QUESTION:
PREFACE
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
