Daniel A. Rauch, MD

Resident duty hour restrictions were initially implemented in New York in 1989 with New York State Code 405 in response to a patient death in a New York City Emergency Department.1 This case initiated an evaluation of potential risks to patient safety when residents were inadequately supervised and overfatigued. In 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented resident duty hours nationally due to concerns for patient safety and quality of care.2 These restrictions involved the implementation of the 80‐hour work week (averaged over 4 weeks), a maximum duty length of 30 hours, and prescriptive supervision guidelines. In December 2008, the Institute of Medicine (IOM) proposed additional changes to further restrict resident duty hours which also included overnight protected sleep periods and additional days off per month.3 The ACGME responded by mandating new resident duty hour restrictions in October 2010 which will be implemented in July 2011. The ACGME's new changes include a change in the maximum duty hour length for residents in their first year of training (PGY‐1) of 16 hours. Residents in their second year of training (PGY‐2) level and above may work a maximum of 24 hours with an additional 4 hours for transition of care and resident education. The ACGME strongly recommends strategic napping, but do not have a protected overnight sleep period in place4 (Table 1).

There is growing concern regarding the impact of these new resident duty hour restrictions on the coverage of inpatient services, particularly during the overnight period. To our knowledge, there is no published national data on how pediatric inpatient teaching services are staffed at night. The objective of this study was to survey the current landscape of pediatric resident coverage of noncritical care inpatient teaching services. In addition, we sought to explore how changes in work hour restrictions might affect the role of pediatric hospitalists in training programs.

METHODS

We developed an institutional review board (IRB)‐approved Web‐based electronic survey. The survey consisted of 17 questions. The survey obtained information regarding the demographics of the program including: number of residents, daily patient census per ward intern, information regarding staff‐only pediatric ward services, overnight coverage, and current attending in‐house overnight coverage (see Appendix). We also examined the prevalence of pediatric hospitalists in training programs, their current role in staffing patients, and how that role may change with the implementation of additional resident duty hour restrictions. Initially, the survey was reviewed and tested by several pediatric hospitalists and program directors. It was then reviewed and approved by the Association of Pediatric Program Director (APPD) research task force. The survey was sent out to 196 US pediatric residency programs via the APPD listserve in January 2010. Program directors were given the option of completing it themselves or specifically designating someone else to complete it. Two reminders were sent. We then sent an additional request for program participation on the pediatric hospitalist listserve. All data was collected by February 2010.

RESULTS

One hundred twenty unique responses were received (61% of total pediatric residency programs). As of 2009, this represented 5201 pediatric residents (58% of total pediatric residents). The average program size was 43 residents (range: 12‐156 residents, median 43). The average daily patient census per ward intern during daytime hours was 6.65 patients (range: 3‐17, median 6). Twenty percent of training programs had staff‐only (no residents) pediatric ward services during daytime hours. In the programs with both staff‐only and resident pediatric ward services, only 19% of patients were covered by the staff‐only teams and 81% of patients were covered by resident teams.

During the overnight period, 86% of resident teams did not have caps on the number of new patient admissions. An average of 3.6 providers per training program were in‐house overnight to accept patient admissions to pediatric wards. Ninety‐four percent of these providers in‐house were residents (399 residents in‐house/425 total providers in‐house each night).

Twenty‐five percent of the training programs that responded to the survey had pediatric hospitalist attendings in‐house at night. This included both overnight and partial nights (ie, until midnight). Other attendings in‐house at night include: neonatal intensive care unit (NICU) attendings (53% of programs), pediatric intensive care unit (PICU) attendings (46% of programs), Pediatric Emergency Medicine attendings (65% of programs), and Pediatric Surgery attendings (6.4% of programs). Twenty‐two percent of programs had no in‐house attendings at night (Figure 1).

Figure 1

Pediatric hospitalists were involved with 84% (n = 97) of training programs. Sixty percent (n = 58) of the pediatric hospitalist teams were staffed with both teaching attendings and residents. Fourteen percent (n = 14) of the pediatric hospitalist teams did not involve residents (staff‐only) and 25% (n = 25) had both types of teams. Specifically, of the programs that had pediatric hospitalists, 20% (n = 19) of them had hospitalist attendings in‐house 24 hours per day and 13% (n = 12) of teams had hospitalist attendings in‐house into the evening hours for a varying amount of time. Of the programs with hospitalist attendings in‐house 24 hours per day, 52% (n = 11) had started this coverage within the past 3 years.

Looking towards the future, and prior to the enactment of the October 2010 ACGME standards, 31% (n = 35) of the training programs that lacked 24/7 hospitalist in‐house coverage in January 2010 anticipated adding this level of coverage within the next 5 years. Notably, 70% (n = 81) of training programs felt that further resident work hour restrictions, which have since been enacted, would likely require the addition of more hospitalist attendings at night. Our survey allowed program directors to make open‐ended comments on how further work hour restrictions may change inpatient staffing in noncritical care inpatient teaching services.

DISCUSSION

To our knowledge, this was the first national study of pediatric resident coverage in noncritical care inpatient teaching services. While there was significant variation in how inpatient teaching services were covered across these programs, in January 2010, residents were involved in the majority of patient care with only 20% of programs having attending‐only hospitalist teams during the daytime. During the overnight period, the proportion of patient care provided by residents became even more significant with residents representing 94% of the total in‐house providers accepting new admissions. While pediatric hospitalists were prevalent at these training programs, their role in direct patient care overnight was limited. Only 6% of total in‐house providers accepting admissions at night were pediatric hospitalists.

The comments made by program directors are representative of the overall concerns regarding changes to resident work hours (see Table 2). In a position statement by the Association of Pediatric Program Directors in regards to the IOM recommendations, concerns were raised stating that the recommendations of the IOM Committee are intended to enhance patient safety without appropriate consideration for the educational and professional development of trainees.5 While the newly mandated ACGME standards are different than the previous IOM recommendations, it is clear that there will be very significant changes to accommodate these new standards. Our study was done prior to the new ACGME's standards. At the time of the survey, less than a third of programs were anticipating the addition of 24/7 pediatric hospitalist coverage; however, if resident work hours were further restricted, 70% of programs felt that additional hospitalists would be needed. This is a significant increase in the previously anticipated need for overnight attending hospitalist coverage, especially in light of the further restrictions mandated by the ACGME. We know that the response of New York State programs to the 405 regulations varied by program size, but all made significant changes to accommodate the new standards.6 It is clear that many program directors nationally are anticipating significant changes to their residencies when these new restrictions are enacted. The respondents in our survey felt that pediatric hospitalists are going to have to play an even bigger role at night when additional resident work hour restrictions are put into place.

Pediatric hospital medicine remains a rapidly growing field.7 Eighty‐four percent of pediatric training programs utilize pediatric hospitalists. Over 60% of these pediatric hospitalist teams are involved in teaching teams with residents. While we did not directly study the supply and demand of pediatric hospitalists, there is some concern that even despite its rapid growth, the supply of pediatric hospitalists will not keep up with the demand when further resident work hours restrictions are implemented. At time of submission, a cost‐analysis has not yet been publicly published on the ACGME's new changes. There is data available based on the IOM's 2008 recommendations. A study by Nuckols and Escarce8 suggests that if the IOM's recommendations were implemented, the entire healthcare system nationally would have to develop and fill new full‐time positions equal to 5001 attending physicians, 5984 midlevel providers (nurse practitioners or physician assistants), 320 licensed vocational nurses, 229 nursing aides, and 45 laboratory technicians. This would be equivalent to adding an additional 8247 residency positions across all specialties.810 While the ACGME's new mandated changes are different than the IOM's recommendations, they will also restrict resident duty hours that we believe could lead to gaps in patient care requiring significant personnel changes in the healthcare system.

There are several limitations to our study. We did not study the role of pediatric subspecialty fellows and their involvement in pediatric inpatient services in these training programs. We also did not study the prevalence and use of resident night float systems. While night floats may be used in some programs, it may become more prevalent with the possible restriction in intern work hours down to 16 hours. As with any survey, there remains both volunteer and nonresponse bias with the programs that decide to complete or disregard the survey. Finally, there remains some concern over the data collection after the survey was sent out to the hospitalist listserve. Pediatric hospitalists may have incorrectly filled out the data for their program after their program director had already completed the survey. We attempted to minimize this problem by specifically instructing hospitalists to encourage their program director to fill out the survey if they had not already done so. We also compared computer Internet Protocol (IP) addresses and actual program responses, before and after the hospitalist e‐mail was sent, in an attempt to minimize the chance of including duplicated responses from the same program. Lastly, the January 2010 survey predated the October 2010 ACGME response to the IOM recommendations, and the responses may be different now that the specific restrictions have been mandated with an actual implementation date.

CONCLUSIONS

This study shows that pediatric teaching services varied significantly in how they provided overnight coverage in 2010 prior to new ACGME recommendations. Overall, residents were providing the overwhelming majority of the patient care overnight in pediatric training programs. While hospitalists were prevalent in pediatric training programs, in 2010 they had limited roles in direct patient care at night. The ACGME has now mandated additional residency work hour restrictions to be implemented July 2011. With these restrictions, hospitalists will likely need to expand their services, and additional hospitalists will be needed to provide overnight coverage. It is unclear where those hospitalists will come from and what their role will be. It is also unclear what the impact of increased demand and changed job description will be on the continued evolution of the field of Pediatric Hospital Medicine.

Future work needs to be done to establish benchmarks for inpatient coverage. The benchmarks could include guidelines on balancing patient safety with resident education. This may also involve the implementation of resident night float models. There needs to be monitoring on how changes in resident work hours and staffing affect coverage and, ultimately, how changes affect patient and resident outcomes.

Resident duty hour restrictions were initially implemented in New York in 1989 with New York State Code 405 in response to a patient death in a New York City Emergency Department.1 This case initiated an evaluation of potential risks to patient safety when residents were inadequately supervised and overfatigued. In 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented resident duty hours nationally due to concerns for patient safety and quality of care.2 These restrictions involved the implementation of the 80‐hour work week (averaged over 4 weeks), a maximum duty length of 30 hours, and prescriptive supervision guidelines. In December 2008, the Institute of Medicine (IOM) proposed additional changes to further restrict resident duty hours which also included overnight protected sleep periods and additional days off per month.3 The ACGME responded by mandating new resident duty hour restrictions in October 2010 which will be implemented in July 2011. The ACGME's new changes include a change in the maximum duty hour length for residents in their first year of training (PGY‐1) of 16 hours. Residents in their second year of training (PGY‐2) level and above may work a maximum of 24 hours with an additional 4 hours for transition of care and resident education. The ACGME strongly recommends strategic napping, but do not have a protected overnight sleep period in place4 (Table 1).

There is growing concern regarding the impact of these new resident duty hour restrictions on the coverage of inpatient services, particularly during the overnight period. To our knowledge, there is no published national data on how pediatric inpatient teaching services are staffed at night. The objective of this study was to survey the current landscape of pediatric resident coverage of noncritical care inpatient teaching services. In addition, we sought to explore how changes in work hour restrictions might affect the role of pediatric hospitalists in training programs.

METHODS

We developed an institutional review board (IRB)‐approved Web‐based electronic survey. The survey consisted of 17 questions. The survey obtained information regarding the demographics of the program including: number of residents, daily patient census per ward intern, information regarding staff‐only pediatric ward services, overnight coverage, and current attending in‐house overnight coverage (see Appendix). We also examined the prevalence of pediatric hospitalists in training programs, their current role in staffing patients, and how that role may change with the implementation of additional resident duty hour restrictions. Initially, the survey was reviewed and tested by several pediatric hospitalists and program directors. It was then reviewed and approved by the Association of Pediatric Program Director (APPD) research task force. The survey was sent out to 196 US pediatric residency programs via the APPD listserve in January 2010. Program directors were given the option of completing it themselves or specifically designating someone else to complete it. Two reminders were sent. We then sent an additional request for program participation on the pediatric hospitalist listserve. All data was collected by February 2010.

RESULTS

One hundred twenty unique responses were received (61% of total pediatric residency programs). As of 2009, this represented 5201 pediatric residents (58% of total pediatric residents). The average program size was 43 residents (range: 12‐156 residents, median 43). The average daily patient census per ward intern during daytime hours was 6.65 patients (range: 3‐17, median 6). Twenty percent of training programs had staff‐only (no residents) pediatric ward services during daytime hours. In the programs with both staff‐only and resident pediatric ward services, only 19% of patients were covered by the staff‐only teams and 81% of patients were covered by resident teams.

During the overnight period, 86% of resident teams did not have caps on the number of new patient admissions. An average of 3.6 providers per training program were in‐house overnight to accept patient admissions to pediatric wards. Ninety‐four percent of these providers in‐house were residents (399 residents in‐house/425 total providers in‐house each night).

Twenty‐five percent of the training programs that responded to the survey had pediatric hospitalist attendings in‐house at night. This included both overnight and partial nights (ie, until midnight). Other attendings in‐house at night include: neonatal intensive care unit (NICU) attendings (53% of programs), pediatric intensive care unit (PICU) attendings (46% of programs), Pediatric Emergency Medicine attendings (65% of programs), and Pediatric Surgery attendings (6.4% of programs). Twenty‐two percent of programs had no in‐house attendings at night (Figure 1).

Figure 1

Pediatric hospitalists were involved with 84% (n = 97) of training programs. Sixty percent (n = 58) of the pediatric hospitalist teams were staffed with both teaching attendings and residents. Fourteen percent (n = 14) of the pediatric hospitalist teams did not involve residents (staff‐only) and 25% (n = 25) had both types of teams. Specifically, of the programs that had pediatric hospitalists, 20% (n = 19) of them had hospitalist attendings in‐house 24 hours per day and 13% (n = 12) of teams had hospitalist attendings in‐house into the evening hours for a varying amount of time. Of the programs with hospitalist attendings in‐house 24 hours per day, 52% (n = 11) had started this coverage within the past 3 years.

Looking towards the future, and prior to the enactment of the October 2010 ACGME standards, 31% (n = 35) of the training programs that lacked 24/7 hospitalist in‐house coverage in January 2010 anticipated adding this level of coverage within the next 5 years. Notably, 70% (n = 81) of training programs felt that further resident work hour restrictions, which have since been enacted, would likely require the addition of more hospitalist attendings at night. Our survey allowed program directors to make open‐ended comments on how further work hour restrictions may change inpatient staffing in noncritical care inpatient teaching services.

DISCUSSION

To our knowledge, this was the first national study of pediatric resident coverage in noncritical care inpatient teaching services. While there was significant variation in how inpatient teaching services were covered across these programs, in January 2010, residents were involved in the majority of patient care with only 20% of programs having attending‐only hospitalist teams during the daytime. During the overnight period, the proportion of patient care provided by residents became even more significant with residents representing 94% of the total in‐house providers accepting new admissions. While pediatric hospitalists were prevalent at these training programs, their role in direct patient care overnight was limited. Only 6% of total in‐house providers accepting admissions at night were pediatric hospitalists.

The comments made by program directors are representative of the overall concerns regarding changes to resident work hours (see Table 2). In a position statement by the Association of Pediatric Program Directors in regards to the IOM recommendations, concerns were raised stating that the recommendations of the IOM Committee are intended to enhance patient safety without appropriate consideration for the educational and professional development of trainees.5 While the newly mandated ACGME standards are different than the previous IOM recommendations, it is clear that there will be very significant changes to accommodate these new standards. Our study was done prior to the new ACGME's standards. At the time of the survey, less than a third of programs were anticipating the addition of 24/7 pediatric hospitalist coverage; however, if resident work hours were further restricted, 70% of programs felt that additional hospitalists would be needed. This is a significant increase in the previously anticipated need for overnight attending hospitalist coverage, especially in light of the further restrictions mandated by the ACGME. We know that the response of New York State programs to the 405 regulations varied by program size, but all made significant changes to accommodate the new standards.6 It is clear that many program directors nationally are anticipating significant changes to their residencies when these new restrictions are enacted. The respondents in our survey felt that pediatric hospitalists are going to have to play an even bigger role at night when additional resident work hour restrictions are put into place.

Pediatric hospital medicine remains a rapidly growing field.7 Eighty‐four percent of pediatric training programs utilize pediatric hospitalists. Over 60% of these pediatric hospitalist teams are involved in teaching teams with residents. While we did not directly study the supply and demand of pediatric hospitalists, there is some concern that even despite its rapid growth, the supply of pediatric hospitalists will not keep up with the demand when further resident work hours restrictions are implemented. At time of submission, a cost‐analysis has not yet been publicly published on the ACGME's new changes. There is data available based on the IOM's 2008 recommendations. A study by Nuckols and Escarce8 suggests that if the IOM's recommendations were implemented, the entire healthcare system nationally would have to develop and fill new full‐time positions equal to 5001 attending physicians, 5984 midlevel providers (nurse practitioners or physician assistants), 320 licensed vocational nurses, 229 nursing aides, and 45 laboratory technicians. This would be equivalent to adding an additional 8247 residency positions across all specialties.810 While the ACGME's new mandated changes are different than the IOM's recommendations, they will also restrict resident duty hours that we believe could lead to gaps in patient care requiring significant personnel changes in the healthcare system.

There are several limitations to our study. We did not study the role of pediatric subspecialty fellows and their involvement in pediatric inpatient services in these training programs. We also did not study the prevalence and use of resident night float systems. While night floats may be used in some programs, it may become more prevalent with the possible restriction in intern work hours down to 16 hours. As with any survey, there remains both volunteer and nonresponse bias with the programs that decide to complete or disregard the survey. Finally, there remains some concern over the data collection after the survey was sent out to the hospitalist listserve. Pediatric hospitalists may have incorrectly filled out the data for their program after their program director had already completed the survey. We attempted to minimize this problem by specifically instructing hospitalists to encourage their program director to fill out the survey if they had not already done so. We also compared computer Internet Protocol (IP) addresses and actual program responses, before and after the hospitalist e‐mail was sent, in an attempt to minimize the chance of including duplicated responses from the same program. Lastly, the January 2010 survey predated the October 2010 ACGME response to the IOM recommendations, and the responses may be different now that the specific restrictions have been mandated with an actual implementation date.

CONCLUSIONS

This study shows that pediatric teaching services varied significantly in how they provided overnight coverage in 2010 prior to new ACGME recommendations. Overall, residents were providing the overwhelming majority of the patient care overnight in pediatric training programs. While hospitalists were prevalent in pediatric training programs, in 2010 they had limited roles in direct patient care at night. The ACGME has now mandated additional residency work hour restrictions to be implemented July 2011. With these restrictions, hospitalists will likely need to expand their services, and additional hospitalists will be needed to provide overnight coverage. It is unclear where those hospitalists will come from and what their role will be. It is also unclear what the impact of increased demand and changed job description will be on the continued evolution of the field of Pediatric Hospital Medicine.

Future work needs to be done to establish benchmarks for inpatient coverage. The benchmarks could include guidelines on balancing patient safety with resident education. This may also involve the implementation of resident night float models. There needs to be monitoring on how changes in resident work hours and staffing affect coverage and, ultimately, how changes affect patient and resident outcomes.

Resident duty hour restrictions were initially implemented in New York in 1989 with New York State Code 405 in response to a patient death in a New York City Emergency Department.1 This case initiated an evaluation of potential risks to patient safety when residents were inadequately supervised and overfatigued. In 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented resident duty hours nationally due to concerns for patient safety and quality of care.2 These restrictions involved the implementation of the 80‐hour work week (averaged over 4 weeks), a maximum duty length of 30 hours, and prescriptive supervision guidelines. In December 2008, the Institute of Medicine (IOM) proposed additional changes to further restrict resident duty hours which also included overnight protected sleep periods and additional days off per month.3 The ACGME responded by mandating new resident duty hour restrictions in October 2010 which will be implemented in July 2011. The ACGME's new changes include a change in the maximum duty hour length for residents in their first year of training (PGY‐1) of 16 hours. Residents in their second year of training (PGY‐2) level and above may work a maximum of 24 hours with an additional 4 hours for transition of care and resident education. The ACGME strongly recommends strategic napping, but do not have a protected overnight sleep period in place4 (Table 1).

There is growing concern regarding the impact of these new resident duty hour restrictions on the coverage of inpatient services, particularly during the overnight period. To our knowledge, there is no published national data on how pediatric inpatient teaching services are staffed at night. The objective of this study was to survey the current landscape of pediatric resident coverage of noncritical care inpatient teaching services. In addition, we sought to explore how changes in work hour restrictions might affect the role of pediatric hospitalists in training programs.

METHODS

We developed an institutional review board (IRB)‐approved Web‐based electronic survey. The survey consisted of 17 questions. The survey obtained information regarding the demographics of the program including: number of residents, daily patient census per ward intern, information regarding staff‐only pediatric ward services, overnight coverage, and current attending in‐house overnight coverage (see Appendix). We also examined the prevalence of pediatric hospitalists in training programs, their current role in staffing patients, and how that role may change with the implementation of additional resident duty hour restrictions. Initially, the survey was reviewed and tested by several pediatric hospitalists and program directors. It was then reviewed and approved by the Association of Pediatric Program Director (APPD) research task force. The survey was sent out to 196 US pediatric residency programs via the APPD listserve in January 2010. Program directors were given the option of completing it themselves or specifically designating someone else to complete it. Two reminders were sent. We then sent an additional request for program participation on the pediatric hospitalist listserve. All data was collected by February 2010.

RESULTS

One hundred twenty unique responses were received (61% of total pediatric residency programs). As of 2009, this represented 5201 pediatric residents (58% of total pediatric residents). The average program size was 43 residents (range: 12‐156 residents, median 43). The average daily patient census per ward intern during daytime hours was 6.65 patients (range: 3‐17, median 6). Twenty percent of training programs had staff‐only (no residents) pediatric ward services during daytime hours. In the programs with both staff‐only and resident pediatric ward services, only 19% of patients were covered by the staff‐only teams and 81% of patients were covered by resident teams.

During the overnight period, 86% of resident teams did not have caps on the number of new patient admissions. An average of 3.6 providers per training program were in‐house overnight to accept patient admissions to pediatric wards. Ninety‐four percent of these providers in‐house were residents (399 residents in‐house/425 total providers in‐house each night).

Twenty‐five percent of the training programs that responded to the survey had pediatric hospitalist attendings in‐house at night. This included both overnight and partial nights (ie, until midnight). Other attendings in‐house at night include: neonatal intensive care unit (NICU) attendings (53% of programs), pediatric intensive care unit (PICU) attendings (46% of programs), Pediatric Emergency Medicine attendings (65% of programs), and Pediatric Surgery attendings (6.4% of programs). Twenty‐two percent of programs had no in‐house attendings at night (Figure 1).

Figure 1

Pediatric hospitalists were involved with 84% (n = 97) of training programs. Sixty percent (n = 58) of the pediatric hospitalist teams were staffed with both teaching attendings and residents. Fourteen percent (n = 14) of the pediatric hospitalist teams did not involve residents (staff‐only) and 25% (n = 25) had both types of teams. Specifically, of the programs that had pediatric hospitalists, 20% (n = 19) of them had hospitalist attendings in‐house 24 hours per day and 13% (n = 12) of teams had hospitalist attendings in‐house into the evening hours for a varying amount of time. Of the programs with hospitalist attendings in‐house 24 hours per day, 52% (n = 11) had started this coverage within the past 3 years.

Looking towards the future, and prior to the enactment of the October 2010 ACGME standards, 31% (n = 35) of the training programs that lacked 24/7 hospitalist in‐house coverage in January 2010 anticipated adding this level of coverage within the next 5 years. Notably, 70% (n = 81) of training programs felt that further resident work hour restrictions, which have since been enacted, would likely require the addition of more hospitalist attendings at night. Our survey allowed program directors to make open‐ended comments on how further work hour restrictions may change inpatient staffing in noncritical care inpatient teaching services.

DISCUSSION

To our knowledge, this was the first national study of pediatric resident coverage in noncritical care inpatient teaching services. While there was significant variation in how inpatient teaching services were covered across these programs, in January 2010, residents were involved in the majority of patient care with only 20% of programs having attending‐only hospitalist teams during the daytime. During the overnight period, the proportion of patient care provided by residents became even more significant with residents representing 94% of the total in‐house providers accepting new admissions. While pediatric hospitalists were prevalent at these training programs, their role in direct patient care overnight was limited. Only 6% of total in‐house providers accepting admissions at night were pediatric hospitalists.

The comments made by program directors are representative of the overall concerns regarding changes to resident work hours (see Table 2). In a position statement by the Association of Pediatric Program Directors in regards to the IOM recommendations, concerns were raised stating that the recommendations of the IOM Committee are intended to enhance patient safety without appropriate consideration for the educational and professional development of trainees.5 While the newly mandated ACGME standards are different than the previous IOM recommendations, it is clear that there will be very significant changes to accommodate these new standards. Our study was done prior to the new ACGME's standards. At the time of the survey, less than a third of programs were anticipating the addition of 24/7 pediatric hospitalist coverage; however, if resident work hours were further restricted, 70% of programs felt that additional hospitalists would be needed. This is a significant increase in the previously anticipated need for overnight attending hospitalist coverage, especially in light of the further restrictions mandated by the ACGME. We know that the response of New York State programs to the 405 regulations varied by program size, but all made significant changes to accommodate the new standards.6 It is clear that many program directors nationally are anticipating significant changes to their residencies when these new restrictions are enacted. The respondents in our survey felt that pediatric hospitalists are going to have to play an even bigger role at night when additional resident work hour restrictions are put into place.

Pediatric hospital medicine remains a rapidly growing field.7 Eighty‐four percent of pediatric training programs utilize pediatric hospitalists. Over 60% of these pediatric hospitalist teams are involved in teaching teams with residents. While we did not directly study the supply and demand of pediatric hospitalists, there is some concern that even despite its rapid growth, the supply of pediatric hospitalists will not keep up with the demand when further resident work hours restrictions are implemented. At time of submission, a cost‐analysis has not yet been publicly published on the ACGME's new changes. There is data available based on the IOM's 2008 recommendations. A study by Nuckols and Escarce8 suggests that if the IOM's recommendations were implemented, the entire healthcare system nationally would have to develop and fill new full‐time positions equal to 5001 attending physicians, 5984 midlevel providers (nurse practitioners or physician assistants), 320 licensed vocational nurses, 229 nursing aides, and 45 laboratory technicians. This would be equivalent to adding an additional 8247 residency positions across all specialties.810 While the ACGME's new mandated changes are different than the IOM's recommendations, they will also restrict resident duty hours that we believe could lead to gaps in patient care requiring significant personnel changes in the healthcare system.

There are several limitations to our study. We did not study the role of pediatric subspecialty fellows and their involvement in pediatric inpatient services in these training programs. We also did not study the prevalence and use of resident night float systems. While night floats may be used in some programs, it may become more prevalent with the possible restriction in intern work hours down to 16 hours. As with any survey, there remains both volunteer and nonresponse bias with the programs that decide to complete or disregard the survey. Finally, there remains some concern over the data collection after the survey was sent out to the hospitalist listserve. Pediatric hospitalists may have incorrectly filled out the data for their program after their program director had already completed the survey. We attempted to minimize this problem by specifically instructing hospitalists to encourage their program director to fill out the survey if they had not already done so. We also compared computer Internet Protocol (IP) addresses and actual program responses, before and after the hospitalist e‐mail was sent, in an attempt to minimize the chance of including duplicated responses from the same program. Lastly, the January 2010 survey predated the October 2010 ACGME response to the IOM recommendations, and the responses may be different now that the specific restrictions have been mandated with an actual implementation date.

CONCLUSIONS

This study shows that pediatric teaching services varied significantly in how they provided overnight coverage in 2010 prior to new ACGME recommendations. Overall, residents were providing the overwhelming majority of the patient care overnight in pediatric training programs. While hospitalists were prevalent in pediatric training programs, in 2010 they had limited roles in direct patient care at night. The ACGME has now mandated additional residency work hour restrictions to be implemented July 2011. With these restrictions, hospitalists will likely need to expand their services, and additional hospitalists will be needed to provide overnight coverage. It is unclear where those hospitalists will come from and what their role will be. It is also unclear what the impact of increased demand and changed job description will be on the continued evolution of the field of Pediatric Hospital Medicine.

Future work needs to be done to establish benchmarks for inpatient coverage. The benchmarks could include guidelines on balancing patient safety with resident education. This may also involve the implementation of resident night float models. There needs to be monitoring on how changes in resident work hours and staffing affect coverage and, ultimately, how changes affect patient and resident outcomes.

The number of pediatric hospitalists (PH) in the United States is increasing rapidly. The membership of the American Academy of Pediatrics (AAP) Section on Hospital Medicine has grown to 880 (7/10, AAP Section on Hospital Medicine), and there over 10,000 members of the Society of Hospital Medicine of which an estimated 5% care for children (7/10, Society of Hospital Medicine). Little is known about the educational contributions of pediatric hospitalists, residents' perceptions of hospitalists' roles, or how hospitalists may influence residents' eventual career plans even though 89% of pediatric hospitalists report they serve as teaching attendings.1 Teaching by hospitalists is well received and valued by residents, but, to date, all such data are from single institution studies of individual hospitalist programs.27 Less is known regarding what residents perceive about the differences in patient care provided by hospitalists as compared with traditional pediatric teaching attendings. There is a paucity of information about the level of interest of current pediatric residents in becoming hospitalists, including how many plan such a career, reasons why residents might prefer to become hospitalists, and their perceptions of Pediatric Hospital Medicine (PHM) careers as either long or short term. In addition, the effects of new residency graduates going into Hospital Medicine on the overall pediatric workforce, and how the availability of Hospital Medicine careers affects the choice of practice in Primary Care Pediatrics have not been examined.

We surveyed a national, randomly selected representative sample of pediatric residents to determine their level of exposure to hospitalist attending physicians during training. We asked the resident cohort about their educational experiences with hospitalists, patient care provided by hospitalists on their team, and career plans regarding becoming a hospitalist, including perceived needs for different or additional training. We obtained further information about reasons why hospitalist positions were appealing and about the current relationship between careers in Pediatric Hospital Medicine and Primary Care. To our knowledge, this is the first national study of how pediatric hospitalists might influence residents in the domains of education, patient care, and career planning.

METHODS

We conducted a survey of randomly selected pediatric residents from the AAP membership database. The selection was done by random generation by the AAP Department of Research from the membership database, in the same way members are selected for the annual Survey of Fellows and the annual pediatric level 3 (PL3) survey. Permission was obtained from the American Academy of Pediatrics Section on Residents (AAP SORe) to survey a selection of US pediatric residents in June 2007. The full sample of US pediatric residents included 9569 residents. The AAP SORe had 7694 e‐mail addresses from which the AAP Department of Research generated a random sample of 300 for our use, including Medicine‐Pediatric, Pediatric, and Pediatric Chief residents. One of the researchers (A.H.) sent an e‐mail with the title $200 AAP Career Raffle Survey containing a link to a SurveyMonkey survey (see Supporting Appendix AQuestionnaire in the online version of this article) and offering incentivized participation with a raffle. The need for informed consent was waived, as consent was implied by participation in the survey. The survey was taken anonymously by connecting through the link, and when it was completed, residents were asked to separately e‐mail a Section on Hospital Medicine address if they wished to participate in the raffle. Their raffle request was not linked to their survey results in any way. The $200 was supplied by the AAP Section on Hospital Medicine. The survey was sent 3 times. We analyzed responses with descriptive statistics. Institutional Review Board approval was obtained from Concord Hospital in Concord, New Hampshire.

RESULTS

The respondents are described in Figure 1 and Table 1. For their exposure to PHM, 54% (73 of 111) reported PH attendings in medical school; 90% (75 of 83) did have or will have PH attendings during residency, with no significant variation by program size (small, medium, large, or extra large). The degree of exposure was not asked. To learn about PHM, 47% (46 of 97 respondents) asked a PH in their program, while 28% (27 of 99) visited the AAP web site. Sixty‐eight percent (73 of 108) felt familiar or very familiar with PHM.

Figure 1

Table 2 summarizes the respondents' perception of PHM. They report a positive opinion of the field and overwhelmingly feel that PHM is a growing/developing field. Almost none feel PHM will not survive. A small percentage (10%, 28 of 99) felt there was no difference between PH and residents, with 25% (25 of 99) feeling some ambiguity about whether the PH role differs from that of a resident. Many (35 of 99) did not disagree that there is little difference between PH and resident positions, although most did. Sixty percent (59 of 99) agreed or strongly agreed that a PH position would be a good job for the short‐term. Forty‐seven percent (46 of 99) agreed in some form that PHM gives you something to do while you are waiting for another position. Given the choice of PHM as a long‐term opportunity, short‐term opportunity, either or not sure: 21% (21 of 98) saw PHM as a short‐term option only; 26% (25 of 98) saw PHM as a long‐term career only; 49% (48 of 98) saw it as either a short‐term option or long‐term career. Most (65%, 64 of 99) believed PH were better than primary care providers at caring for complex inpatients, but only 28% (28 of 99) thought PH provided better care for routine admissions. Most (82%, 81 of 99) agreed in some form that working with pediatric hospitalists enhances a resident's education.

On a 5‐point scale ranging from would definitely not include to might or might not include to would definitely include, the majority of respondents felt a PHM job would definitely include Pediatric Wards (86%, 84 of 98) and Inpatient Consultant for Specialists (54%, 52 of 97). Only 47% (46/97) felt the responsibilities would probably or definitely include Medical Student and Resident Education (47%, 46 of 97). The respondents were less certain (might or might not response) if PHM should include Normal Newborn Nursery (37%, 36 of 98), Delivery Room (42%, 41 of 98), Intensive Care Nursery (35%, 34 of 98), ED/Urgent Care (34%, 33 of 98), or Research (50%, 49 of 98). A majority of respondents felt PHM unlikely to include, or felt the job might not or might include: Outpatient Clinics (77%, 75 of 98), Outpatient Consults (81%, 79 of 98), and Pediatric Intensive Care Unit work (70%, 68 of 98).

Of categorical pediatric trainees answering the question, 35% (28 of 80) are considering a PHM career. Immediately post‐residency, 30% (24 of 80) of categorical trainees plan to enter Primary Care (PC), 4% (3 of 80) plan on PHM, and 3% (2 of 80) plan to pursue PH fellowship.

Of all respondents given the choice of whether a factor plays no role, limited role, or strong role in considering a career in PHM: flexible hours (96%, 94 of 98), opportunities to participate in education (97%, 95 of 98), and better salary than PC (94%, 91 of 97) would influence their decision to choose PHM. For 49% (48 of 98), ability to do the job without fellowship would play a strong role in choosing a career in PHM.

Forty‐five percent (44 of 97) support training in addition to residency; 16.5% (16 of 97) are against it; the remaining 38% (37 of 97) are unsure. Three percent (3 of 98) thought 3‐year fellowship best, while 28% (27 of 98) preferred 2‐year fellowship; 29% (28 of 98) would like a hospitalist‐track residency; 28% (27 of 98) believe standard residency sufficient; and 4% (4 of 98) felt a chief year adequate. If they were to pursue PHM, 31% (30 of 98) would enter PH fellowship, 34% (33 of 98) would not, and 36% (35 of 98) were unsure.

On a 5‐point scale, respondents were asked about barriers identified to choosing a career in PHM: 28% (27 of 96) agreed or strongly agreed that not feeling well‐enough trained was a barrier to entering the field; 42% (40 of 96) were agreed in some form that they were unsure of what training they needed; 39% (37 of 95) were unsure about where positions are available. Seven percent (7 of 98) of respondents were less likely to choose to practice Primary Care (PC) pediatrics because of hospitalists. Of respondents choosing PC, 59% (34 of 58) prefer or must have PH to work within their future practices, while 12% (7 of 58) prefer not to, or definitely do not want to, work with PH.

DISCUSSION

In 2006, the American Board of Pediatrics (ABP) General Pediatrics Career Survey found that 1% of first‐time applicants were taking a hospitalist position.8 In 2007, this number grew to 3% choosing a position in Pediatric Hospital Medicine.9, 10 The 2009‐2010 survey data found that 7.6% of first‐time applicants would be taking a job as hospitalist as of July 1.11 Our data suggest this number will continue to grow over the next few years. The growth of PHM has prompted an in‐depth look at the field by the ABP.1, 12, 13 PHM programs appear to have become part of the fabric of pediatric care, with the majority of hospitals with PHM programs planning to continue the programs despite the need to pay for value‐added by hospitalists beyond revenue received for their direct clinical service.13 Looking forward, when the Institute of Medicine recommendations to further restrict resident work hours to 16 hour shifts are implemented, many programs plan on increasing their PHM programs.14, 15 Therefore, residents' views of a career in PHM are important, as they give perspective on attitudes of those who might be, or interact with, hospitalists in the future, and should impact training programs for residents regardless of their interest in a career in PHM.

Our national data support local, large institution studies that hospitalists are positively impacting education.27 However, this study suggests that this is not only a local or large academic center phenomenon, but a national trend towards providing a different and positive education experience for pediatric residents. This mirrors the opinion of the majority of residency and clerkship directors who feel that hospitalists are more accessible to trainees than traditional attendings.12 Training programs should consider this impact when selecting attending hospitalists and supporting their roles as mentors and educators.

As residents finish their training and seek positions as pediatric hospitalists, programs need to be aware that a significant percentage of residents in our survey see PHM as a short‐term career option and/or fail to see a difference between a PH job and their own. Program Directors also need to be aware of the breadth of PHM practice which can include areas our respondents felt were less likely to be part of PHM, such as other inpatient areas and the expectation of research.

While 1 option to address some of these issues is fellowship training, this is not a simple decision. PHM needs to determine if fellowship is truly the best option for future hospitalists and, if so, what the fellowship should look like in terms of duration and scope. While the needs of optimal training should be paramount, resident preferences to not commit to an additional 3 years of training must be considered. Many residents fail to see a difference between the role of PH and their own role during training, and feel that the current format of residency training is all the preparation needed to step into a career as a PH. This demonstrates a clear gap between resident perceptions of PHM and the accepted definition of a hospitalist,16 which reaches far beyond direct inpatient care. While The Core Competencies for Pediatric Hospital Medicine17 address a number of these areas, neither trainees nor hospitalists themselves have fully integrated these into their practice. PH must recognize and prepare for their position as mentors and role models to residents. This responsibility should differentiate PH role from that of a resident, demonstrating roles PH play in policy making, patient safety and quality initiatives, in administration, and in providing advanced thinking in direct patient care. Finally, PH and their employers must work to build programs that present PHM as a long‐term career option for residents.

There is a significant impact on the field if those who enter it see it only as something to do while waiting for a position elsewhere. While some of these new‐careerists may stay with the field once they have tried it and become significant contributors, inherent in these answers are the issues of turnover and lack of senior experience many Hospital Medicine programs currently face. Additionally, and outside the scope of this survey, it is unclear what those next positions are and how a brief experience as a hospitalist might impact their future practice.

It is a significant change that residents entering a Primary Care career expect to work with pediatric hospitalists and, in general, see this as a benefit and necessity. The 2007 American Board of Pediatrics' survey found that 27% of respondents planned a career in General Pediatrics with little or no inpatient care.10 Hospitalists of the near future will likely face a dichotomy of needs between primary care providers who trained before, and those who trained after, the existence of hospitalists. Hospitalists will need to understand and address the ongoing needs of both of these groups in order to adequately serve them and their patient‐bases.

Limitations of our study include our small sample size, with a response rate of 43% at best (individual question response rate varied). Though the group was nationally representative, it was skewed towards first year respondents, likely due to the time of year in which it was distributed. There is likely some bias due to the low response rate, in that those more interested in careers as hospitalists might be more likely to respond. This might potentially inflate the percentages of those who state they are interested in being a hospitalist. In addition, given that the last round of the survey went out at the very end of the academic year, graduating residents had a lower response rate.

We were unable to compare opinions across unexposed and exposed residents because only 6.5% reported knowing nothing about the field, and only 2 respondents had not had any exposure to pediatric hospitalists to date. Given that most residencies have PHM services,12 this distinction is unlikely to be significant. In looking at training desires, we did not compare them to residents considering entering other fields of medicine. It may be true that residents considering other fellowships do not desire to do 3 years of fellowship training. That being said, it in no way diminishes the implication that 3‐year fellowships for PHM may not be the right answer for future training.

Strengths of the study include that it is, to our knowledge, the first national study of a group of residents regarding exposure to, and career plans as related to, PH. In addition, the group is gender‐balanced, and represents residents from a range of training sites (urban, suburban, rural) and program sizes. This study offers important information that must be considered in the further development of the field of Pediatric Hospital Medicine.

CONCLUSION

This was the first national study of residents regarding Pediatric Hospital Medicine. Almost all residents are exposed to PH during their training, though a gap of no exposure still exists. More work needs to be done to improve the perception of PHM as a viable long‐term career. Nevertheless, PHM has become a career consideration for trainees. Nearly half agreed that some type of specialized training would be helpful. This information should impact on the development of PHM training programs.

The number of pediatric hospitalists (PH) in the United States is increasing rapidly. The membership of the American Academy of Pediatrics (AAP) Section on Hospital Medicine has grown to 880 (7/10, AAP Section on Hospital Medicine), and there over 10,000 members of the Society of Hospital Medicine of which an estimated 5% care for children (7/10, Society of Hospital Medicine). Little is known about the educational contributions of pediatric hospitalists, residents' perceptions of hospitalists' roles, or how hospitalists may influence residents' eventual career plans even though 89% of pediatric hospitalists report they serve as teaching attendings.1 Teaching by hospitalists is well received and valued by residents, but, to date, all such data are from single institution studies of individual hospitalist programs.27 Less is known regarding what residents perceive about the differences in patient care provided by hospitalists as compared with traditional pediatric teaching attendings. There is a paucity of information about the level of interest of current pediatric residents in becoming hospitalists, including how many plan such a career, reasons why residents might prefer to become hospitalists, and their perceptions of Pediatric Hospital Medicine (PHM) careers as either long or short term. In addition, the effects of new residency graduates going into Hospital Medicine on the overall pediatric workforce, and how the availability of Hospital Medicine careers affects the choice of practice in Primary Care Pediatrics have not been examined.

We surveyed a national, randomly selected representative sample of pediatric residents to determine their level of exposure to hospitalist attending physicians during training. We asked the resident cohort about their educational experiences with hospitalists, patient care provided by hospitalists on their team, and career plans regarding becoming a hospitalist, including perceived needs for different or additional training. We obtained further information about reasons why hospitalist positions were appealing and about the current relationship between careers in Pediatric Hospital Medicine and Primary Care. To our knowledge, this is the first national study of how pediatric hospitalists might influence residents in the domains of education, patient care, and career planning.

METHODS

We conducted a survey of randomly selected pediatric residents from the AAP membership database. The selection was done by random generation by the AAP Department of Research from the membership database, in the same way members are selected for the annual Survey of Fellows and the annual pediatric level 3 (PL3) survey. Permission was obtained from the American Academy of Pediatrics Section on Residents (AAP SORe) to survey a selection of US pediatric residents in June 2007. The full sample of US pediatric residents included 9569 residents. The AAP SORe had 7694 e‐mail addresses from which the AAP Department of Research generated a random sample of 300 for our use, including Medicine‐Pediatric, Pediatric, and Pediatric Chief residents. One of the researchers (A.H.) sent an e‐mail with the title $200 AAP Career Raffle Survey containing a link to a SurveyMonkey survey (see Supporting Appendix AQuestionnaire in the online version of this article) and offering incentivized participation with a raffle. The need for informed consent was waived, as consent was implied by participation in the survey. The survey was taken anonymously by connecting through the link, and when it was completed, residents were asked to separately e‐mail a Section on Hospital Medicine address if they wished to participate in the raffle. Their raffle request was not linked to their survey results in any way. The $200 was supplied by the AAP Section on Hospital Medicine. The survey was sent 3 times. We analyzed responses with descriptive statistics. Institutional Review Board approval was obtained from Concord Hospital in Concord, New Hampshire.

RESULTS

The respondents are described in Figure 1 and Table 1. For their exposure to PHM, 54% (73 of 111) reported PH attendings in medical school; 90% (75 of 83) did have or will have PH attendings during residency, with no significant variation by program size (small, medium, large, or extra large). The degree of exposure was not asked. To learn about PHM, 47% (46 of 97 respondents) asked a PH in their program, while 28% (27 of 99) visited the AAP web site. Sixty‐eight percent (73 of 108) felt familiar or very familiar with PHM.

Figure 1

Table 2 summarizes the respondents' perception of PHM. They report a positive opinion of the field and overwhelmingly feel that PHM is a growing/developing field. Almost none feel PHM will not survive. A small percentage (10%, 28 of 99) felt there was no difference between PH and residents, with 25% (25 of 99) feeling some ambiguity about whether the PH role differs from that of a resident. Many (35 of 99) did not disagree that there is little difference between PH and resident positions, although most did. Sixty percent (59 of 99) agreed or strongly agreed that a PH position would be a good job for the short‐term. Forty‐seven percent (46 of 99) agreed in some form that PHM gives you something to do while you are waiting for another position. Given the choice of PHM as a long‐term opportunity, short‐term opportunity, either or not sure: 21% (21 of 98) saw PHM as a short‐term option only; 26% (25 of 98) saw PHM as a long‐term career only; 49% (48 of 98) saw it as either a short‐term option or long‐term career. Most (65%, 64 of 99) believed PH were better than primary care providers at caring for complex inpatients, but only 28% (28 of 99) thought PH provided better care for routine admissions. Most (82%, 81 of 99) agreed in some form that working with pediatric hospitalists enhances a resident's education.

On a 5‐point scale ranging from would definitely not include to might or might not include to would definitely include, the majority of respondents felt a PHM job would definitely include Pediatric Wards (86%, 84 of 98) and Inpatient Consultant for Specialists (54%, 52 of 97). Only 47% (46/97) felt the responsibilities would probably or definitely include Medical Student and Resident Education (47%, 46 of 97). The respondents were less certain (might or might not response) if PHM should include Normal Newborn Nursery (37%, 36 of 98), Delivery Room (42%, 41 of 98), Intensive Care Nursery (35%, 34 of 98), ED/Urgent Care (34%, 33 of 98), or Research (50%, 49 of 98). A majority of respondents felt PHM unlikely to include, or felt the job might not or might include: Outpatient Clinics (77%, 75 of 98), Outpatient Consults (81%, 79 of 98), and Pediatric Intensive Care Unit work (70%, 68 of 98).

Of categorical pediatric trainees answering the question, 35% (28 of 80) are considering a PHM career. Immediately post‐residency, 30% (24 of 80) of categorical trainees plan to enter Primary Care (PC), 4% (3 of 80) plan on PHM, and 3% (2 of 80) plan to pursue PH fellowship.

Of all respondents given the choice of whether a factor plays no role, limited role, or strong role in considering a career in PHM: flexible hours (96%, 94 of 98), opportunities to participate in education (97%, 95 of 98), and better salary than PC (94%, 91 of 97) would influence their decision to choose PHM. For 49% (48 of 98), ability to do the job without fellowship would play a strong role in choosing a career in PHM.

Forty‐five percent (44 of 97) support training in addition to residency; 16.5% (16 of 97) are against it; the remaining 38% (37 of 97) are unsure. Three percent (3 of 98) thought 3‐year fellowship best, while 28% (27 of 98) preferred 2‐year fellowship; 29% (28 of 98) would like a hospitalist‐track residency; 28% (27 of 98) believe standard residency sufficient; and 4% (4 of 98) felt a chief year adequate. If they were to pursue PHM, 31% (30 of 98) would enter PH fellowship, 34% (33 of 98) would not, and 36% (35 of 98) were unsure.

On a 5‐point scale, respondents were asked about barriers identified to choosing a career in PHM: 28% (27 of 96) agreed or strongly agreed that not feeling well‐enough trained was a barrier to entering the field; 42% (40 of 96) were agreed in some form that they were unsure of what training they needed; 39% (37 of 95) were unsure about where positions are available. Seven percent (7 of 98) of respondents were less likely to choose to practice Primary Care (PC) pediatrics because of hospitalists. Of respondents choosing PC, 59% (34 of 58) prefer or must have PH to work within their future practices, while 12% (7 of 58) prefer not to, or definitely do not want to, work with PH.

DISCUSSION

In 2006, the American Board of Pediatrics (ABP) General Pediatrics Career Survey found that 1% of first‐time applicants were taking a hospitalist position.8 In 2007, this number grew to 3% choosing a position in Pediatric Hospital Medicine.9, 10 The 2009‐2010 survey data found that 7.6% of first‐time applicants would be taking a job as hospitalist as of July 1.11 Our data suggest this number will continue to grow over the next few years. The growth of PHM has prompted an in‐depth look at the field by the ABP.1, 12, 13 PHM programs appear to have become part of the fabric of pediatric care, with the majority of hospitals with PHM programs planning to continue the programs despite the need to pay for value‐added by hospitalists beyond revenue received for their direct clinical service.13 Looking forward, when the Institute of Medicine recommendations to further restrict resident work hours to 16 hour shifts are implemented, many programs plan on increasing their PHM programs.14, 15 Therefore, residents' views of a career in PHM are important, as they give perspective on attitudes of those who might be, or interact with, hospitalists in the future, and should impact training programs for residents regardless of their interest in a career in PHM.

Our national data support local, large institution studies that hospitalists are positively impacting education.27 However, this study suggests that this is not only a local or large academic center phenomenon, but a national trend towards providing a different and positive education experience for pediatric residents. This mirrors the opinion of the majority of residency and clerkship directors who feel that hospitalists are more accessible to trainees than traditional attendings.12 Training programs should consider this impact when selecting attending hospitalists and supporting their roles as mentors and educators.

As residents finish their training and seek positions as pediatric hospitalists, programs need to be aware that a significant percentage of residents in our survey see PHM as a short‐term career option and/or fail to see a difference between a PH job and their own. Program Directors also need to be aware of the breadth of PHM practice which can include areas our respondents felt were less likely to be part of PHM, such as other inpatient areas and the expectation of research.

While 1 option to address some of these issues is fellowship training, this is not a simple decision. PHM needs to determine if fellowship is truly the best option for future hospitalists and, if so, what the fellowship should look like in terms of duration and scope. While the needs of optimal training should be paramount, resident preferences to not commit to an additional 3 years of training must be considered. Many residents fail to see a difference between the role of PH and their own role during training, and feel that the current format of residency training is all the preparation needed to step into a career as a PH. This demonstrates a clear gap between resident perceptions of PHM and the accepted definition of a hospitalist,16 which reaches far beyond direct inpatient care. While The Core Competencies for Pediatric Hospital Medicine17 address a number of these areas, neither trainees nor hospitalists themselves have fully integrated these into their practice. PH must recognize and prepare for their position as mentors and role models to residents. This responsibility should differentiate PH role from that of a resident, demonstrating roles PH play in policy making, patient safety and quality initiatives, in administration, and in providing advanced thinking in direct patient care. Finally, PH and their employers must work to build programs that present PHM as a long‐term career option for residents.

There is a significant impact on the field if those who enter it see it only as something to do while waiting for a position elsewhere. While some of these new‐careerists may stay with the field once they have tried it and become significant contributors, inherent in these answers are the issues of turnover and lack of senior experience many Hospital Medicine programs currently face. Additionally, and outside the scope of this survey, it is unclear what those next positions are and how a brief experience as a hospitalist might impact their future practice.

It is a significant change that residents entering a Primary Care career expect to work with pediatric hospitalists and, in general, see this as a benefit and necessity. The 2007 American Board of Pediatrics' survey found that 27% of respondents planned a career in General Pediatrics with little or no inpatient care.10 Hospitalists of the near future will likely face a dichotomy of needs between primary care providers who trained before, and those who trained after, the existence of hospitalists. Hospitalists will need to understand and address the ongoing needs of both of these groups in order to adequately serve them and their patient‐bases.

Limitations of our study include our small sample size, with a response rate of 43% at best (individual question response rate varied). Though the group was nationally representative, it was skewed towards first year respondents, likely due to the time of year in which it was distributed. There is likely some bias due to the low response rate, in that those more interested in careers as hospitalists might be more likely to respond. This might potentially inflate the percentages of those who state they are interested in being a hospitalist. In addition, given that the last round of the survey went out at the very end of the academic year, graduating residents had a lower response rate.

We were unable to compare opinions across unexposed and exposed residents because only 6.5% reported knowing nothing about the field, and only 2 respondents had not had any exposure to pediatric hospitalists to date. Given that most residencies have PHM services,12 this distinction is unlikely to be significant. In looking at training desires, we did not compare them to residents considering entering other fields of medicine. It may be true that residents considering other fellowships do not desire to do 3 years of fellowship training. That being said, it in no way diminishes the implication that 3‐year fellowships for PHM may not be the right answer for future training.

Strengths of the study include that it is, to our knowledge, the first national study of a group of residents regarding exposure to, and career plans as related to, PH. In addition, the group is gender‐balanced, and represents residents from a range of training sites (urban, suburban, rural) and program sizes. This study offers important information that must be considered in the further development of the field of Pediatric Hospital Medicine.

CONCLUSION

This was the first national study of residents regarding Pediatric Hospital Medicine. Almost all residents are exposed to PH during their training, though a gap of no exposure still exists. More work needs to be done to improve the perception of PHM as a viable long‐term career. Nevertheless, PHM has become a career consideration for trainees. Nearly half agreed that some type of specialized training would be helpful. This information should impact on the development of PHM training programs.

The number of pediatric hospitalists (PH) in the United States is increasing rapidly. The membership of the American Academy of Pediatrics (AAP) Section on Hospital Medicine has grown to 880 (7/10, AAP Section on Hospital Medicine), and there over 10,000 members of the Society of Hospital Medicine of which an estimated 5% care for children (7/10, Society of Hospital Medicine). Little is known about the educational contributions of pediatric hospitalists, residents' perceptions of hospitalists' roles, or how hospitalists may influence residents' eventual career plans even though 89% of pediatric hospitalists report they serve as teaching attendings.1 Teaching by hospitalists is well received and valued by residents, but, to date, all such data are from single institution studies of individual hospitalist programs.27 Less is known regarding what residents perceive about the differences in patient care provided by hospitalists as compared with traditional pediatric teaching attendings. There is a paucity of information about the level of interest of current pediatric residents in becoming hospitalists, including how many plan such a career, reasons why residents might prefer to become hospitalists, and their perceptions of Pediatric Hospital Medicine (PHM) careers as either long or short term. In addition, the effects of new residency graduates going into Hospital Medicine on the overall pediatric workforce, and how the availability of Hospital Medicine careers affects the choice of practice in Primary Care Pediatrics have not been examined.

We surveyed a national, randomly selected representative sample of pediatric residents to determine their level of exposure to hospitalist attending physicians during training. We asked the resident cohort about their educational experiences with hospitalists, patient care provided by hospitalists on their team, and career plans regarding becoming a hospitalist, including perceived needs for different or additional training. We obtained further information about reasons why hospitalist positions were appealing and about the current relationship between careers in Pediatric Hospital Medicine and Primary Care. To our knowledge, this is the first national study of how pediatric hospitalists might influence residents in the domains of education, patient care, and career planning.

METHODS

We conducted a survey of randomly selected pediatric residents from the AAP membership database. The selection was done by random generation by the AAP Department of Research from the membership database, in the same way members are selected for the annual Survey of Fellows and the annual pediatric level 3 (PL3) survey. Permission was obtained from the American Academy of Pediatrics Section on Residents (AAP SORe) to survey a selection of US pediatric residents in June 2007. The full sample of US pediatric residents included 9569 residents. The AAP SORe had 7694 e‐mail addresses from which the AAP Department of Research generated a random sample of 300 for our use, including Medicine‐Pediatric, Pediatric, and Pediatric Chief residents. One of the researchers (A.H.) sent an e‐mail with the title $200 AAP Career Raffle Survey containing a link to a SurveyMonkey survey (see Supporting Appendix AQuestionnaire in the online version of this article) and offering incentivized participation with a raffle. The need for informed consent was waived, as consent was implied by participation in the survey. The survey was taken anonymously by connecting through the link, and when it was completed, residents were asked to separately e‐mail a Section on Hospital Medicine address if they wished to participate in the raffle. Their raffle request was not linked to their survey results in any way. The $200 was supplied by the AAP Section on Hospital Medicine. The survey was sent 3 times. We analyzed responses with descriptive statistics. Institutional Review Board approval was obtained from Concord Hospital in Concord, New Hampshire.

RESULTS

The respondents are described in Figure 1 and Table 1. For their exposure to PHM, 54% (73 of 111) reported PH attendings in medical school; 90% (75 of 83) did have or will have PH attendings during residency, with no significant variation by program size (small, medium, large, or extra large). The degree of exposure was not asked. To learn about PHM, 47% (46 of 97 respondents) asked a PH in their program, while 28% (27 of 99) visited the AAP web site. Sixty‐eight percent (73 of 108) felt familiar or very familiar with PHM.

Figure 1

Table 2 summarizes the respondents' perception of PHM. They report a positive opinion of the field and overwhelmingly feel that PHM is a growing/developing field. Almost none feel PHM will not survive. A small percentage (10%, 28 of 99) felt there was no difference between PH and residents, with 25% (25 of 99) feeling some ambiguity about whether the PH role differs from that of a resident. Many (35 of 99) did not disagree that there is little difference between PH and resident positions, although most did. Sixty percent (59 of 99) agreed or strongly agreed that a PH position would be a good job for the short‐term. Forty‐seven percent (46 of 99) agreed in some form that PHM gives you something to do while you are waiting for another position. Given the choice of PHM as a long‐term opportunity, short‐term opportunity, either or not sure: 21% (21 of 98) saw PHM as a short‐term option only; 26% (25 of 98) saw PHM as a long‐term career only; 49% (48 of 98) saw it as either a short‐term option or long‐term career. Most (65%, 64 of 99) believed PH were better than primary care providers at caring for complex inpatients, but only 28% (28 of 99) thought PH provided better care for routine admissions. Most (82%, 81 of 99) agreed in some form that working with pediatric hospitalists enhances a resident's education.

On a 5‐point scale ranging from would definitely not include to might or might not include to would definitely include, the majority of respondents felt a PHM job would definitely include Pediatric Wards (86%, 84 of 98) and Inpatient Consultant for Specialists (54%, 52 of 97). Only 47% (46/97) felt the responsibilities would probably or definitely include Medical Student and Resident Education (47%, 46 of 97). The respondents were less certain (might or might not response) if PHM should include Normal Newborn Nursery (37%, 36 of 98), Delivery Room (42%, 41 of 98), Intensive Care Nursery (35%, 34 of 98), ED/Urgent Care (34%, 33 of 98), or Research (50%, 49 of 98). A majority of respondents felt PHM unlikely to include, or felt the job might not or might include: Outpatient Clinics (77%, 75 of 98), Outpatient Consults (81%, 79 of 98), and Pediatric Intensive Care Unit work (70%, 68 of 98).

Of categorical pediatric trainees answering the question, 35% (28 of 80) are considering a PHM career. Immediately post‐residency, 30% (24 of 80) of categorical trainees plan to enter Primary Care (PC), 4% (3 of 80) plan on PHM, and 3% (2 of 80) plan to pursue PH fellowship.

Of all respondents given the choice of whether a factor plays no role, limited role, or strong role in considering a career in PHM: flexible hours (96%, 94 of 98), opportunities to participate in education (97%, 95 of 98), and better salary than PC (94%, 91 of 97) would influence their decision to choose PHM. For 49% (48 of 98), ability to do the job without fellowship would play a strong role in choosing a career in PHM.

Forty‐five percent (44 of 97) support training in addition to residency; 16.5% (16 of 97) are against it; the remaining 38% (37 of 97) are unsure. Three percent (3 of 98) thought 3‐year fellowship best, while 28% (27 of 98) preferred 2‐year fellowship; 29% (28 of 98) would like a hospitalist‐track residency; 28% (27 of 98) believe standard residency sufficient; and 4% (4 of 98) felt a chief year adequate. If they were to pursue PHM, 31% (30 of 98) would enter PH fellowship, 34% (33 of 98) would not, and 36% (35 of 98) were unsure.

On a 5‐point scale, respondents were asked about barriers identified to choosing a career in PHM: 28% (27 of 96) agreed or strongly agreed that not feeling well‐enough trained was a barrier to entering the field; 42% (40 of 96) were agreed in some form that they were unsure of what training they needed; 39% (37 of 95) were unsure about where positions are available. Seven percent (7 of 98) of respondents were less likely to choose to practice Primary Care (PC) pediatrics because of hospitalists. Of respondents choosing PC, 59% (34 of 58) prefer or must have PH to work within their future practices, while 12% (7 of 58) prefer not to, or definitely do not want to, work with PH.

DISCUSSION

In 2006, the American Board of Pediatrics (ABP) General Pediatrics Career Survey found that 1% of first‐time applicants were taking a hospitalist position.8 In 2007, this number grew to 3% choosing a position in Pediatric Hospital Medicine.9, 10 The 2009‐2010 survey data found that 7.6% of first‐time applicants would be taking a job as hospitalist as of July 1.11 Our data suggest this number will continue to grow over the next few years. The growth of PHM has prompted an in‐depth look at the field by the ABP.1, 12, 13 PHM programs appear to have become part of the fabric of pediatric care, with the majority of hospitals with PHM programs planning to continue the programs despite the need to pay for value‐added by hospitalists beyond revenue received for their direct clinical service.13 Looking forward, when the Institute of Medicine recommendations to further restrict resident work hours to 16 hour shifts are implemented, many programs plan on increasing their PHM programs.14, 15 Therefore, residents' views of a career in PHM are important, as they give perspective on attitudes of those who might be, or interact with, hospitalists in the future, and should impact training programs for residents regardless of their interest in a career in PHM.

Our national data support local, large institution studies that hospitalists are positively impacting education.27 However, this study suggests that this is not only a local or large academic center phenomenon, but a national trend towards providing a different and positive education experience for pediatric residents. This mirrors the opinion of the majority of residency and clerkship directors who feel that hospitalists are more accessible to trainees than traditional attendings.12 Training programs should consider this impact when selecting attending hospitalists and supporting their roles as mentors and educators.

As residents finish their training and seek positions as pediatric hospitalists, programs need to be aware that a significant percentage of residents in our survey see PHM as a short‐term career option and/or fail to see a difference between a PH job and their own. Program Directors also need to be aware of the breadth of PHM practice which can include areas our respondents felt were less likely to be part of PHM, such as other inpatient areas and the expectation of research.

While 1 option to address some of these issues is fellowship training, this is not a simple decision. PHM needs to determine if fellowship is truly the best option for future hospitalists and, if so, what the fellowship should look like in terms of duration and scope. While the needs of optimal training should be paramount, resident preferences to not commit to an additional 3 years of training must be considered. Many residents fail to see a difference between the role of PH and their own role during training, and feel that the current format of residency training is all the preparation needed to step into a career as a PH. This demonstrates a clear gap between resident perceptions of PHM and the accepted definition of a hospitalist,16 which reaches far beyond direct inpatient care. While The Core Competencies for Pediatric Hospital Medicine17 address a number of these areas, neither trainees nor hospitalists themselves have fully integrated these into their practice. PH must recognize and prepare for their position as mentors and role models to residents. This responsibility should differentiate PH role from that of a resident, demonstrating roles PH play in policy making, patient safety and quality initiatives, in administration, and in providing advanced thinking in direct patient care. Finally, PH and their employers must work to build programs that present PHM as a long‐term career option for residents.

There is a significant impact on the field if those who enter it see it only as something to do while waiting for a position elsewhere. While some of these new‐careerists may stay with the field once they have tried it and become significant contributors, inherent in these answers are the issues of turnover and lack of senior experience many Hospital Medicine programs currently face. Additionally, and outside the scope of this survey, it is unclear what those next positions are and how a brief experience as a hospitalist might impact their future practice.

It is a significant change that residents entering a Primary Care career expect to work with pediatric hospitalists and, in general, see this as a benefit and necessity. The 2007 American Board of Pediatrics' survey found that 27% of respondents planned a career in General Pediatrics with little or no inpatient care.10 Hospitalists of the near future will likely face a dichotomy of needs between primary care providers who trained before, and those who trained after, the existence of hospitalists. Hospitalists will need to understand and address the ongoing needs of both of these groups in order to adequately serve them and their patient‐bases.

Limitations of our study include our small sample size, with a response rate of 43% at best (individual question response rate varied). Though the group was nationally representative, it was skewed towards first year respondents, likely due to the time of year in which it was distributed. There is likely some bias due to the low response rate, in that those more interested in careers as hospitalists might be more likely to respond. This might potentially inflate the percentages of those who state they are interested in being a hospitalist. In addition, given that the last round of the survey went out at the very end of the academic year, graduating residents had a lower response rate.

We were unable to compare opinions across unexposed and exposed residents because only 6.5% reported knowing nothing about the field, and only 2 respondents had not had any exposure to pediatric hospitalists to date. Given that most residencies have PHM services,12 this distinction is unlikely to be significant. In looking at training desires, we did not compare them to residents considering entering other fields of medicine. It may be true that residents considering other fellowships do not desire to do 3 years of fellowship training. That being said, it in no way diminishes the implication that 3‐year fellowships for PHM may not be the right answer for future training.

Strengths of the study include that it is, to our knowledge, the first national study of a group of residents regarding exposure to, and career plans as related to, PH. In addition, the group is gender‐balanced, and represents residents from a range of training sites (urban, suburban, rural) and program sizes. This study offers important information that must be considered in the further development of the field of Pediatric Hospital Medicine.

CONCLUSION

This was the first national study of residents regarding Pediatric Hospital Medicine. Almost all residents are exposed to PH during their training, though a gap of no exposure still exists. More work needs to be done to improve the perception of PHM as a viable long‐term career. Nevertheless, PHM has become a career consideration for trainees. Nearly half agreed that some type of specialized training would be helpful. This information should impact on the development of PHM training programs.

Hospitalists are the fastest growing segment of physicians in the United States.1 Given the growing field of Pediatric Hospital Medicine (PHM) and the need to define strategic direction, the Society of Hospital Medicine (SHM), the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA) sponsored a strategic planning meeting in February 2009 that brought together 22 PHM leaders to discuss the future of the field.

PHM is at a critical juncture in terms of clinical practice, research, workforce issues, and quality improvement. The field has developed sufficiently to produce leaders capable of setting an agenda and moving forward. A discussion with the American Board of Pediatrics (ABP) by PHM leaders from the AAP, APA, and SHM at the Pediatric Hospital Medicine 2007 Conference regarding subspecialty designation stimulated convening the PHM Strategic Planning Roundtable to address the task of coordinating further development of PHM (Table 1).

The objective of this article is to describe: (1) the Strategic Planning Roundtable's vision for the field of pediatric hospital medicine; (2) the generation and progress on specific initiatives in clinical practice, quality, research, and workforce identified by the Strategic Planning Roundtable; and (3) issues in the designation of PHM as a subspecialty.

METHODS

The PHM Strategic Planning Roundtable was conducted by a facilitator (S.M.) during a 2‐day retreat using established healthcare strategic planning methods.2

Participants were the existing PHM leaders from the AAP, APA, and SHM, as well as other national leaders in clinical practice, quality, research, and workforce. Development of the vision statement was a key step in which the participants developed a consensus‐based aspirational view of the future. The draft version of the vision statement was initially developed after extensive interviews with key stakeholders and experts in PHM, and was revised by the participants in the course of a facilitated group discussion during the retreat. Following creation of the vision statement, the group then defined the elements of transformation pertaining to PHM and detailed the components of the vision.

Analysis of internal and external environmental factors was critical in the strategic planning process. This type of analysis, detailing the current state of PHM practice, permitted the strategic planners to understand the gaps that existed between the aspirational vision statement and today's reality, and set the stage to identify and implement initiatives to achieve the vision. Several months before the meeting, 4 expert panels comprised of PHM specialists representing a variety of academic and clinical practice settings were brought together via e‐mail and conference calls to focus on 4 domains of PHM: clinical practice, quality of care, research, and workforce. These groups were asked to describe the current status, challenges, and opportunities in these areas. Combining literature review and key stakeholder interviews, their findings and recommendations were distilled into brief summaries that were presented at the Roundtable meeting. Following the presentations, the participants, working in small groups representing all areas of focus,provided additional feedback.

Following the creation of a consensus vision statement and review of internal and external factors, the participants worked to identify specific initiatives in the 4 domains that would advance the field towards the goals contained in the vision statement. These initiatives were grouped into categories. Initiatives by category were scored and prioritized according to predetermined criteria including potential impact, cost, operational complexity, and achievability.

For each initiative selected, the group developed targets and metrics that would be used to track progress. Assigning leadership, accountability, and a timeline to each of the selected projects completed the implementation plan. In addition, the group developed an organizational structure to provide oversight for the overall process, and designated individuals representing the sponsoring organizations into those roles. In conclusion, the group discussed potential structures to guide the future of PHM.

CLINICAL PRACTICE

The Roundtable defined clinical practice for PHM as the general medical care of the hospitalized child, including direct patient care and leadership of the inpatient service. Clinical practice is affected by a number of current national trends including: fewer primary care providers interested in, or with the time to provide, inpatient care; resident work hour restrictions; increasing complexity of clinical issues; and increasing availability of pediatric hospitalists. At the hospital level, clinical practice is affected by increasing need for quality and safety measures, electronic health records and computerized physician order entry, and mounting financial pressures on the hospital system. Hospitalists are assuming more roles in leading quality and safety initiatives, creating computerized systems that address children's needs, and creating financially viable systems of quality pediatric care.3 Hospitalists' clinical care and leadership roles are emerging, and therefore the field faces training and mentorship issues.

Progress to date in this area includes 2 textbooks that define a scope of knowledge and practice, and a newly developed journal in PHM. Core competencies in PHM have been published and provide further refinement of scope and a template for future training.4

Multiple opportunities exist for hospitalists to establish themselves as clinical leaders. Hospitalists can become the preferred providers for hospitalized chronically ill children, with specific initiatives to improve care coordination and multidisciplinary communication. In addition to care coordination and decreasing length of stay, hospitalists, with their intimate knowledge of hospital operations, can be leaders in hospital capacity management and patient flow to increase operational efficiency. Hospitalists can expand evidence‐based guidelines for, and data about, inpatient conditions, and explore the effect of workload and hours on patient care. In addition, there is an expanding role into administrative areas, as well as alternate care arenas, such as: intensive care support (pediatric and neonatal), transport, sedation, palliative care, and pain management. Activities in administrative and alternate care areas have profound direct affects on patient care, as well as providing value added services and additional revenue streams which can further support clinical needs. Finally, achieving quality targets will likely be increasingly linked to payment, so hospitalists may play a key role in the incentives paid to their hospitals. Meeting these challenges will further solidify the standing of hospitalists in the clinical realm.

QUALITY

National and governmental agencies have influenced quality and performance improvement measurements in adult healthcare, resulting in improvements in adult healthcare quality measurement.5 There is limited similar influence or measure development in pediatric medicine, so the quality chasm between adult and child healthcare has widened. Few resources are invested in improving quality and safety of pediatric inpatient care. Of the 18 private health insurance plans' quality and pay for performance programs identified by Leapfrog, only 17% developed pediatric‐specific inpatient measures.6 Only 5 of 40 controlled trials of quality improvement efforts for children published between 1980 and 1998 addressed inpatient problems.7

There have been recent efforts at the national level addressing these issues, highlighted by the introduction of The Children's Health Care Quality Act, in 2007. Early studies in PHM systems focused on overall operational efficiency, documenting 9% to 16% decreases in length of stay and cost compared to traditional models of care.8 Conway et al. identified higher reported adherence to evidence‐based care for hospitalists compared to community pediatricians.9 However, Landrigan et al. demonstrated that there is still large variation in care that exists in the management of common inpatient diagnoses, lacking strong evidence‐based guidelines even among pediatric hospitalists.10 Moreover, there have been no significant studies reviewing the impact of pediatric hospitalists on safety of inpatient care. Magnifying these challenges is the reality that our healthcare system is fragmented with various entities scrambling to define, measure, and compare the effectiveness and safety of pediatric healthcare.

These challenges create an opportunity for PHM to develop a model of how to deliver the highest quality and safest care to our patients. The solution is complex and will take cooperation at many levels of our healthcare system. Improving the safety and quality of care for children in all settings of inpatient care in the United States may best be accomplished via an effective collaborative. This collaborative should be comprehensive and inclusive, and focused on demonstrating and disseminating how standardized, evidence‐based care in both clinical and safety domains can lead to high‐value and high‐quality outcomes. The success of PHM will be measured by its ability to deliver a clear value proposition to all consumers and payers of healthcare. The creation of a robust national collaborative network is a first step towards meeting this goal and will take an extraordinary effort. A PHM Quality Improvement (QI) Collaborative workgroup was created in August 2009. Three collaboratives have been commissioned: (1) Reduction of patient identification errors; (2) Improving discharge communication to referring primary care providers for pediatric hospitalist programs, and (3) Reducing the misuse and overuse of bronchodilators for bronchiolitis. All the collaborative groups have effectively engaged key groups of stakeholders and utilized standard QI tools, demonstrating improvement by the fall of 2010 (unpublished data, S.N.).

RESEARCH

Despite being a relatively young field, there is a critical mass of pediatric hospitalist‐investigators who are establishing research career paths for themselves by securing external grant funding for their work, publishing, and receiving mentorship from largely non‐hospitalist mentors. Some hospitalists are now in a position to mentor junior investigators. These hospitalist‐investigators identified a collective goal of working together across multiple sites in a clinical research network. The goal is to conduct high‐quality studies and provide the necessary clinical information to allow practicing hospitalists to make better decisions regarding patient care. This new inpatient evidence‐base will have the added advantage of helping further define the field of PHM.

The Pediatric Research in Inpatient Settings Network (PRIS) was identified as the vehicle to accomplish these goals. A series of objectives were identified to redesign PRIS in order to accommodate and organize this new influx of hospitalist‐investigators. These objectives included having hospitalist‐investigators commit their time to the prioritization, design, and execution of multicenter studies, drafting new governance documents for PRIS, securing external funding, redefining the relationships of the 3 existing organizations that formed PRIS (AAP, APA, SHM), defining how new clinical sites could be added to PRIS, creating a pipeline for junior hospitalist‐investigators to transition to leadership roles, securing a data coordinating center with established expertise in conducting multicenter studies, and establishing an external research advisory committee of leaders in pediatric clinical research and QI.

Several critical issues were identified, but funding remained a priority for the sustainability of PRIS. Comparative effectiveness (CE) was recognized as a potential important source of future funding. Pediatric studies on CE (eg, surgery vs medical management) conducted by PRIS would provide important new data to allow hospitalists to practice evidence‐based medicine and to improve quality.

A Research Leadership Task Force was created with 4 members of the PHM Strategic Planning Roundtable to work on the identified issues. The APA leadership worked with PRIS to establish a new Executive Council (comprised of additional qualified hospitalist‐investigators). The Executive Council was charged with accomplishing the tasks outlined from the Strategic Planning Roundtable. They have created the governance documents and standard operating procedures necessary for PRIS to conduct multicenter studies, defined a strategic framework for PRIS including the mission, vision and values, and funding strategy. In February 2010, PRIS received a 3‐year award for over $1 million from the Child Health Corporation of America to both fund the infrastructure of PRIS and to conduct a Prioritization Project. The Prioritization Project seeks to identify the conditions that are costly, prevalent, and demonstrate high inter‐hospital variation in resource utilization, which signals either lack of high‐quality data upon which to base medical decisions, and/or an opportunity to standardize care across hospitals. Some of these conditions will warrant further investigation to define the evidence base, whereas other conditions may require implementation studies to reliably introduce evidence into practice. Members of the Executive Council received additional funding to investigate community settings, as most children are hospitalized outside of large children's hospitals. PRIS also reengaged all 3 societies (APA, AAP, and SHM) for support for the first face‐to‐face meeting of the Executive Council. PRIS applied for 2 Recovery Act stimulus grants, and received funding for both of approximately $12 million. The processes used to design, provide feedback, and shepherd these initial studies formed the basis for the standard operating procedures for the Network. PRIS is now reengaging its membership to establish how sites may be able to conduct research, and receive new ideas to be considered for study in PRIS.

Although much work remains to be done, the Executive Council is continuing the charge with quarterly face‐to‐face meetings, hiring of a full‐time PRIS Coordinator, and carrying out these initial projects, while maintaining the goal of meeting the needs of the membership and PHM. If PRIS is to accomplish its mission of improving the health of, and healthcare delivery to, hospitalized children and their families, then the types of studies undertaken will include not only original research questions, but also comparative implementation methods to better understand how hospitalists in a variety of settings can best translate research findings into clinical practice and ultimately improve patient outcomes.

WORKFORCE

The current number of pediatric hospitalists is difficult to gauge11; estimates range from 1500 to 3000 physicians. There are groups of pediatric hospitalists within several national organizations including the AAP, APA, and SHM, in addition to a very active listserve community. It is likely that only a portion of pediatric hospitalists are represented by membership in these organizations.

Most physicians entering the field of PHM come directly out of residency. A recent survey by Freed et al.12 reported that 3% of current pediatric residents are interested in PHM as a career. In another survey by Freed et al., about 6% of recent pediatric residency graduates reported currently practicing as pediatric hospitalists.13 This difference may indicate a number of pediatricians practicing transiently as pediatric hospitalists.

There are numerous issues that will affect the growth and sustainability of PHM. A large number of pediatric residents entering the field will be needed to maintain current numbers. With 45% of hospitalists in practice less than 3 years,11 the growth of PHM in both numbers and influence will require an increasing number of hospitalists with sustained careers in the field. Recognition as experts in inpatient care, as well as expansion of the role of hospitalists beyond the clinical realm to education, research, and hospital leadership, will foster long‐term career satisfaction. The increasingly common stature of hospital medicine as an independent division, equivalent to general pediatrics and subspecialty divisions within a department, may further bolster the perception of hospital medicine as a career.

The majority of pediatric hospitalists believe that current pediatric residency training does not provide all of the skills necessary to practice as a pediatric hospitalist,14 though there is disagreement regarding how additional training in pediatric hospital medicine should be achieved: a dedicated fellowship versus continuing medical education (CME). There are several initiatives with the potential to transform the way pediatric hospitalists are trained and certified. The Residency Review and Redesign Project indicates that pediatric residency is likely to be reformed to better meet the training demands of the individual resident's chosen career path. Changing residency to better prepare pediatric residents to take positions in pediatric hospital medicine will certainly affect the workforce emerging from residency programs and their subsequent training needs.15 The American Board of Internal Medicine and the American Board of Family Medicine have approved a Recognition of Focused Practice in Hospital Medicine. This recognition is gained through the Maintenance of Certification (MOC) Program of the respective boards after a minimum of 3 years of practice. SHM is offering fellow recognition in tiered designations of Fellow of Hospital Medicine (FHM), Senior Fellow of Hospital Medicine, and Master of Hospital Medicine. Five hundred hospitalists, including many pediatric hospitalists, received the inaugural FHM designation in 2009. Organizational recognition is a common process in many other medical fields, although previously limited in pediatrics to Fellow of the AAP. FHM is an important step, but cannot substitute for specific training and certification.

Academic fellowships in PHM will aid in the training of hospitalists with scholarly skills and will help produce more pediatric hospitalists with clinical, quality, administrative, and leadership skills. A model of subspecialty fellowship training and certification of all PHM physicians would require a several‐fold increase in available fellowships, currently approximately 15.

Ongoing CME offerings are also critical to sustaining and developing the workforce. The annual national meetings of the APA, AAP, and SHM all offer PHM‐dedicated content, and there is an annual PHM conference sponsored by these 3 organizations. There are now multiple additional national and regional meetings focused on PHM, reflecting the growing audience for PHM CME content. The AAP offers a PHM study guide and an Education in quality improvement for pediatric practice (eQIPP) module on inpatient asthma, specifically designed to facilitate the MOC process for pediatric hospitalists.

Some form of ABP recognition may be necessary to provide the status for PHM to be widely recognized as a viable academic career in the larger pediatric community. This would entail standardized fellowships that will ensure graduates have demonstrated proficiency in the core competencies. PHM leaders have engaged the ABP to better understand the subspecialty approval process and thoughtfully examine the ramifications of subspecialty status, specifically what subspecialty certification would mean for PHM providers and hospitals. Achieving ABP certification may create a new standard of care meaning that noncertified PHM providers will be at a disadvantage. It is unknown what the impact on pediatric inpatient care would be if a PHM standard was set without the supply of practitioners to provide that care.

STRUCTURE

The efforts of the Roundtable demonstrate the potential effectiveness of the current structure that guides the field: that of the cooperative interchange between the PHM leaders within the APA, AAP, and SHM. It may be that, similar to Pediatric Emergency Medicine (PEM), no formal, unifying structure is necessary. Alternatively, both Adolescent Medicine and Behavioral and Developmental Pediatrics (BDP) have their own organizations that guide their respective fields. A hybrid model is that of Pediatric Cardiology which has the Joint Council on Congenital Heart Disease. This structure assures that the leaders of the various organizations concerned with congenital heart disease meet at least annually to report on their activities and coordinate future efforts. Its makeup is similar to how the planning committee of the annual national PHM conference is constructed. Although PHM has largely succeeded with the current organizational structure, it is possible that a more formal structure is needed to continue forward.

CONCLUSION

The Roundtable members developed the following vision for PHM: Pediatric hospitalists will transform the delivery of hospital care for children. This will be done by achieving 7 goals (Table 2).

Attaining this vision will take tremendous dedication, effort, and collaboration. As a starting point, the following initiatives were proposed and implemented as noted:

Hospitalists are the fastest growing segment of physicians in the United States.1 Given the growing field of Pediatric Hospital Medicine (PHM) and the need to define strategic direction, the Society of Hospital Medicine (SHM), the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA) sponsored a strategic planning meeting in February 2009 that brought together 22 PHM leaders to discuss the future of the field.

PHM is at a critical juncture in terms of clinical practice, research, workforce issues, and quality improvement. The field has developed sufficiently to produce leaders capable of setting an agenda and moving forward. A discussion with the American Board of Pediatrics (ABP) by PHM leaders from the AAP, APA, and SHM at the Pediatric Hospital Medicine 2007 Conference regarding subspecialty designation stimulated convening the PHM Strategic Planning Roundtable to address the task of coordinating further development of PHM (Table 1).

The objective of this article is to describe: (1) the Strategic Planning Roundtable's vision for the field of pediatric hospital medicine; (2) the generation and progress on specific initiatives in clinical practice, quality, research, and workforce identified by the Strategic Planning Roundtable; and (3) issues in the designation of PHM as a subspecialty.

METHODS

The PHM Strategic Planning Roundtable was conducted by a facilitator (S.M.) during a 2‐day retreat using established healthcare strategic planning methods.2

Participants were the existing PHM leaders from the AAP, APA, and SHM, as well as other national leaders in clinical practice, quality, research, and workforce. Development of the vision statement was a key step in which the participants developed a consensus‐based aspirational view of the future. The draft version of the vision statement was initially developed after extensive interviews with key stakeholders and experts in PHM, and was revised by the participants in the course of a facilitated group discussion during the retreat. Following creation of the vision statement, the group then defined the elements of transformation pertaining to PHM and detailed the components of the vision.

Analysis of internal and external environmental factors was critical in the strategic planning process. This type of analysis, detailing the current state of PHM practice, permitted the strategic planners to understand the gaps that existed between the aspirational vision statement and today's reality, and set the stage to identify and implement initiatives to achieve the vision. Several months before the meeting, 4 expert panels comprised of PHM specialists representing a variety of academic and clinical practice settings were brought together via e‐mail and conference calls to focus on 4 domains of PHM: clinical practice, quality of care, research, and workforce. These groups were asked to describe the current status, challenges, and opportunities in these areas. Combining literature review and key stakeholder interviews, their findings and recommendations were distilled into brief summaries that were presented at the Roundtable meeting. Following the presentations, the participants, working in small groups representing all areas of focus,provided additional feedback.

Following the creation of a consensus vision statement and review of internal and external factors, the participants worked to identify specific initiatives in the 4 domains that would advance the field towards the goals contained in the vision statement. These initiatives were grouped into categories. Initiatives by category were scored and prioritized according to predetermined criteria including potential impact, cost, operational complexity, and achievability.

For each initiative selected, the group developed targets and metrics that would be used to track progress. Assigning leadership, accountability, and a timeline to each of the selected projects completed the implementation plan. In addition, the group developed an organizational structure to provide oversight for the overall process, and designated individuals representing the sponsoring organizations into those roles. In conclusion, the group discussed potential structures to guide the future of PHM.

CLINICAL PRACTICE

The Roundtable defined clinical practice for PHM as the general medical care of the hospitalized child, including direct patient care and leadership of the inpatient service. Clinical practice is affected by a number of current national trends including: fewer primary care providers interested in, or with the time to provide, inpatient care; resident work hour restrictions; increasing complexity of clinical issues; and increasing availability of pediatric hospitalists. At the hospital level, clinical practice is affected by increasing need for quality and safety measures, electronic health records and computerized physician order entry, and mounting financial pressures on the hospital system. Hospitalists are assuming more roles in leading quality and safety initiatives, creating computerized systems that address children's needs, and creating financially viable systems of quality pediatric care.3 Hospitalists' clinical care and leadership roles are emerging, and therefore the field faces training and mentorship issues.

Progress to date in this area includes 2 textbooks that define a scope of knowledge and practice, and a newly developed journal in PHM. Core competencies in PHM have been published and provide further refinement of scope and a template for future training.4

Multiple opportunities exist for hospitalists to establish themselves as clinical leaders. Hospitalists can become the preferred providers for hospitalized chronically ill children, with specific initiatives to improve care coordination and multidisciplinary communication. In addition to care coordination and decreasing length of stay, hospitalists, with their intimate knowledge of hospital operations, can be leaders in hospital capacity management and patient flow to increase operational efficiency. Hospitalists can expand evidence‐based guidelines for, and data about, inpatient conditions, and explore the effect of workload and hours on patient care. In addition, there is an expanding role into administrative areas, as well as alternate care arenas, such as: intensive care support (pediatric and neonatal), transport, sedation, palliative care, and pain management. Activities in administrative and alternate care areas have profound direct affects on patient care, as well as providing value added services and additional revenue streams which can further support clinical needs. Finally, achieving quality targets will likely be increasingly linked to payment, so hospitalists may play a key role in the incentives paid to their hospitals. Meeting these challenges will further solidify the standing of hospitalists in the clinical realm.

QUALITY

National and governmental agencies have influenced quality and performance improvement measurements in adult healthcare, resulting in improvements in adult healthcare quality measurement.5 There is limited similar influence or measure development in pediatric medicine, so the quality chasm between adult and child healthcare has widened. Few resources are invested in improving quality and safety of pediatric inpatient care. Of the 18 private health insurance plans' quality and pay for performance programs identified by Leapfrog, only 17% developed pediatric‐specific inpatient measures.6 Only 5 of 40 controlled trials of quality improvement efforts for children published between 1980 and 1998 addressed inpatient problems.7

There have been recent efforts at the national level addressing these issues, highlighted by the introduction of The Children's Health Care Quality Act, in 2007. Early studies in PHM systems focused on overall operational efficiency, documenting 9% to 16% decreases in length of stay and cost compared to traditional models of care.8 Conway et al. identified higher reported adherence to evidence‐based care for hospitalists compared to community pediatricians.9 However, Landrigan et al. demonstrated that there is still large variation in care that exists in the management of common inpatient diagnoses, lacking strong evidence‐based guidelines even among pediatric hospitalists.10 Moreover, there have been no significant studies reviewing the impact of pediatric hospitalists on safety of inpatient care. Magnifying these challenges is the reality that our healthcare system is fragmented with various entities scrambling to define, measure, and compare the effectiveness and safety of pediatric healthcare.

These challenges create an opportunity for PHM to develop a model of how to deliver the highest quality and safest care to our patients. The solution is complex and will take cooperation at many levels of our healthcare system. Improving the safety and quality of care for children in all settings of inpatient care in the United States may best be accomplished via an effective collaborative. This collaborative should be comprehensive and inclusive, and focused on demonstrating and disseminating how standardized, evidence‐based care in both clinical and safety domains can lead to high‐value and high‐quality outcomes. The success of PHM will be measured by its ability to deliver a clear value proposition to all consumers and payers of healthcare. The creation of a robust national collaborative network is a first step towards meeting this goal and will take an extraordinary effort. A PHM Quality Improvement (QI) Collaborative workgroup was created in August 2009. Three collaboratives have been commissioned: (1) Reduction of patient identification errors; (2) Improving discharge communication to referring primary care providers for pediatric hospitalist programs, and (3) Reducing the misuse and overuse of bronchodilators for bronchiolitis. All the collaborative groups have effectively engaged key groups of stakeholders and utilized standard QI tools, demonstrating improvement by the fall of 2010 (unpublished data, S.N.).

RESEARCH

Despite being a relatively young field, there is a critical mass of pediatric hospitalist‐investigators who are establishing research career paths for themselves by securing external grant funding for their work, publishing, and receiving mentorship from largely non‐hospitalist mentors. Some hospitalists are now in a position to mentor junior investigators. These hospitalist‐investigators identified a collective goal of working together across multiple sites in a clinical research network. The goal is to conduct high‐quality studies and provide the necessary clinical information to allow practicing hospitalists to make better decisions regarding patient care. This new inpatient evidence‐base will have the added advantage of helping further define the field of PHM.

The Pediatric Research in Inpatient Settings Network (PRIS) was identified as the vehicle to accomplish these goals. A series of objectives were identified to redesign PRIS in order to accommodate and organize this new influx of hospitalist‐investigators. These objectives included having hospitalist‐investigators commit their time to the prioritization, design, and execution of multicenter studies, drafting new governance documents for PRIS, securing external funding, redefining the relationships of the 3 existing organizations that formed PRIS (AAP, APA, SHM), defining how new clinical sites could be added to PRIS, creating a pipeline for junior hospitalist‐investigators to transition to leadership roles, securing a data coordinating center with established expertise in conducting multicenter studies, and establishing an external research advisory committee of leaders in pediatric clinical research and QI.

Several critical issues were identified, but funding remained a priority for the sustainability of PRIS. Comparative effectiveness (CE) was recognized as a potential important source of future funding. Pediatric studies on CE (eg, surgery vs medical management) conducted by PRIS would provide important new data to allow hospitalists to practice evidence‐based medicine and to improve quality.

A Research Leadership Task Force was created with 4 members of the PHM Strategic Planning Roundtable to work on the identified issues. The APA leadership worked with PRIS to establish a new Executive Council (comprised of additional qualified hospitalist‐investigators). The Executive Council was charged with accomplishing the tasks outlined from the Strategic Planning Roundtable. They have created the governance documents and standard operating procedures necessary for PRIS to conduct multicenter studies, defined a strategic framework for PRIS including the mission, vision and values, and funding strategy. In February 2010, PRIS received a 3‐year award for over $1 million from the Child Health Corporation of America to both fund the infrastructure of PRIS and to conduct a Prioritization Project. The Prioritization Project seeks to identify the conditions that are costly, prevalent, and demonstrate high inter‐hospital variation in resource utilization, which signals either lack of high‐quality data upon which to base medical decisions, and/or an opportunity to standardize care across hospitals. Some of these conditions will warrant further investigation to define the evidence base, whereas other conditions may require implementation studies to reliably introduce evidence into practice. Members of the Executive Council received additional funding to investigate community settings, as most children are hospitalized outside of large children's hospitals. PRIS also reengaged all 3 societies (APA, AAP, and SHM) for support for the first face‐to‐face meeting of the Executive Council. PRIS applied for 2 Recovery Act stimulus grants, and received funding for both of approximately $12 million. The processes used to design, provide feedback, and shepherd these initial studies formed the basis for the standard operating procedures for the Network. PRIS is now reengaging its membership to establish how sites may be able to conduct research, and receive new ideas to be considered for study in PRIS.

Although much work remains to be done, the Executive Council is continuing the charge with quarterly face‐to‐face meetings, hiring of a full‐time PRIS Coordinator, and carrying out these initial projects, while maintaining the goal of meeting the needs of the membership and PHM. If PRIS is to accomplish its mission of improving the health of, and healthcare delivery to, hospitalized children and their families, then the types of studies undertaken will include not only original research questions, but also comparative implementation methods to better understand how hospitalists in a variety of settings can best translate research findings into clinical practice and ultimately improve patient outcomes.

WORKFORCE

The current number of pediatric hospitalists is difficult to gauge11; estimates range from 1500 to 3000 physicians. There are groups of pediatric hospitalists within several national organizations including the AAP, APA, and SHM, in addition to a very active listserve community. It is likely that only a portion of pediatric hospitalists are represented by membership in these organizations.

Most physicians entering the field of PHM come directly out of residency. A recent survey by Freed et al.12 reported that 3% of current pediatric residents are interested in PHM as a career. In another survey by Freed et al., about 6% of recent pediatric residency graduates reported currently practicing as pediatric hospitalists.13 This difference may indicate a number of pediatricians practicing transiently as pediatric hospitalists.

There are numerous issues that will affect the growth and sustainability of PHM. A large number of pediatric residents entering the field will be needed to maintain current numbers. With 45% of hospitalists in practice less than 3 years,11 the growth of PHM in both numbers and influence will require an increasing number of hospitalists with sustained careers in the field. Recognition as experts in inpatient care, as well as expansion of the role of hospitalists beyond the clinical realm to education, research, and hospital leadership, will foster long‐term career satisfaction. The increasingly common stature of hospital medicine as an independent division, equivalent to general pediatrics and subspecialty divisions within a department, may further bolster the perception of hospital medicine as a career.

The majority of pediatric hospitalists believe that current pediatric residency training does not provide all of the skills necessary to practice as a pediatric hospitalist,14 though there is disagreement regarding how additional training in pediatric hospital medicine should be achieved: a dedicated fellowship versus continuing medical education (CME). There are several initiatives with the potential to transform the way pediatric hospitalists are trained and certified. The Residency Review and Redesign Project indicates that pediatric residency is likely to be reformed to better meet the training demands of the individual resident's chosen career path. Changing residency to better prepare pediatric residents to take positions in pediatric hospital medicine will certainly affect the workforce emerging from residency programs and their subsequent training needs.15 The American Board of Internal Medicine and the American Board of Family Medicine have approved a Recognition of Focused Practice in Hospital Medicine. This recognition is gained through the Maintenance of Certification (MOC) Program of the respective boards after a minimum of 3 years of practice. SHM is offering fellow recognition in tiered designations of Fellow of Hospital Medicine (FHM), Senior Fellow of Hospital Medicine, and Master of Hospital Medicine. Five hundred hospitalists, including many pediatric hospitalists, received the inaugural FHM designation in 2009. Organizational recognition is a common process in many other medical fields, although previously limited in pediatrics to Fellow of the AAP. FHM is an important step, but cannot substitute for specific training and certification.

Academic fellowships in PHM will aid in the training of hospitalists with scholarly skills and will help produce more pediatric hospitalists with clinical, quality, administrative, and leadership skills. A model of subspecialty fellowship training and certification of all PHM physicians would require a several‐fold increase in available fellowships, currently approximately 15.

Ongoing CME offerings are also critical to sustaining and developing the workforce. The annual national meetings of the APA, AAP, and SHM all offer PHM‐dedicated content, and there is an annual PHM conference sponsored by these 3 organizations. There are now multiple additional national and regional meetings focused on PHM, reflecting the growing audience for PHM CME content. The AAP offers a PHM study guide and an Education in quality improvement for pediatric practice (eQIPP) module on inpatient asthma, specifically designed to facilitate the MOC process for pediatric hospitalists.

Some form of ABP recognition may be necessary to provide the status for PHM to be widely recognized as a viable academic career in the larger pediatric community. This would entail standardized fellowships that will ensure graduates have demonstrated proficiency in the core competencies. PHM leaders have engaged the ABP to better understand the subspecialty approval process and thoughtfully examine the ramifications of subspecialty status, specifically what subspecialty certification would mean for PHM providers and hospitals. Achieving ABP certification may create a new standard of care meaning that noncertified PHM providers will be at a disadvantage. It is unknown what the impact on pediatric inpatient care would be if a PHM standard was set without the supply of practitioners to provide that care.

STRUCTURE

The efforts of the Roundtable demonstrate the potential effectiveness of the current structure that guides the field: that of the cooperative interchange between the PHM leaders within the APA, AAP, and SHM. It may be that, similar to Pediatric Emergency Medicine (PEM), no formal, unifying structure is necessary. Alternatively, both Adolescent Medicine and Behavioral and Developmental Pediatrics (BDP) have their own organizations that guide their respective fields. A hybrid model is that of Pediatric Cardiology which has the Joint Council on Congenital Heart Disease. This structure assures that the leaders of the various organizations concerned with congenital heart disease meet at least annually to report on their activities and coordinate future efforts. Its makeup is similar to how the planning committee of the annual national PHM conference is constructed. Although PHM has largely succeeded with the current organizational structure, it is possible that a more formal structure is needed to continue forward.

CONCLUSION

The Roundtable members developed the following vision for PHM: Pediatric hospitalists will transform the delivery of hospital care for children. This will be done by achieving 7 goals (Table 2).

Attaining this vision will take tremendous dedication, effort, and collaboration. As a starting point, the following initiatives were proposed and implemented as noted:

Hospitalists are the fastest growing segment of physicians in the United States.1 Given the growing field of Pediatric Hospital Medicine (PHM) and the need to define strategic direction, the Society of Hospital Medicine (SHM), the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA) sponsored a strategic planning meeting in February 2009 that brought together 22 PHM leaders to discuss the future of the field.

PHM is at a critical juncture in terms of clinical practice, research, workforce issues, and quality improvement. The field has developed sufficiently to produce leaders capable of setting an agenda and moving forward. A discussion with the American Board of Pediatrics (ABP) by PHM leaders from the AAP, APA, and SHM at the Pediatric Hospital Medicine 2007 Conference regarding subspecialty designation stimulated convening the PHM Strategic Planning Roundtable to address the task of coordinating further development of PHM (Table 1).

The objective of this article is to describe: (1) the Strategic Planning Roundtable's vision for the field of pediatric hospital medicine; (2) the generation and progress on specific initiatives in clinical practice, quality, research, and workforce identified by the Strategic Planning Roundtable; and (3) issues in the designation of PHM as a subspecialty.

METHODS

The PHM Strategic Planning Roundtable was conducted by a facilitator (S.M.) during a 2‐day retreat using established healthcare strategic planning methods.2

Participants were the existing PHM leaders from the AAP, APA, and SHM, as well as other national leaders in clinical practice, quality, research, and workforce. Development of the vision statement was a key step in which the participants developed a consensus‐based aspirational view of the future. The draft version of the vision statement was initially developed after extensive interviews with key stakeholders and experts in PHM, and was revised by the participants in the course of a facilitated group discussion during the retreat. Following creation of the vision statement, the group then defined the elements of transformation pertaining to PHM and detailed the components of the vision.

Analysis of internal and external environmental factors was critical in the strategic planning process. This type of analysis, detailing the current state of PHM practice, permitted the strategic planners to understand the gaps that existed between the aspirational vision statement and today's reality, and set the stage to identify and implement initiatives to achieve the vision. Several months before the meeting, 4 expert panels comprised of PHM specialists representing a variety of academic and clinical practice settings were brought together via e‐mail and conference calls to focus on 4 domains of PHM: clinical practice, quality of care, research, and workforce. These groups were asked to describe the current status, challenges, and opportunities in these areas. Combining literature review and key stakeholder interviews, their findings and recommendations were distilled into brief summaries that were presented at the Roundtable meeting. Following the presentations, the participants, working in small groups representing all areas of focus,provided additional feedback.

Following the creation of a consensus vision statement and review of internal and external factors, the participants worked to identify specific initiatives in the 4 domains that would advance the field towards the goals contained in the vision statement. These initiatives were grouped into categories. Initiatives by category were scored and prioritized according to predetermined criteria including potential impact, cost, operational complexity, and achievability.

For each initiative selected, the group developed targets and metrics that would be used to track progress. Assigning leadership, accountability, and a timeline to each of the selected projects completed the implementation plan. In addition, the group developed an organizational structure to provide oversight for the overall process, and designated individuals representing the sponsoring organizations into those roles. In conclusion, the group discussed potential structures to guide the future of PHM.

CLINICAL PRACTICE

The Roundtable defined clinical practice for PHM as the general medical care of the hospitalized child, including direct patient care and leadership of the inpatient service. Clinical practice is affected by a number of current national trends including: fewer primary care providers interested in, or with the time to provide, inpatient care; resident work hour restrictions; increasing complexity of clinical issues; and increasing availability of pediatric hospitalists. At the hospital level, clinical practice is affected by increasing need for quality and safety measures, electronic health records and computerized physician order entry, and mounting financial pressures on the hospital system. Hospitalists are assuming more roles in leading quality and safety initiatives, creating computerized systems that address children's needs, and creating financially viable systems of quality pediatric care.3 Hospitalists' clinical care and leadership roles are emerging, and therefore the field faces training and mentorship issues.

Progress to date in this area includes 2 textbooks that define a scope of knowledge and practice, and a newly developed journal in PHM. Core competencies in PHM have been published and provide further refinement of scope and a template for future training.4

Multiple opportunities exist for hospitalists to establish themselves as clinical leaders. Hospitalists can become the preferred providers for hospitalized chronically ill children, with specific initiatives to improve care coordination and multidisciplinary communication. In addition to care coordination and decreasing length of stay, hospitalists, with their intimate knowledge of hospital operations, can be leaders in hospital capacity management and patient flow to increase operational efficiency. Hospitalists can expand evidence‐based guidelines for, and data about, inpatient conditions, and explore the effect of workload and hours on patient care. In addition, there is an expanding role into administrative areas, as well as alternate care arenas, such as: intensive care support (pediatric and neonatal), transport, sedation, palliative care, and pain management. Activities in administrative and alternate care areas have profound direct affects on patient care, as well as providing value added services and additional revenue streams which can further support clinical needs. Finally, achieving quality targets will likely be increasingly linked to payment, so hospitalists may play a key role in the incentives paid to their hospitals. Meeting these challenges will further solidify the standing of hospitalists in the clinical realm.

QUALITY

National and governmental agencies have influenced quality and performance improvement measurements in adult healthcare, resulting in improvements in adult healthcare quality measurement.5 There is limited similar influence or measure development in pediatric medicine, so the quality chasm between adult and child healthcare has widened. Few resources are invested in improving quality and safety of pediatric inpatient care. Of the 18 private health insurance plans' quality and pay for performance programs identified by Leapfrog, only 17% developed pediatric‐specific inpatient measures.6 Only 5 of 40 controlled trials of quality improvement efforts for children published between 1980 and 1998 addressed inpatient problems.7

There have been recent efforts at the national level addressing these issues, highlighted by the introduction of The Children's Health Care Quality Act, in 2007. Early studies in PHM systems focused on overall operational efficiency, documenting 9% to 16% decreases in length of stay and cost compared to traditional models of care.8 Conway et al. identified higher reported adherence to evidence‐based care for hospitalists compared to community pediatricians.9 However, Landrigan et al. demonstrated that there is still large variation in care that exists in the management of common inpatient diagnoses, lacking strong evidence‐based guidelines even among pediatric hospitalists.10 Moreover, there have been no significant studies reviewing the impact of pediatric hospitalists on safety of inpatient care. Magnifying these challenges is the reality that our healthcare system is fragmented with various entities scrambling to define, measure, and compare the effectiveness and safety of pediatric healthcare.

These challenges create an opportunity for PHM to develop a model of how to deliver the highest quality and safest care to our patients. The solution is complex and will take cooperation at many levels of our healthcare system. Improving the safety and quality of care for children in all settings of inpatient care in the United States may best be accomplished via an effective collaborative. This collaborative should be comprehensive and inclusive, and focused on demonstrating and disseminating how standardized, evidence‐based care in both clinical and safety domains can lead to high‐value and high‐quality outcomes. The success of PHM will be measured by its ability to deliver a clear value proposition to all consumers and payers of healthcare. The creation of a robust national collaborative network is a first step towards meeting this goal and will take an extraordinary effort. A PHM Quality Improvement (QI) Collaborative workgroup was created in August 2009. Three collaboratives have been commissioned: (1) Reduction of patient identification errors; (2) Improving discharge communication to referring primary care providers for pediatric hospitalist programs, and (3) Reducing the misuse and overuse of bronchodilators for bronchiolitis. All the collaborative groups have effectively engaged key groups of stakeholders and utilized standard QI tools, demonstrating improvement by the fall of 2010 (unpublished data, S.N.).

RESEARCH

Despite being a relatively young field, there is a critical mass of pediatric hospitalist‐investigators who are establishing research career paths for themselves by securing external grant funding for their work, publishing, and receiving mentorship from largely non‐hospitalist mentors. Some hospitalists are now in a position to mentor junior investigators. These hospitalist‐investigators identified a collective goal of working together across multiple sites in a clinical research network. The goal is to conduct high‐quality studies and provide the necessary clinical information to allow practicing hospitalists to make better decisions regarding patient care. This new inpatient evidence‐base will have the added advantage of helping further define the field of PHM.

The Pediatric Research in Inpatient Settings Network (PRIS) was identified as the vehicle to accomplish these goals. A series of objectives were identified to redesign PRIS in order to accommodate and organize this new influx of hospitalist‐investigators. These objectives included having hospitalist‐investigators commit their time to the prioritization, design, and execution of multicenter studies, drafting new governance documents for PRIS, securing external funding, redefining the relationships of the 3 existing organizations that formed PRIS (AAP, APA, SHM), defining how new clinical sites could be added to PRIS, creating a pipeline for junior hospitalist‐investigators to transition to leadership roles, securing a data coordinating center with established expertise in conducting multicenter studies, and establishing an external research advisory committee of leaders in pediatric clinical research and QI.

Several critical issues were identified, but funding remained a priority for the sustainability of PRIS. Comparative effectiveness (CE) was recognized as a potential important source of future funding. Pediatric studies on CE (eg, surgery vs medical management) conducted by PRIS would provide important new data to allow hospitalists to practice evidence‐based medicine and to improve quality.

A Research Leadership Task Force was created with 4 members of the PHM Strategic Planning Roundtable to work on the identified issues. The APA leadership worked with PRIS to establish a new Executive Council (comprised of additional qualified hospitalist‐investigators). The Executive Council was charged with accomplishing the tasks outlined from the Strategic Planning Roundtable. They have created the governance documents and standard operating procedures necessary for PRIS to conduct multicenter studies, defined a strategic framework for PRIS including the mission, vision and values, and funding strategy. In February 2010, PRIS received a 3‐year award for over $1 million from the Child Health Corporation of America to both fund the infrastructure of PRIS and to conduct a Prioritization Project. The Prioritization Project seeks to identify the conditions that are costly, prevalent, and demonstrate high inter‐hospital variation in resource utilization, which signals either lack of high‐quality data upon which to base medical decisions, and/or an opportunity to standardize care across hospitals. Some of these conditions will warrant further investigation to define the evidence base, whereas other conditions may require implementation studies to reliably introduce evidence into practice. Members of the Executive Council received additional funding to investigate community settings, as most children are hospitalized outside of large children's hospitals. PRIS also reengaged all 3 societies (APA, AAP, and SHM) for support for the first face‐to‐face meeting of the Executive Council. PRIS applied for 2 Recovery Act stimulus grants, and received funding for both of approximately $12 million. The processes used to design, provide feedback, and shepherd these initial studies formed the basis for the standard operating procedures for the Network. PRIS is now reengaging its membership to establish how sites may be able to conduct research, and receive new ideas to be considered for study in PRIS.

Although much work remains to be done, the Executive Council is continuing the charge with quarterly face‐to‐face meetings, hiring of a full‐time PRIS Coordinator, and carrying out these initial projects, while maintaining the goal of meeting the needs of the membership and PHM. If PRIS is to accomplish its mission of improving the health of, and healthcare delivery to, hospitalized children and their families, then the types of studies undertaken will include not only original research questions, but also comparative implementation methods to better understand how hospitalists in a variety of settings can best translate research findings into clinical practice and ultimately improve patient outcomes.

WORKFORCE

The current number of pediatric hospitalists is difficult to gauge11; estimates range from 1500 to 3000 physicians. There are groups of pediatric hospitalists within several national organizations including the AAP, APA, and SHM, in addition to a very active listserve community. It is likely that only a portion of pediatric hospitalists are represented by membership in these organizations.

Most physicians entering the field of PHM come directly out of residency. A recent survey by Freed et al.12 reported that 3% of current pediatric residents are interested in PHM as a career. In another survey by Freed et al., about 6% of recent pediatric residency graduates reported currently practicing as pediatric hospitalists.13 This difference may indicate a number of pediatricians practicing transiently as pediatric hospitalists.

There are numerous issues that will affect the growth and sustainability of PHM. A large number of pediatric residents entering the field will be needed to maintain current numbers. With 45% of hospitalists in practice less than 3 years,11 the growth of PHM in both numbers and influence will require an increasing number of hospitalists with sustained careers in the field. Recognition as experts in inpatient care, as well as expansion of the role of hospitalists beyond the clinical realm to education, research, and hospital leadership, will foster long‐term career satisfaction. The increasingly common stature of hospital medicine as an independent division, equivalent to general pediatrics and subspecialty divisions within a department, may further bolster the perception of hospital medicine as a career.

The majority of pediatric hospitalists believe that current pediatric residency training does not provide all of the skills necessary to practice as a pediatric hospitalist,14 though there is disagreement regarding how additional training in pediatric hospital medicine should be achieved: a dedicated fellowship versus continuing medical education (CME). There are several initiatives with the potential to transform the way pediatric hospitalists are trained and certified. The Residency Review and Redesign Project indicates that pediatric residency is likely to be reformed to better meet the training demands of the individual resident's chosen career path. Changing residency to better prepare pediatric residents to take positions in pediatric hospital medicine will certainly affect the workforce emerging from residency programs and their subsequent training needs.15 The American Board of Internal Medicine and the American Board of Family Medicine have approved a Recognition of Focused Practice in Hospital Medicine. This recognition is gained through the Maintenance of Certification (MOC) Program of the respective boards after a minimum of 3 years of practice. SHM is offering fellow recognition in tiered designations of Fellow of Hospital Medicine (FHM), Senior Fellow of Hospital Medicine, and Master of Hospital Medicine. Five hundred hospitalists, including many pediatric hospitalists, received the inaugural FHM designation in 2009. Organizational recognition is a common process in many other medical fields, although previously limited in pediatrics to Fellow of the AAP. FHM is an important step, but cannot substitute for specific training and certification.

Academic fellowships in PHM will aid in the training of hospitalists with scholarly skills and will help produce more pediatric hospitalists with clinical, quality, administrative, and leadership skills. A model of subspecialty fellowship training and certification of all PHM physicians would require a several‐fold increase in available fellowships, currently approximately 15.

Ongoing CME offerings are also critical to sustaining and developing the workforce. The annual national meetings of the APA, AAP, and SHM all offer PHM‐dedicated content, and there is an annual PHM conference sponsored by these 3 organizations. There are now multiple additional national and regional meetings focused on PHM, reflecting the growing audience for PHM CME content. The AAP offers a PHM study guide and an Education in quality improvement for pediatric practice (eQIPP) module on inpatient asthma, specifically designed to facilitate the MOC process for pediatric hospitalists.

Some form of ABP recognition may be necessary to provide the status for PHM to be widely recognized as a viable academic career in the larger pediatric community. This would entail standardized fellowships that will ensure graduates have demonstrated proficiency in the core competencies. PHM leaders have engaged the ABP to better understand the subspecialty approval process and thoughtfully examine the ramifications of subspecialty status, specifically what subspecialty certification would mean for PHM providers and hospitals. Achieving ABP certification may create a new standard of care meaning that noncertified PHM providers will be at a disadvantage. It is unknown what the impact on pediatric inpatient care would be if a PHM standard was set without the supply of practitioners to provide that care.

STRUCTURE

The efforts of the Roundtable demonstrate the potential effectiveness of the current structure that guides the field: that of the cooperative interchange between the PHM leaders within the APA, AAP, and SHM. It may be that, similar to Pediatric Emergency Medicine (PEM), no formal, unifying structure is necessary. Alternatively, both Adolescent Medicine and Behavioral and Developmental Pediatrics (BDP) have their own organizations that guide their respective fields. A hybrid model is that of Pediatric Cardiology which has the Joint Council on Congenital Heart Disease. This structure assures that the leaders of the various organizations concerned with congenital heart disease meet at least annually to report on their activities and coordinate future efforts. Its makeup is similar to how the planning committee of the annual national PHM conference is constructed. Although PHM has largely succeeded with the current organizational structure, it is possible that a more formal structure is needed to continue forward.

CONCLUSION

The Roundtable members developed the following vision for PHM: Pediatric hospitalists will transform the delivery of hospital care for children. This will be done by achieving 7 goals (Table 2).

Attaining this vision will take tremendous dedication, effort, and collaboration. As a starting point, the following initiatives were proposed and implemented as noted: