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
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