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