ability to “keep up” with what is needing to be covered in a 3 year training program is more and more difficult.


We also hear you loudly and clearly - the hospitalist is at core an excellent clinician who is a systems improver. At our community sites we certainly know the value of this just as in a tertiary setting. All settings are really teaching settings – it varies by who we teach and to what extent perhaps, but we all teach, we all improve the setting in which we work, we all champion for kids. That latter one is even more palpable in community settings.


The second point is at the heart of the issue. I offer this quote from the latest "Hospitalist":
“Given the changing context of payment, hospitalists are going to have to become true experts in managing the quality of care,” Dr. Conway says. “The days of you just graduating residency, seeing as many patients as you can, and you go home at the end of the day—that’s gone for hospital medicine.”


None of us think every hospitalist will need fellowship training. Just like every pediatrician who works in an ER does not need PEM training. However, at Dr Conway states, leaders and movers do and will need an additional skill set that is simply not available in residency training. The only way to assure this skill set for all those who will be certified as Pediatric Hospitalists is standardized fellowship training. We believe we owe it to our patients and the public to demonstrate a higher level of achievement in order to call ourselves specialists in our environment.


This is not perhaps any answer to your questions, but perhaps does underscore the need to assure care for hospitalized children is taking that next step to meet the challenge of an increasingly complex inpatient environment. “


National PHM Certification Group

PHM Leadership Conference (April 4-5, 2013) Summary: Link to pdf

To view the summary in larger pdf form, please copy and paste this link in your browser: https://docs.google.com/file/d/0B1TsRH5QR5Y2bV9oRk1KeDVSNzg/edit?usp=sharing

National PHM Leaders Conference at ABP (April 4-5, 2013) Summary

PHM Meeting at American Board of Pediatrics (April 4-5, 2013): Frequently Asked Questions

Clarifying information on subspecialty process
FAQs:

1) What is the process for creation of a new subspecialty?
A petition must be submitted to the ABP. The ABP may not accept the petition.
A 2 year fellowship program is not the current standard for fellowships at the
ABP.

2)  If it is successful, how long does the process take to create a new subspecialty?
The process for petitioning the ABP for sub specialty status is typically a 6 year
process during which time ABP and American Board of Medical Specialties
(ABMS) approvals are obtained and the test is created.

3) When would fellowships need to be accredited?
 Once a certifying examination has been implemented, the ACGME will begin the
fellowship program accreditation process. Typically this occurs a year or two
after the first exam.

4) I did not do a fellowship, can I take the test? I am currently in a fellowship; can I take the
test?
 a) Current pediatric hospitalists who meet minimal experiential standards will be
able to sit for the exam the first 3 test dates (so called ‘grandfathering’). The
test is given every other year so there will be 4 years from the first test for non-
fellowship trained individuals to be eligible to take the exam. This process allows
everyone currently practicing PHM and most future pediatric hospitalists for at
least the next 7-8 years the ability to sit for the exam.
b) Everyone in a fellowship program that exists at the time testing begins to be
offered will be eligible for the test. All PHM fellowship programs are currently
not ABP accredited, as no such accreditation exists. Once the fellowship
accreditation process does exist, then only ACGME approved fellowships will be
able to have their graduates sit for the exam.

5) When do I have to take the test, if I want to be “grandfathered”?
If someone applies and is approved for the exam, he/she has 7 years to become
certified, i.e. take and pass the exam. So one can actually defer taking the exam
beyond the "grandfathering " period. The clock starts ticking for the seven year
time limit the year of approval for the exam if under the practice pathway.

6) I am not in a fellowship now. Do I have to get into one in the next few years?
     o No, if you are currently in practice, or if you are in a currently non-accredited
fellowship you will be “grandfathered” in as noted above. Only those entering
the field of hospital medicine in the future - after the ACGME approves
fellowships – will need to be in a fellowship in order to sit for the certification
test.

7) When would future pediatric residency graduates need to enter a PHM fellowship?
After the ACGME approves fellowships, or approximately 8 years from the time
of initiating the subspecialty process.

8) If I take the PHM subspecialty boards, do I also need to maintain my general pediatric
board certificate?
No, there will be no need to maintain board certification in General Pediatrics
once PHM certification is attained.

9) What does “accredited” mean? What does “certified” mean?
 An accredited training program is a residency or fellowship program that is
approved by a reviewing body, such as the ACGME. A certified individual is one
who has met the expectations of a reviewing body, such as the ABP.

Other comments?