Talking Points Re: a Proposed Pediatric Hospitalist Accredited Fellowship

MPPDA Executive Committee

Talking Points re: A Proposed Pediatric Hospitalist Accredited Fellowship

October 2014

Introduction

The primary role of the Medicine-Pediatrics Program Director Association (MPPDA) Executive Committee is to assist the program directors of combined training programs in Internal Medicine and Pediatrics (Med-Peds) and to develop educational programs and assessment strategies to prepare trainees to care for patients across the lifespan continuum. As such, we do not feel it is appropriate for MPPDA to formally take a stance in support of, or in opposition to, the proposal of accrediting Pediatric Hospitalist fellowship training. However, in support of our organization’s mission, it is important that we support our membership with information and education on this issue. We seek to articulate for our membership both the potential benefits and potential unintended consequences that an accredited fellowship in Pediatric Hospital Medicine may have on Med-Peds trainees who wish to pursue careers in Hospital Medicine.

Background

The Joint Council on Pediatric Hospital Medicine (JCPHM) is an organization comprised of Pediatric Hospitalists who have undertaken the task of seeking accreditation for fellowship training in Pediatric Hospital Medicine. The organization has explored this proposal for several years and moved forward to seek fellowship accreditation in April 2013. The primary goals of accreditation are to improve care for children, to ensure public trust, and to advance the field of Hospital Medicine (1,2). The meetings of the JCPHM were open to members of the Society of Hospital Medicine (SHM) and AAP Section on Hospital Medicine (AAP-SOHM). Input from Med-Peds hospitalists was solicited during the process. Dr. Russ Kolarik, as president of the MPPDA in 2013, served as a Med-Peds representative on the JCPHM. Several other Med-Peds physicians served on subcommittees within the JCPHM. The JCPHM presented its proposal to the American Board of Pediatrics (ABP) on October 21, 2014. The ABP will review the JCPHM proposal and fully examine its implications on the field of Pediatrics. If approved, the ABP would then submit the proposal to the American Board of Medical Specialties (ABMS) for final review and approval.

The intended goals of accreditation

As stated by the JCPHM, the intended goals of accreditation are: to improve care for hospitalized children, to ensure public trust, and to advance the field of Pediatric Hospital Medicine. The JCPHM has been inclusive of the Med-Peds community as this process has gone forward. The JCPHM has also voiced interest in developing pathways within Pediatric Hospital Medicine fellowships (whether accredited or non-accredited) that will help Med-Peds trainees enhance skills in caring for hospitalized pediatric and young adult patients with special health care needs. However, it remains to be seen how such training programs might be tailored to meet the specific needs of Med-Peds hospitalists.

The unintended consequences

In principle, the spirit of combined training is resonant with the goals outlined by JCPHM- namely, to improve the care of children as well as adults, and to ensure public trust. Med-Peds trained hospitalists currently constitute more than 10% of the Pediatric Hospitalist workforce and greater than 25% of these providers care for young adults with special health care needs (3). Requiring Pediatric fellowship training in Hospital Medicine may lead to unintended consequences that may adversely affect the discipline and practice of Med-Peds as a specialty and limit access to care provided by Med-Peds hospitalists. We have highlighted areas for consideration as the ABP and ABMS examine the potential implications of accreditation on various stakeholders:

1) Decrease in the overall Pediatric Hospital Medicine workforce:

A recent work force survey conducted by the MPPDA estimates Med-Peds trained physicians comprise between 10-20% of the Pediatric Hospitalist workforce, not including Med-Peds trained ambulatory providers who continue to care for hospitalized children (3). For many reasons, residents training in Med-Peds may decline to seek additional training required to obtain certification to see children in a hospitalized setting. Reasons include lack of parity with Internal Medicine (e.g. no additional fellowship required for Internal Medicine), reduced compensation caring for both hospitalized children and adults, and delays in starting careers as a result of additional training time. Each of these may have a significant negative impact on the work force of those who desire and are qualified to care for children in an inpatient setting.

2) It will be challenging to create a combined Hospital Medicine fellowship to allow dual-board certification given that an accredited fellowship for Adult Hospital Medicine does not exist:

Residents completing their training in Internal Medicine or in Med-Peds may practice Adult Hospital Medicine immediately upon completion of their residency training. Although a board examination for hospital medicine does not exist through the ABIM, adult hospitalists are eligible to take a focused concentration in hospital medicine examination as part of recertification. Adult Hospitalist fellowships are not required to take the focused concentration in hospital exam. Given the absence of an Adult Hospitalist fellowship and different requirements for certification, defining a Hospitalist fellowship in Pediatrics that incorporates combined trainees in Med-Peds will need to resolve these inconsistencies.

3) Negative impact on Med-Peds residents who are choosing Hospital Medicine as a career:

A current Med-Peds graduate may begin his/her hospitalist career upon completion of residency training (4 years). For many providers, it will be a difficult decision to add up to an additional three years of Pediatric fellowship training, especially when this does not incorporate preparation for Adult Hospital Medicine. As noted above, compensation for Med-Peds hospitalists is lower than those practicing Adult Hospital Medicine. The combination of additional training time, coupled with reduced compensation (e.g. negative impact on paying back educational debt), may result in a decreased desire for residents to pursue careers who practice both Adult and Pediatric Hospital Medicine.

4) Negative impact on medical students’ decision to pursue Med-Peds training:

At present, many medical students who pursue Med-Peds training are interested in hospitalist careers. The MPPDA is concerned that students who previously may have pursued Med-Peds as a path to hospitalist careers may now decide to choose categorical Internal Medicine over Med-Peds as there is no fellowship required for that pathway. Instead of 4 years of med-peds and 2-3 years for Pediatrics Hospitalist fellowship for up to 7 years of training, they may chose categorical Internal Medicine and be ready for clinical practice as an Adult Hospitalist in 3 years.

References:

1. O’Toole, Et. Al. The Practice Patterns of Recently Graduated Internal Medicine-Pediatric Hospitalists. Accepted to Hospital Pediatrics. September 2014.