Other Training Options?

Please let us know what other training options you would like to see explored for PHM.

Is PHM a subspecialty?

Probably one of the first questions to be answered, prior to reading through the training options here, is whether Pediatric Hospital Medicine should be a subspecialty of Pediatrics or not.  We can make a pro/con list for you, but we want to hear from you first!  Please comment and let us know what you think.

Thanks!

The STP Committee

3-year Fellowship Option with ABP subspecialty certification

Pros:

• Traditional and accepted model for developing a subspecialty 
• Further develops identity and standardization of Pediatric Hospitalists 
• Will create recognition for pediatric hospitalist amongst various organizations 
• May improve reimbursement rates 
• Improves value (quality/cost) of hospital medicine clinical care 
• Able to monitor and gauge clinical progression of trainees with direct observation over a period of time. 
• Opportunity to teach/hone/expose to medical procedures that may be limited duringresidency
• Develop a standardized curriculum in hospital medicine for areas of clinical practice, administration/ leadership, and scholarship/ Quality Improvement 
• Provide a safe environment to learn pediatric hospitalist skills 
• Provide protected time to learn about leadership/administrative theory 
• Provide protected time to be on hospital/university committees 
• Fellow-trained graduates will more likely contribute in areas of administration and leadership at the start of the job. 
• Help ensure “qualified” people every year to provide leadership and mentorship 
• Provide protected time to adequately train for and pursue research and QI project 
• Pediatric Hospitalists would be better prepared to compete for funding opportunities 
• May lead to more hospitalists in future leadership/administrative positions. 
• Accelerate opportunities for research collaboration with other subspecialties 
• Better help identify research needs in the field of pediatrics hospital medicine and thus concentrate research endeavors to relevant high-yield efforts

Cons:

• Large opportunity cost for trainee (3 years loss of time / loss of revenue) 
• Lack of significant prospective financial benefits for additional training 
• Lack of current number of fellowship program for projected demand 
• Currently no standardization of fellowship training
• Lack of standardization of clinical responsibilities in hospitalist work may make it difficult to standardize curriculum.
• Ability for administrative and leadership standardized experience may be difficult to mandate in a fellowship program
• May risk producing lower-quality research in order to simply meet PHM fellowships or credentialing agency requirements
• Not a route of specialization in Internal Medicine or Family Medicine 
• Current GME funding environment is poor, may be difficult to fund the fellowships 
• Increase cost for training to the enter GME system 
• Perception by graduating pediatric residents that additional 3 years of fellowship may not be necessary due to multitude of current pediatric hospitalists without formal fellowship training 
• May create more barriers for general pediatrician to practice inpatient medicine

Focused Practice in PHM Option

Pros:

• Accepted model for Maintenance of Certification in Internal Medicine 
• Develops an identity and recognition for Pediatric Hospitalists due to specific test questions for MOC 
• Requires Process Improvement Module every three years to assist clinicians in providing high quality care 
• Improves value (quality/cost) of hospital medicine clinical care 
• No opportunity cost (no lost wages or time due to additional formal training)
• Can modify Internal Medicine procedures to meet Pediatric needs 
• Can be used by a variety of hospitalists working in different settings (academic and community, NICU, PICU, etc.)

Cons:

• ABIM model is still in pilot phase and this may not be available for other fields
• Not a popular option in Adult Hospital Medicine field
• No formal training in research 
• No formal training in administration/leadership; difficult to find mentors
• No formal training in QI/PI 
• May create more barriers for general pediatrician to practice inpatient medicine 
• Some graduating residents may not have the clinical experience necessary to begin work as a pediatric hospitalist without additional formal training. 
• Similar “Cons” to No-Change

Status Quo or Optional Extra Training

No Change/Optional Extra Training Pros and Cons

Pros:

• Meets current market needs for additional hospitalists, especially as ACGME Duty- hours rules change that require additional inpatient coverage
• Does not require additional funds or curricular changes 
• Keeps the field open to all those who are interested
• Financial benefit to the physician, who is able to make attending-level salary out of residency rather than waiting until after fellowship (no opportunity cost) 
• Even after fellowship, most academic subspecialist salaries are lower than private practice general pediatricians 
• There are other ways of enhancing educational skills outside of residency or fellowship (through the APA and the AAP, e.g.) 
• There are other ways of collaborating and gaining research skills outside of residency and fellowship (through the PRIS and VIP networks, e.g.) 
• Nationally, other opportunities exist for additional training to gain skills in teaching, research and administration following residency that do not require a formal fellowship 
• Mechanisms can be placed for Maintenance of Certification (MOC) and Focused practice in Pediatric Hospital Medicine.

Cons:

• We do not have explicit competencies in most residency programs regarding Pediatric Hospital Medicine core skills so physicians complete residency with different skill sets.
• Some graduating residents may not have the clinical experience necessary to begin work as a pediatric hospitalist without additional formal training.
• There are few opportunities for those who have not practiced Hospital Medicine to learn the required skills except on-the-job training.
• May not be the best option for the hospitalized pediatric patient (wide range of competencies in PHM physicians)
• Some may not have the teaching, research or administrative experience necessary to begin work as a pediatric hospitalist without additional formal training.
• We may lose graduating residents to other fellowships due to the perception that Pediatric Hospital Medicine is just resident work.
• Most graduating pediatric residents do not have the necessary skills to produce high- quality academic scholarship without formal training
• Without additional training, subspecialists may be preferentially selected for academic leadership positions.
• Focus of practice in Pediatric Hospital Medicine may not be viewed as an additional skill set*

*Also see "Focus of Practice" Pros and Cons List

1-year Fellowship

Pros: 

Career Path: Clinical Excellence or Clinician Educator

• Only 1 year extra funding needed 
• Less of an opportunity cost to the physician 
• May still meet PHM workforce needs 
• More time to gain protected clinical experience especially in light of changing residency work hours 
• May work well for those who want to do only clinical work (community setting) 
• Time for more practice in advanced clinical skills 
• Allows extension of resident research projects, work on quality improvement projects , patient safety projects
• More time for research training and projects, which could be source of partial funding 
• Can enter after any General Pediatrics or Medicine-Pediatrics residency
• Could have set curriculum to ensure all clinical and core skills topics are covered and to work on communication skills. 
• Gain educational skills through formal and informal teaching during clinical rotations 
• Options of additional training in educational and administrative skills through courses on line or by participating in workshops (PAS,APA, AAP) with One Area of Focus 
• Could obtain certificate of skills acquisition 
• Could combine with work towards an MPH or other advanced degree

Cons: 

• With limits on residency work hours, may not provide enough time for training 
• Requires additional time so may lose good candidates 
• Need funding for the additional year and programs to develop a 1-year fellowship 
• Inadequate training for academic hospitalist career
• -Little to no time for formal training in how to conduct research
• Limited time for a research project 
• Limited time to practice administrative and Quality Improvement skills 
• Does not help to advance the field of PHM due to lack of time for scholarly
• activities 
• If there is a focus on research, this may overtake clinical training in the extra time 
• Potentially lower chance of ABP subspecialty certification

Fast-Track Fellowship (2 years of General Pediatric Residency and 2-3 years of PHM Fellowship) Option

Pros: 

• Allows sufficient time for training in research, administrative, and Quality Improvement skills 
• Sufficient time for research projects 
• Scholarly work in fellowships will help to advance the field of PHM 
• Training for an advanced degree (e.g., MPH, Masters in Education) can be built into this 4-5 year program 
• Extra time could allow for training in Specialized Clinical Services (Hospice and
Palliative care, sedation, etc.) 
• Keeps field open to those who decide to enter PHM later: for those who don’t Fast-track, PHM fellowship can be done after a full 3-year residency 
• Allows for broad range of rotations- PICU, NICU, sedation etc. 
• Would have options of participation on hospital committees to learn administrative and Quality Improvement skills 
• Less opportunity cost to the physician than a full residency plus 3-year fellowship 
• Potentially less funding needed than for 3-year fellowship 
• May attract more physicians to complete a PHM fellowship 
• Should be adequate training for both General Pediatrics and PHM subspecialty certification 
• Allows in-depth focus into one area (advanced degree), leading to a well-trained
researcher or clinician-administrator career path

Cons: 

• NOT an option for ABP subspecialty certification
-Very early career decision needed for Fast-Track model 
• More complicated match for residency since matching to both residency and
fellowship at the same time 
• Only 2 years of training in General Pediatrics runs a risk of missing out on the
training and experiences of a 3rd year of Pediatric Residency 
• May not work well in smaller residency programs 
• Will need research/QI mentors, either nationally or program-level 
• May be difficult if physician changes career plans away from PHM during residency or afterwards

Hospitalist Residency Track + 1-year Fellowship

Pros:

• Focused residency training that would allow trainee to gain PHM competencies in common clinical diagnoses and conditions as well as to gain PHM Core Skills
• Extra year may allow for training in Specialized Clinical Services (Hospice and Palliative care, sedation, etc.)
• Less time than 2- or 3-year fellowship (less funding needed, less opportunity cost to the physician)
• Allows for broad range of rotations--PICU, NICU, sedation etc. than Residency Track alone
• PGY-3 year and extra year can be dedicated to formal research training and work 
• Research project can begin during 2nd or 3rd year of residency and extend into fellowship year 
• May have enough time to work on creating educational material and peer-reviewed workshops
• Can develop a longitudinal administrative skill curriculum: early involvement on hospital committees, followed by focused workshops during fellowship year (Leadership training; APA, PAS workshops) 
• Meets workforce needs

Cons: 

• Extra year may deter some good physicians from entering PHM 
• Not all residency programs can offer this track; may hurt smaller residencies when competing for applicants 
• Still would compete with other residents for sufficient procedures
•  Early career decision needed. (Exact timing depends on when track starts in residency, but those who decided to enter PHM late in residency or after residency would need to find other ways of training. Also, if the physician changed his/her mind, it may be difficult to catch up in other fields.)
• Funding required for fellowship program 
• Programs need to develop 1-year fellowships; may be difficult to match number of programs to need 
• Not all PHM physicians focus on general inpatient pediatric care (e.g., neonatal hospitalists). That type of training would need to be incorporated into the curriculum. 
• Potentially lower chance of ABP subspecialty certification

2-year Fellowship Option

Pros: 

• Does not require early career decision and physician can choose to enter after Pediatrics or Medicine-Pediatrics residency
• Less funding needed than with 3-year fellowship 
• Less time/financial burden than 3-year fellowship 
• Sufficient time for learning to do research and gain expertise in one area and research projects: may have a peer-reviewed scholarly product at the end of the fellowship 
• Scholarly work in fellowships will help to advance the field of PHM
• May allow time for obtaining additional advanced degree (e.g., MPH, Masters in Education) 
• Increased time for learning administrative and Quality Improvement skills; exposure and experience in many different domains 
• May be adequate for ABP subspecialty certification 
• Would have options of participation on committees, etc., workshops , courses during course of training 
• Extra time may allow for training in Specialized Clinical Services (Hospice and Palliative care, sedation, etc.)

Cons: 

• Funding needed for 2 years 
• Need additional fellowship programs to meet need
• Extra time and lower salary for 2 years may be a deterrent to good candidates (opportunity cost) 
• May not be seen as equivalent to other subspecialty training by academic centers 
• Potentially lower chance for ABP subspecialty certification

Residency Track Option

Pros:

• Focused curriculum on inpatient clinical skills, with opportunity for quality/administrative components of hospitalist medicine
• Efficient form of hospitalist training in terms of time/opportunity cost, with significant overlap in current residency training
• Allows/meets need for “individualized” resident curriculum rather than a "one size fits all" structure 
• Research, quality improvement, and administrative electives available; can tailor towards physician’s future career plans 
• Addresses needs of both academic and community pediatric hospitalists, with additional post-residency training available for the individual (e.g., PHM academic fellowships, research fellowships) 
• Financial and time benefits for physician versus fellowship 
• No additional program funding needed
• Meets workforce needs

Cons:

• Early career decision needed. (Exact timing depends on when track starts in residency, but those who decided to enter PHM late in residency or after residency would need to find other ways of training. Also, if the physician changed his/her mind, it may be difficult to catch up in other fields.)
• May not be able to effectively train for Pediatric Hospital Medicine career within a 3-year residency, given other ACGME requirements, changing duty hours and growing inpatient care complexity 
• Potentially sacrifice overall general pediatric training and experience with subspecialty rotations
• Limited time for academic and scholarly activity – i.e. research, Quality Improvement 
• Failure to advance field in terms of research and quality efforts 
• Lack of recognition of subspecialty board certification 
• Difficulty in standardizing curriculum and training across residency programs; difficult for employers to know whether physician is adequately trained to meet hospital’s needs 
• Low probability of additional formal training
• May be difficult for smaller residency programs to offer this track

STP Committee Update for March 2012

Pediatric Hospital Medicine

Brought to you with support from the Joint Council of Pediatric Hospital Medicine (JCPHM)

Strategic Planning (STP) Committee UPDATE

In the past months since PHM 2011, the STP Committee has been working on documents to share with the pediatric hospital medicine community that reflect the work done to date on certification options for our field. On this site, you will find the options considered with “pro and con” lists for each.  Please feel free to leave your comments for each option or general comments on this blog.  The options are not listed in any preferential order.

At PHM 2011, many questions were generated and answered. The following FAQs may be of value:

What am I to do with this information on options for PHM certification? --- Please review the documents; if you wish to provide a comment, please do so with the link below.

What is going to be done with the comments?--- The STP co-chairs will collate all comments over the next 3 months. An additional STP Update will be posted if clarifications are needed based on comments received.

What are the next steps in this review process? – The STP committee will review the work to date and vet each option. They will use any resources needed to assure a balanced review is completed. A prioritized list of these options will be provided to the Pediatric Hospital Medicine community. The APA, AAP, and SHM society representatives to the JCPHM will similarly address all options, soliciting input from the respective society boards and pediatric hospitalist members and leadership of the three core societies. The JCPHM will use this information to prioritize certification options. A final decision on certification will be made using all of this information.

If I cannot commit the time to participate in the next phase STP Committee work, how can I let my views be know? --- Please use the link below to post a comment. Please also contact your society representative in the APA, AAP, and/or SHM to present your views.

How were decisions made for other subspecialties in pediatrics? Did they use a similar process? --- Other subspecialties did not use this process. Pediatric emergency medicine, child abuse, adult hospital medicine, and others used varied methods but the assessment of options and participation of the community at large was not a component of their work. By instituting the STP Committee and the above process, the pediatric hospital medicine certification assessment and decision-making process allows for more engagement of practicing pediatric hospitalists.

To post a comment please email:

PHM.StrategicPlanning@gmail.com

or leave a comment on this blog.


Thank you,


STP Committee Members and Co-Chairs
Suzanne Swanson Méndez, MD
Chris Maloney, MD, PhD