Original Research

Characteristics of pediatric hospital medicine fellowships and training programs

Abstract

Abstract

OBJECTIVE:

To explore the structure, components, and training goals of pediatric hospitalist fellowship programs in North America.

DESIGN:

We constructed a 17‐item structured questionnaire to be administered by phone. Questionnaire items focused on documenting goals, training, requirements, and clinical duties of pediatric hospitalist training programs. From February through June 2007, research staff contacted directors of the programs. Responses were analyzed to determine program characteristics, including goals, formal training requirements, clinical rotations, and participation in hospital administrative activities.

RESULTS:

All 8 training programs completed the survey. There appear to be 2 distinct tracks for pediatric hospitalist training programs: clinical or academic specialization. Currently there are no standards or requirements for fellowship training from an external accrediting body and the curriculum for these programs is likely driven by service requirements and speculation on the needs of a future generation of pediatric hospitalists. The stated goals of the programs were quite similar. Seven reported that the provision of advanced training in the clinical care of hospitalized patients, quality improvement (QI), and hospital administration are central goals of their training program. Six reported training in the education of medical students and residents to be a primary goal, while 5 indicated training in health services research as a primary goal.

CONCLUSIONS:

Pediatric hospitalist fellowships are in the very early stages of their development. In time, greater structure across institutions will need to be put in place if they are to succeed in becoming a necessary prerequisite to the practice of hospital medicine. Journal of Hospital Medicine 2009;4:157–163. © 2009 Society of Hospital Medicine.

Copyright © 2009 Society of Hospital Medicine

The field of pediatric hospital medicine is undergoing rapid growth. In 2002, there were approximately 600 pediatric hospitalists1 and in 2006 this number was estimated to be approximately 1000.2 A recent study found that approximately 25% of pediatric hospitalist practices are less than 2 years old.3 As such, there are many new physicians entering the field and most do so without specific training in hospital medicine prior to beginning their employment.4 There is also significant variability in the roles, work patterns, and scope of practice across institutions,3 and hospitalists are engaged in a wide variety of clinical, educational, and administrative functions.

A survey of pediatric department chairs in 2001 found that very few believed that any additional training beyond a pediatric residency was required to perform hospitalist medicine.5 However, since then the field has undergone significant growth. A more recent survey of practicing hospitalists found that 92% believed there was a need for additional training in a variety of domains.6 Specifically, respondents were most interested in achieving greater skill in performing critical care procedures and academic training. These hospitalists regarded pediatric hospitalist fellowships as the best way to gain the additional skills in teaching, research, and administration needed for their positions.

Nonetheless, for a variety of reasons, not the least of which is perhaps the paucity of hospitalist fellowship training programs, few hospitalists in practice today have completed a fellowship in hospital medicine. Over the past several years, a number of pediatric‐specific hospitalist fellowship programs have been initiated, yet little is known of their requirements or curricula. We conducted a study to explore the structure, components, and training goals of the pediatric hospitalist fellowship programs in North America.

MATERIALS AND METHODS

Sample

To examine the characteristics of pediatric hospitalist training in North America, we examined all 8 fellowships or training programs that were in existence in early 2007. The total sample included the following sites: Children's Hospital Boston, Children's Specialists of San Diego, Children's National Medical Center, Children's Healthcare of Atlanta, Texas Children's Hospital, All Children's Hospital, University of North Carolina, and The Hospital for Sick Children.

Survey Instrument

We constructed a 17‐item structured questionnaire to be administered by phone. The instrument was designed to be completed in approximately 10 minutes. Questionnaire items focused on documenting the goals, training, requirements, and clinical duties that characterize current pediatric hospitalist training programs. The questionnaire was comprised of a mixture of fixed‐choice and open‐ended questions. A draft of the instrument was shared with representatives of the Society of Hospital Medicine Pediatrics Committee for comment and suggestions.

Questionnaire Administration

The research team sent a prenotification letter to directors of the 8 pediatric hospitalist training programs to inform them of the research study. From February through June 2007, research staff contacted the directors of the programs, explained the purpose of the study, and obtained verbal consent.

Data Analysis

Responses were reviewed to compare and contrast the characteristics of the various programs. The study was approved by the University of Michigan Medical Institutional Review Board.

RESULTS

Response Rate

Of the 8 training programs, all completed the survey, representing a response rate of 100%. One institution offers 2 separate fellowship paths: academic and clinical.

Pediatric Hospitalist Fellowship and Training Program Overview

The first pediatric hospital medicine fellowship was initiated 15 years ago. However, the majority of pediatric hospitalist training programs in North America were established more recently, between 2003 and 2007.

Most pediatric hospitalist training programs offer 1 position per year. The duration of the training programs range from 1 to 3 years. Minimum clinical duties required by the programs vary from 4 to 8 months and the maximum amount of clinical time permitted ranges from 4 to 20 months. Most programs indicated that there is some flexibility in the clinical duties required or available to the fellows.

Six of the 8 programs offer an academic degree. Table 1 provides an overview of the programs, types of degrees offered, and funding sources for academic work. Subsequent tables provide blinded results to protect respondent confidentiality.

Pediatric Hospital Medicine Fellowships and Training Programs in North America, 2007
ProgramYear EstablishedDivisionNumber of Positions, 2007Duration of ProgramMinimum Clinical TimeMaximum Clinical TimeDegree Possible?Who Pays for Degree?
  • Abbreviations: MAS, Master of Academic Sciences; MEd, Master of Education; MME, Master of Medical Education; MPH, Master of Public Health; MPP, Master of Public Policy; MS, Master of Science.

Toronto‐Academic1992Pediatric medicine32 years4 months4 monthsYes: fellow's choiceFellow
Children's Boston1998Emergency medicine12 years8 months12 monthsYes: MPH, MEd, MPPDepart. funds; Externalfunds (creative)
Children's National2003Hospital medicine1‐22‐3 years6 months20 monthsYes: MPHFaculty benefits
Children's Spec. San Diego2003Hospital medicine11‐2 years7 monthsNAYes: MASDivision
Toronto‐Clinical2004Pediatric medicine11 year8 months8 monthsNoNA
Texas2005Emergency medicine12 years8 months8 monthsYes: MPH, MMEVaries
University of North Carolina2006General pediatrics and adolescent medicine11 year5 months6 monthsNoNA
All Children's2007General pediatrics12 years8 months9 monthsYes: MPH, MSExternal funding pending (federal grants)
Children's Atlanta2007Pediatric hospitalist section11 year6 months6 monthsNoNA

The number of fellowship or training program positions available each year has remained fairly consistent. However, to date, enrollment has not kept up with position availability (Table 2).

Pediatric Hospital Medicine Fellowship and Training Program Availability and Enrollment
Program2006‐2007 Positions Available2006‐2007 Fellows Enrolled2007‐2008 Positions Available
ANANA1
B212
C111
DNANA1
E102
F101
G203
H121
I110

Program Goals

Seven out of 8 programs reported the provision of advanced training in the clinical care of hospitalized patients, quality improvement (QI), and hospital administration to be central goals of their training program. Six respondents reported the provision of training in the education of medical students and residents to be a primary goal of their program, while 5 indicated training in health services research to be a primary goal.

Participation in General Hospital Activities

Trainees in all programs participate in clinical care, resident education, student education, research activities, and hospital committees. Seven out of 8 programs reported that fellows or trainees participate in patient safety activities and guideline development.

Formal Training

Half of the programs reported that they provide formal coursework in areas of education and hospital administration including quality improvement, resident teaching, and student teaching. Three of the 8 programs provide formal coursework in hospital economics.

Three of the 8 programs provide seminars in resident teaching, student teaching, hospital economics, and leading a healthcare team (Table 3).

Formal Hospital Administration Training Provided by Pediatric Hospitalist Fellowship and Training Programs
ProgramsResident TeachingStudent TeachingHospital EconomicsQuality ImprovementLeading a Healthcare Team
CourseworkSeminarsCourseworkSeminarsCourseworkSeminarsCourseworkSeminarsCourseworkSeminars
  • NOTE: Blank equals No.

A Yes Yes YesYes
BYes Yes Yes Yes Yes
C YesYesYesYes Yes
DYes Yes Yes Yes Yes
E Yes Yes Yes Yes
F Yes
GYesYesYesYes Yes Yes
HYesYesYesYes Yes Yes
IYes Yes

Seven of 8 pediatric hospitalist training programs provide formal coursework in epidemiology and research methodology. Six programs reported that they provide formal coursework in biostatistics and 5 in publications or grant writing. Four offer seminars in health economics, research methodology, and QI methodology (Table 4).

Formal Research Training Provided by Pediatric Hospitalist Fellowship and Training Programs
EpidemiologyBiostatisticsHealth EconomicsResearch MethodologyQI MethodologyPublications/Grant WritingTranslation ResearchEducational Research
CourseSeminarCourseSeminarCourseSeminarCourseSeminarCourseSeminarCourseSeminarCourseSeminarCourseSeminar
  • NOTE: Blank equals No.

AYes Yes YesYes YesYes Yes Yes
BYes Yes Yes Yes Yes YesYesYes Yes
CYes Yes YesYesYes Yes Yes
DYes Yes YesYes Yes Yes Yes
EYes Yes Yes YesYes Yes Yes
FYes Yes YesYes YesYes
GYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
HYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
I

Program Requirements

Seven pediatric hospitalist training programs require fellows to complete a research project. Six programs reported that they require fellows or trainees to complete a quality improvement project or participate on a hospital committee. Six of the programs require pediatric hospitalist fellows to attempt to present at a national meeting, and 4 programs require that fellows attempt to publish their research in a peer‐reviewed publication. Graduate degrees are required at 3 of the 8 pediatric hospitalist training programs (Table 5).

Fellowship or Training Program Requirements
QI ProjectResearch ProjectAbstract/Presentation at National Meeting*Peer‐Reviewed Publication*Committee Participation at HospitalAttending on General Ward Leading Resident TeamSpecific Advanced Clinical TrainingGraduate Degree ProgramOther
  • NOTE: Blank equals No.

  • Required to try.

AYesYesYesYesYesYes Yes
B Yes Yes
CYesYesYesYesYesYesYes
DYesYesYes YesYesYes
EYesYesYesYesYes YesYes
FYesYesYesYesYesYesYes
GYesYesYes Yes
H
I YesYesYes Journal club

Clinical Service Requirements

All programs indicated that they require the fellow or trainee to serve as an attending on the general pediatric ward. Five programs require the fellow or trainee to provide service at the fellow or PL‐3 level in the pediatric intensive care unit (PICU), anesthesia service, and transport team. Four programs reported that they require service in the emergency department, and 3 programs require service in the neonatal intensive care unit (NICU), newborn nursery, and general pediatric ward at the fellow or PL‐3 level. Only 2 programs require service in the pediatric subspecialty ward, and 1 program requires service in outpatient urgent care. No program requires primary care service (Table 6).

Assigned Clinical Duties in Pediatric Hospitalist Fellowship and Training Programs
PICUNICUAnesthesiaPrimary Care (Outpatient)Emergency DepartmentUrgent CareTransportGeneral Pediatric WardPediatric Subspecialty Ward
AttdFellowAttdFellowAttdFellowAttdFellowAttdFellowAttdFellowAttdFellowAttdFellowAttdFellowOther Units
  • NOTE: Blank equals No. Abbreviations: Attd, attending; ICU, intensive care unit; NICU, neonatal ICU; PICU, pediatric ICU.

A Yes Yes Yes YesYes Newborn nursery
B Yes
C Yes Yes Yes Yes YesYesYes Stepdown ICU
D Yes Yes Yes Yes YesYes
E Yes Yes Yes YesYes Child abuse, newborn nursery, subacute care rehabilitation facility
F Yes Yes Yes YesYesYes YesVariety of hospitals (county‐based)
G Yes Child abuse, consultation clinic, community‐based practice
H Yes Child abuse, consultation clinic, community‐based practice
I Yes YesYes YesNewborn nursery

Pediatric Hospitalist Fellowship and Training Program Funding Sources

Five of the programs use department funds to finance the fellowship program. Four of the programs utilize the fellow or trainee's clinical work as a funding source. Two of the programs reported that the program is paid for through hospital funds.

Pediatric Hospitalist Fellow or Trainee Independence

Respondents indicated that fellows or trainees become increasingly independent over the course of the program. Fellows are supervised or mentored by hospitalists on staff. Half of the programs surveyed allow fellows or trainees to bill independently under certain circumstances (Table 7).

Independence in Pediatric Hospitalist Fellowship and Training Programs
Bill Independently?Supervision?
ANo: bill under a supervising attendingSupervised by hospitalist and given autonomy with supervision from hospitalist attending.
BYesFirst couple of months during fellow's clinical period, more interaction with supervisors. Senior folks always available for consultation.
CYes: after 3 monthsClinical mentor (1 of 4 senior hospitalists) with whom they discuss patients on a more informal basis when on service.
DYes: on general wards, when functioning as attendingFellows meet weekly with fellowship director. Hospitalist on call available for consult.
EFellows: no; faculty fellows: yesTraditional fellowship role. Fellows complete several clinical electives with various levels of supervision.
FYes: after first 6 monthsFellows are supervised in their first year by hospitalist faculty.
GNoDay to day in patient care, senior staff review as needed. Each fellow has 1 primary supervisor. When on service overnight, fellows call staff attending.
HNoDay to day in patient care, senior staff review as needed. Each fellow has 1 primary supervisor. When on service overnight, fellows call staff attending.
IYesTrainees are supervised by the director of the hospitalist program, the inpatient attending, and other hospitalists.

DISCUSSION

There appear to be 2 distinct tracks for pediatric hospitalist training programs: clinical or academic specialization. However, this is not surprising, as most programs are relatively new and there are no standards or requirements for fellowship training from an external accrediting body. As such, the curriculum for these programs is likely driven by a combination of service requirements and local speculation on the needs of a future generation of pediatric hospitalists. Most programs also reported that they provide significant flexibility for each fellow based on their self‐perceived training needs and background.

Although there has been considerable emphasis on the potential educational role of hospitalists, formal coursework in teaching and education is not a part of the curriculum for half of the existing fellowship programs. Recent reports have demonstrated that hospitalists have received better teaching evaluations than traditional subspecialty attendings.7 However, this is in the absence of additional training in education and may reflect greater time that hospitalists might devote to their clinical trainees. The opportunity to further improve the educational training of hospitalists could be an important part of the fellowship experience.

Hospitalists have also been hypothesized to be in a prime position to either lead or have meaningful participation in quality improvement and cost‐saving efforts in the hospital setting. However, only half of programs provide formal coursework in QI and even fewer in areas of hospital economics.

Interestingly, most programs provide coursework in research methods, epidemiology, and grant writing. Requirements regarding clinical duties ranged from a minimum of 17% to a maximum of 67% of program time. It is unclear what the long‐term expectations in career achievement with regard to research will be for those physicians who spend the majority of their training time providing clinical care rather than in research. Previous authors have described the fallacy of expecting brief periods of coursework to prepare individuals for independent research careers.8 However, such coursework can certainly assist graduates of such programs to meaningfully participate in research projects and to put to valuable use their knowledge in both the educational and clinical aspects of their work. Though trainees enrolled in 1‐year programs will spend a larger proportion of their time providing clinical care based on program requirements, trainees in multiyear programs can choose to spend additional time performing clinical duties. Thus, 1 of the possible advantages of a 2‐year or 3‐year program may simply be the flexibility that the fellow has to tailor the program to his or her individual career goals.

Although previous studies have demonstrated that pediatric hospitalists may provide clinical service in a variety of hospital settings,2, 3, 911 most of the current fellowship programs do not provide extensive clinical experiences beyond the general pediatric ward. If hospitalists are to play a more comprehensive role in the care of the pediatric hospitalized patient, programs should consider expanding the scope of clinical training and exposure they provide.

The financial viability of hospitalist fellowship programs is also an important issue. If the additional training provided by these programs is felt to be of value to individual hospitals, it is likely that there will be an increase in the proportion of hospitals who wish to fund such training. A likely incentive for hospitals would be to position themselves to attract and retain hospitalists who possess a unique skill set for which they ascribe value for their patients and/or their bottom line.

Currently, in contrast to traditional, subspecialty‐based fellowships, half of the existing hospitalist fellowship programs allow hospitalist fellows to bill independently. This will have important implications both from an economic perspective, as well as relative to the perceptions of the degree of supervision provided by the respective training programs. This finding may also raise questions as to whether the need for additional clinical training after residency is really necessary to practice hospital medicine.

Whether the training and experience provided by these programs will be seen as a necessary precursor for careers in hospital medicine remains unknown. However, currently there appears to be a mismatch between what some hospitalists have identified as potential clinical educational needs6 with more than 50% desiring additional training in intensive care unit settings, and what is provided through the existing programs. In 2001, a survey of pediatric department chairs found that most did not believe additional formal training beyond residency was necessary to take on the role of a pediatric hospitalist.5 The value of pediatric hospitalist training programs may lie in their provision of or exposure to academic skill sets and the provision of administrative opportunities, in addition to targeted clinical training.

Potential Future Areas of Focus

The potential of a mismatch between education and practice or a training practice gap has been identified in internal medicine hospitalist training programs.12 To provide guidance to address this gap, Glasheen et al.13 assessed the spectrum and volume of specific diagnoses encountered in hospitals and the level of involvement of hospitalists in the care of these patients. They posit that training prioritized to the case mix expected to be encountered by hospitalists would be an appropriate concentration on which both tracked residency and fellowships could focus.

Of significant importance to many community physicians is the pattern of communication between hospitalists and the primary care physician of their patients. Recent reports have suggested this is a problem for many hospitalist programs.14 As such, it seems relevant that any hospitalist training program both develop a defined communication protocol and include instruction in physician‐to‐physician communication as a distinct part of their curriculum. Specifically, the importance of initial contact and timely discharge summaries should be addressed.

We did not explicitly ask respondents to discuss the scope of mentorship in their fellowship programs. However, based on respondents' descriptions of fellow or trainee supervision, we believe that the structure of mentorship programs likely varies across fellowships. Further study will be needed to determine the scope of mentorship in pediatric hospitalist training programs, and the impact of mentorship on training efficacy.

CONCLUSIONS

Pediatric hospitalist fellowship training programs are in the very early stages of their development. In time, greater structure across institutions will need to be put in place if they are to succeed in becoming a necessary prerequisite to the practice of hospital medicine. As the roles of hospitalists become more defined, the nature and extent of their advanced training needs will do so as well.

References

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