JoAnna K Leyenaar, MD, PhD, MPH

As one of the youngest fields of pediatric practice in the United States, pediatric hospital medicine (PHM) has grown rapidly over the past 2 decades. Approximately 10% of recent graduates from pediatric residency programs in the United States have entered PHM, with two-thirds reporting an intention to remain as hospitalists long term.^1,2

In October 2016, the American Board of Medical Specialties (ABMS) approved a petition for PHM to become the newest pediatric subspecialty.³ The application for subspeciality status, led by the Joint Council of Pediatric Hospital Medicine, articulated that subspecialty certification would more clearly define subspecialty hospitalists’ scope of practice, create a “new and larger cadre” of quality improvement (QI) experts, and strengthen opportunities for professional development related to child health safety within healthcare systems.⁴ Approximately 1500 pediatric hospitalists sat for the first PHM board-certification exam in November 2019, illustrating broad interest and commitment to this subspecialty.⁵

Characterizing the current responsibilities, practice settings, and professional interests of pediatric hospitalists is critical to understanding the continued development of the field. However, the most recent national survey of pediatric hospitalists’ roles and responsibilities was conducted more than a decade ago, and shared definitions of what constitutes PHM across institutions are lacking.⁶ Furthermore, studies suggest wide variability in PHM workload.^7-9 We therefore aimed to describe the characteristics, responsibilities, and practice settings of pediatricians who reported practicing PHM in the United States and determine how exclusive PHM practice, compared with PHM practice in combination with primary or subspecialty care, was associated with professional responsibilities and interests. We hypothesized that those reporting exclusive PHM practice would be more likely to report interest in QI leadership and intention to take the PHM certifying exam than those practicing PHM in combination with primary or subspecialty care.

Participants and Survey

Pediatricians enrolling in the American Board of Pediatrics (ABP) Maintenance of Certification (MOC) program in 2017 and 2018 were asked to complete a voluntary survey about their professional roles and scope of practice (Appendix Methods). The survey, offered to all MOC enrollees, included a hospital medicine module administered to those reporting PHM practice, given the ABP’s interest in characterizing PHM roles, responsibilities, practice settings, and interests in QI. Respondents were excluded if they were practicing outside of the United States, if they were unemployed or in a volunteer position, or if they were in fellowship training.

To ascertain areas of clinical practice, respondents were provided with a list of clinical practice areas and asked, “In which of the following areas are you practicing?” Those selecting “hospital medicine” were classified as self-identified hospitalists (hereafter, “hospitalists”). Given variation across institutions in physician roles and responsibilities, we stratified hospitalists into three groups: (1) exclusive PHM practice, representing those who reported PHM as their only area of practice; (2) PHM in combination with general pediatrics, representing those who reported practicing PHM and general pediatrics; and (3) PHM in combination with other subspecialties, representing those who reported practicing PHM in addition to one or more subspecialties. Respondents who reported practicing hospital medicine, general pediatrics, and another subspecialty were classified in the subspecialty group. The ABP’s institutional review board of record deemed the survey exempt from human subjects review.

Hospitalist Characteristics and Clinical Roles

To characterize respondents, we examined their age, gender, medical school location (American medical school or international medical school), and survey year (2017 or 2018). We also examined the following practice characteristics: US Census region, part-time versus full-time employment, academic appointment (yes or no), proportion of time spent providing direct and/or consultative patient care and fulfilling nonclinical responsibilities (research, administration, medical education, and QI), hospital setting (children’s hospital, community hospital, or mix of these hospital types), and work schedule type (shift schedule, on-service work in blocks, or a combination of shift and block schedules).

To examine variation in clinical roles, we determined the proportion of total direct and/or consultative clinical care that was spent in each of the following areas: (1) inpatient pediatric care, defined as inpatient general or subspecialty care in patients up to 21 years of age; (2) neonatal care, defined as labor and delivery, inpatient normal newborn care, and/or neonatal intensive care; (3) outpatient practice, defined as outpatient general or subspecialty care in patients up to 21 years of age; (4) emergency department care; and (5) other, which included pediatric intensive care as well inpatient adult care. Recognizing that scope of practice may differ at community hospitals and children’s hospitals, we stratified this analysis by practice setting (children’s hospital, community hospital).

Dependent Variables

We examined four dependent variables, two that were hypothesis driven and two that were exploratory. To test our hypothesis that respondents practicing PHM exclusively would be more likely to report interest in QI leadership or consultation (given the emphasis on QI in the ABMS application for subspecialty status), we examined the frequency with which respondents endorsed being “somewhat interested” or “very interested” in “serving as a leader or consultant for QI activities.” To test our hypothesis that respondents practicing PHM exclusively would be more likely to report plans to take the PHM certifying exam, we noted the frequency with which respondents reported “yes” to the question, “Do you plan to take a certifying exam in hospitalist medicine when it becomes available?” As an exploratory outcome, we examined satisfaction with allocation of professional time, available on the 2017 survey only; satisfaction was defined as an affirmative response to the question, “Is the allocation of your total professional time approximately what you wanted in your current position?” Finally, intention to maintain more than one ABP certification, also reported only in 2017 and examined as an exploratory outcome, was defined as a reported intention to maintain more than one ABP certification, including general pediatrics, PHM, or any other subspecialty.

Statistical Analysis

We used chi-square tests and analysis of variance as appropriate to examine differences in sociodemographic and professional characteristics among respondents who reported exclusive PHM practice, PHM in combination with general pediatrics, and PHM in combination with another subspecialty. To examine differences across the three PHM groups in their allocation of time to various clinical responsibilities (eg, inpatient care, newborn care), we used Kruskal-Wallis equality-of-population rank tests, stratifying by hospital type. We used multivariable logistic regression to identify associations between exclusive PHM practice and our four dependent variables, adjusting for the sociodemographic and professional characteristics described above. All analyses were conducted using Stata 15 (StataCorp LLC), using two-sided tests, and defining P < .05 as statistically significant.

Study Sample

Of the 19,763 pediatricians enrolling in MOC in 2017 and 2018, 13,839 responded the survey, representing a response rate of 70.0%. There were no significant differences between survey respondents and nonrespondents with respect to gender; differences between respondents and nonrespondents in age, medical school location, and initial year of ABP certification year were small (mean age, 48.1 years and 47.1 years, respectively [P < .01]; 77.0% of respondents were graduates of US medical schools compared with 73.7% of nonrespondents [P < .01]; mean certification year for respondents was 2003 compared with 2004 for nonrespondents [P < .01]). After applying the described exclusion criteria, 1662 of 12,665 respondents self-identified as hospitalists, reflecting 13.1% of the sample and the focus of this analysis (Appendix Figure).

Participant Characteristics and Areas of Practice

Of 1662 self-identified hospitalists, 881 (53.0%) also reported practicing general pediatrics, and 653 (39.3%) also reported practicing at least one subspecialty in addition to PHM. The most frequently reported additional subspecialty practice areas included: (1) neonatology (n = 155, 9.3%); (2) adolescent medicine (n = 138, 8.3%); (3) pediatric critical care (n = 89, 5.4%); (4) pediatric emergency medicine (n = 80, 4.8%); and (5) medicine-pediatrics (n = 30, 4.7%, asked only on the 2018 survey). When stratified into mutually exclusive groups, 491 respondents (29.5%) identified as practicing PHM exclusively, 518 (31.2%) identified as practicing PHM in combination with general pediatrics, and 653 (39.3%) identified as practicing PHM in combination with one or more other subspecialties.

Table 1 summarizes the characteristics of respondents in these three groups. Respondents reporting exclusive PHM practice were, on average, younger, more likely to be female, and more likely to be graduates of US medical schools than those reporting PHM in combination with general or subspecialty pediatrics. In total, approximately two-thirds of the sample (n = 1068, 64.3%) reported holding an academic appointment, including 72.9% (n = 358) of those reporting exclusive PHM practice compared with 56.9% (n = 295) of those also reporting general pediatrics and 63.6% (n = 415) of those also reporting subspecialty care (P < .001). Respondents who reported practicing PHM exclusively most frequently worked at children’s hospitals (64.6%, n = 317), compared with 40.0% (n = 207) and 42.1% (n = 275) of those practicing PHM in combination with general and subspecialty pediatrics, respectively (P < .001).

JHMVol16No11_Leyan06931117e_t1.JPG

Clinical and Nonclinical Roles and Responsibilities

The majority of respondents reported that they spent >75% of their professional time in direct clinical or consultative care, including 62.1% (n = 305) of those reporting PHM exclusively and 77.8% (n = 403) and 66.6% (n = 435) of those reporting PHM with general and subspecialty pediatrics, respectively (P < .001). Overall, <10% reported spending less than 50% of their time proving direct patient care, including 11.2% (n = 55) of those reporting exclusive PHM practice, 11.2% (n = 73) reporting PHM in combination with a subspecialty, and 6% (n = 31) in combination with general pediatrics. The mean proportion of time spent in nonclinical roles was 22.4% (SD, 20.4%), and the mean proportions of time spent in any one area (administration, research, education, or QI) were all <10%.

The proportion of time allocated to inpatient pediatric care, neonatal care, emergency care, and outpatient pediatric care varied substantially across PHM practice groups and settings. Among respondents who practiced at children’s hospitals, the median percentage of clinical time dedicated to inpatient pediatric care was 66.5% (interquartile range [IQR], 15%-100%), with neonatal care being the second most common clinical practice area (Figure, part A; Appendix Table). At community hospitals, the percentage of clinical time dedicated to inpatient pediatric care was lower, with a median of 10% (IQR, 3%-40%) (Figure, part B). Among those reporting exclusive PHM practice, the median proportion of clinical time spent delivering inpatient pediatric care was 100% (IQR, 80%-100%) at children’s hospitals and 40% (IQR, 20%-85%) at community hospitals. At community hospitals, neonatal care accounted for a similar proportion of clinical time as inpatient pediatric care for these respondents (median, 40% [IQR, 0%-70%]). With the exception of emergency room care, we observed significant differences in how clinical time was allocated by respondents reporting exclusive PHM practice compared with those reporting PHM in combination with general or specialty care (all P values < .001, Appendix Table).

JHMVol16No11_Leyan06931117e_f1.JPG

Professional Development Interests

Approximately two-thirds of respondents reported interest in QI leadership or consultation (Table 2), with those reporting exclusive PHM practice significantly more likely to report this (70.3% [n = 345] compared with 57.7% [n = 297] of those practicing PHM with general pediatrics and 66.3% [n = 431] of those practicing PHM with another subspecialty, P < .001). Similarly, 69% (n = 339) of respondents who reported exclusive PHM practice described an intention to take the PHM certifying examination, compared with 20.4% (n = 105) of those practicing PHM and general pediatrics and 17.7% (n = 115) of those practicing PHM and subspeciality pediatrics (P < .001). A total of 82.5% (n = 846) of respondents reported that they were satisfied with the allocation of their professional time; there were no significant differences between those reporting exclusive PHM practice and those reporting PHM in combination with general or subspecialty pediatrics. Of hospitalists reporting exclusive PHM practice, 67.8% (n = 166) reported an intention to maintain more than one ABP certification, compared with 22.1% (n = 78) of those practicing PHM and general pediatrics and 53.9% (n = 230) of those practicing PHM and subspecialty pediatrics (P < .001).

JHMVol16No11_Leyan06931117e_t2.JPG

In multivariate regression analyses, hospitalists reporting exclusive PHM practice had significantly greater odds of reported interest in QI leadership or consultation (adjusted odds ratio [OR], 1.39; 95% CI, 1.09-1.79), intention to take the PHM certifying exam (adjusted OR, 7.10; 95% CI, 5.45-9.25), and intention to maintain more than one ABP certification (adjusted OR, 2.64; 95% CI, 1.89-3.68) than those practicing PHM in combination with general or subspecialty pediatrics (Table 3). There was no significant difference across the three groups in the satisfaction with the allocation of professional time.

JHMVol16No11_Leyan06931117e_t3.JPG

In this national survey of pediatricians seeking MOC from the ABP, 13.1% reported that they practiced hospital medicine, with approximately one-third of these individuals reporting that they practiced PHM exclusively. The distribution of clinical and nonclinical responsibilities differed across those reporting exclusive PHM practice relative to those practicing PHM in combination with general or subspecialty pediatrics. Relative to hospitalists who reported practicing PHM in addition to general or subspecialty care, those reporting exclusive PHM practice were significantly more likely to report an interest in QI leadership or consultation, intention to sit for the PHM board-certification exam, and intention to maintain more than one ABP certification.

These findings offer insight into the evolution of PHM and have important implications for workforce planning. The last nationally representative analysis of the PHM workforce was conducted in 2006, at which time 73% of hospitalists reported working at children’s hospitals.⁶ In the current analysis, less than 50% of hospitalists reported practicing PHM at children’s hospitals only; 10% reported working at both children’s hospitals and community hospitals and 40% at community hospitals alone. This diffusion of PHM from children’s hospitals into community hospitals represents an important development in the field and aligns with the epidemiology of pediatric hospitalization.¹⁰ Pediatric hospitalists who practice at community hospitals experience unique challenges, including a relative paucity of pediatric-specific clinical resources, limited mentorship opportunities and resources for scholarly work, and limited access to data from which to prioritize QI interventions.^11,12 Our findings also illustrate that the scope of practice for hospitalists differs at community hospitals relative to children’s hospitals. Although the PHM fellowship curriculum requires training at a community hospital, the requirement is limited to one 4-week block, which may not provide sufficient preparation for the unique clinical responsibilities in this setting.^13,14

Relative to past analyses of PHM workforce roles and responsibilities, a substantially greater proportion of respondents in the current study reported clinical responsibility for neonatal care, including more than 40% of those self-reporting practicing PHM exclusively and almost three-quarters of those self-reporting PHM in conjunction with general pediatrics.^6,15 Given that more than half of the six million US pediatric hospitalizations that occur each year represent birth hospitalizations,¹⁶ pediatric hospitalists’ responsibilities for newborn care are consistent with these patterns of hospital-based care. Expanding hospitalists’ responsibilities to provide newborn care has also been shown to improve the financial performance of PHM programs with relatively low pediatric volumes, which may further explain this finding, particularly at community hospitals.^17,18 Interestingly, although emergency department care has also been demonstrated as a model to improve the financial stability of PHM programs, relatively few hospitalists reported this as an area of clinical responsibility.^19,20 This finding contrasts with past analyses and may reflect how the scope of PHM clinical responsibilities has changed since these prior studies were conducted.^6,15

Because PHM had not been recognized as a subspecialty prior to 2016, a national count of pediatric hospitalists is lacking. In this study, approximately one in eight pediatricians reported that they practiced PHM, but less than 4% of the survey sample reported practicing PHM exclusively. Based on these results, we estimate that of the 76,214 to 89,608 ABP-certified pediatricians currently practicing in the United States, between 9984 and 11,738 would self-identify as practicing PHM, with between 2945 and 3462 reporting exclusive PHM practice.

Hospitalists who reported practicing PHM exclusively were significantly more likely to report an interest in QI leadership or consultation and plans to take the PHM certifying exam. These findings are consistent with PHM’s focus on QI, as articulated in the application to the ABMS for subspecialty status as well as the PHM Core Competencies and fellowship curriculum.^4,13,21,22 Despite past research questioning the sustainability of some community- and university-based PHM programs and wide variability in workload,^7-9 more than 80% of hospitalists reported satisfaction with the allocation of their professional time, with no significant differences between respondents practicing PHM exclusively or in combination with general or subspecialty care.

This analysis should be interpreted in light of its strengths and limitations. Strengths of this work include its national focus, large sample size, and comprehensive characterization of respondents’ professional roles and characteristics. Study limitations include the fact that respondents were classified as hospitalists based on self-report; we were unable to ascertain if they were classified as hospitalists at their place of employment or if they met the ABP’s eligibility criteria to sit for the PHM subspecialty certifying exam.¹⁹ Additionally, respondents self-reported their allocations of clinical and nonclinical time, and we are unable to correlate this with actual work hours. Respondents’ reported interest in QI leadership or consultation may not be correlated with QI effort in practice; the mean time reportedly dedicated to QI activities was quite low. Additionally, two of our outcomes were available only for respondents who enrolled in MOC in 2017, and the proportion practicing medicine-pediatrics was available only in 2018. Although this analysis represents approximately 40% of all pediatricians enrolling in MOC (2 years of the 5-year MOC cycle), it may not be representative of pediatricians who are not certified by the ABP. Finally, our outcomes related to board certification examined interest and intentions; future study will be needed to determine how many pediatricians take the PHM exam and maintain certification.

In conclusion, the field of PHM has evolved considerably since its inception, with pediatric hospitalists reporting diverse clinical and nonclinical responsibilities. Hospitalists practicing PHM exclusively were more likely to report an interest in QI leadership and intent to sit for the PHM certifying exam than those practicing PHM in combination with general pediatrics or another specialty. Continuing to monitor the evolution of PHM roles and responsibilities over time and across settings will be important to support the professional development needs of the PHM workforce.

As one of the youngest fields of pediatric practice in the United States, pediatric hospital medicine (PHM) has grown rapidly over the past 2 decades. Approximately 10% of recent graduates from pediatric residency programs in the United States have entered PHM, with two-thirds reporting an intention to remain as hospitalists long term.^1,2

In October 2016, the American Board of Medical Specialties (ABMS) approved a petition for PHM to become the newest pediatric subspecialty.³ The application for subspeciality status, led by the Joint Council of Pediatric Hospital Medicine, articulated that subspecialty certification would more clearly define subspecialty hospitalists’ scope of practice, create a “new and larger cadre” of quality improvement (QI) experts, and strengthen opportunities for professional development related to child health safety within healthcare systems.⁴ Approximately 1500 pediatric hospitalists sat for the first PHM board-certification exam in November 2019, illustrating broad interest and commitment to this subspecialty.⁵

Characterizing the current responsibilities, practice settings, and professional interests of pediatric hospitalists is critical to understanding the continued development of the field. However, the most recent national survey of pediatric hospitalists’ roles and responsibilities was conducted more than a decade ago, and shared definitions of what constitutes PHM across institutions are lacking.⁶ Furthermore, studies suggest wide variability in PHM workload.^7-9 We therefore aimed to describe the characteristics, responsibilities, and practice settings of pediatricians who reported practicing PHM in the United States and determine how exclusive PHM practice, compared with PHM practice in combination with primary or subspecialty care, was associated with professional responsibilities and interests. We hypothesized that those reporting exclusive PHM practice would be more likely to report interest in QI leadership and intention to take the PHM certifying exam than those practicing PHM in combination with primary or subspecialty care.

Participants and Survey

Pediatricians enrolling in the American Board of Pediatrics (ABP) Maintenance of Certification (MOC) program in 2017 and 2018 were asked to complete a voluntary survey about their professional roles and scope of practice (Appendix Methods). The survey, offered to all MOC enrollees, included a hospital medicine module administered to those reporting PHM practice, given the ABP’s interest in characterizing PHM roles, responsibilities, practice settings, and interests in QI. Respondents were excluded if they were practicing outside of the United States, if they were unemployed or in a volunteer position, or if they were in fellowship training.

To ascertain areas of clinical practice, respondents were provided with a list of clinical practice areas and asked, “In which of the following areas are you practicing?” Those selecting “hospital medicine” were classified as self-identified hospitalists (hereafter, “hospitalists”). Given variation across institutions in physician roles and responsibilities, we stratified hospitalists into three groups: (1) exclusive PHM practice, representing those who reported PHM as their only area of practice; (2) PHM in combination with general pediatrics, representing those who reported practicing PHM and general pediatrics; and (3) PHM in combination with other subspecialties, representing those who reported practicing PHM in addition to one or more subspecialties. Respondents who reported practicing hospital medicine, general pediatrics, and another subspecialty were classified in the subspecialty group. The ABP’s institutional review board of record deemed the survey exempt from human subjects review.

Hospitalist Characteristics and Clinical Roles

To characterize respondents, we examined their age, gender, medical school location (American medical school or international medical school), and survey year (2017 or 2018). We also examined the following practice characteristics: US Census region, part-time versus full-time employment, academic appointment (yes or no), proportion of time spent providing direct and/or consultative patient care and fulfilling nonclinical responsibilities (research, administration, medical education, and QI), hospital setting (children’s hospital, community hospital, or mix of these hospital types), and work schedule type (shift schedule, on-service work in blocks, or a combination of shift and block schedules).

To examine variation in clinical roles, we determined the proportion of total direct and/or consultative clinical care that was spent in each of the following areas: (1) inpatient pediatric care, defined as inpatient general or subspecialty care in patients up to 21 years of age; (2) neonatal care, defined as labor and delivery, inpatient normal newborn care, and/or neonatal intensive care; (3) outpatient practice, defined as outpatient general or subspecialty care in patients up to 21 years of age; (4) emergency department care; and (5) other, which included pediatric intensive care as well inpatient adult care. Recognizing that scope of practice may differ at community hospitals and children’s hospitals, we stratified this analysis by practice setting (children’s hospital, community hospital).

Dependent Variables

We examined four dependent variables, two that were hypothesis driven and two that were exploratory. To test our hypothesis that respondents practicing PHM exclusively would be more likely to report interest in QI leadership or consultation (given the emphasis on QI in the ABMS application for subspecialty status), we examined the frequency with which respondents endorsed being “somewhat interested” or “very interested” in “serving as a leader or consultant for QI activities.” To test our hypothesis that respondents practicing PHM exclusively would be more likely to report plans to take the PHM certifying exam, we noted the frequency with which respondents reported “yes” to the question, “Do you plan to take a certifying exam in hospitalist medicine when it becomes available?” As an exploratory outcome, we examined satisfaction with allocation of professional time, available on the 2017 survey only; satisfaction was defined as an affirmative response to the question, “Is the allocation of your total professional time approximately what you wanted in your current position?” Finally, intention to maintain more than one ABP certification, also reported only in 2017 and examined as an exploratory outcome, was defined as a reported intention to maintain more than one ABP certification, including general pediatrics, PHM, or any other subspecialty.

Statistical Analysis

We used chi-square tests and analysis of variance as appropriate to examine differences in sociodemographic and professional characteristics among respondents who reported exclusive PHM practice, PHM in combination with general pediatrics, and PHM in combination with another subspecialty. To examine differences across the three PHM groups in their allocation of time to various clinical responsibilities (eg, inpatient care, newborn care), we used Kruskal-Wallis equality-of-population rank tests, stratifying by hospital type. We used multivariable logistic regression to identify associations between exclusive PHM practice and our four dependent variables, adjusting for the sociodemographic and professional characteristics described above. All analyses were conducted using Stata 15 (StataCorp LLC), using two-sided tests, and defining P < .05 as statistically significant.

Study Sample

Of the 19,763 pediatricians enrolling in MOC in 2017 and 2018, 13,839 responded the survey, representing a response rate of 70.0%. There were no significant differences between survey respondents and nonrespondents with respect to gender; differences between respondents and nonrespondents in age, medical school location, and initial year of ABP certification year were small (mean age, 48.1 years and 47.1 years, respectively [P < .01]; 77.0% of respondents were graduates of US medical schools compared with 73.7% of nonrespondents [P < .01]; mean certification year for respondents was 2003 compared with 2004 for nonrespondents [P < .01]). After applying the described exclusion criteria, 1662 of 12,665 respondents self-identified as hospitalists, reflecting 13.1% of the sample and the focus of this analysis (Appendix Figure).

Participant Characteristics and Areas of Practice

Of 1662 self-identified hospitalists, 881 (53.0%) also reported practicing general pediatrics, and 653 (39.3%) also reported practicing at least one subspecialty in addition to PHM. The most frequently reported additional subspecialty practice areas included: (1) neonatology (n = 155, 9.3%); (2) adolescent medicine (n = 138, 8.3%); (3) pediatric critical care (n = 89, 5.4%); (4) pediatric emergency medicine (n = 80, 4.8%); and (5) medicine-pediatrics (n = 30, 4.7%, asked only on the 2018 survey). When stratified into mutually exclusive groups, 491 respondents (29.5%) identified as practicing PHM exclusively, 518 (31.2%) identified as practicing PHM in combination with general pediatrics, and 653 (39.3%) identified as practicing PHM in combination with one or more other subspecialties.

Table 1 summarizes the characteristics of respondents in these three groups. Respondents reporting exclusive PHM practice were, on average, younger, more likely to be female, and more likely to be graduates of US medical schools than those reporting PHM in combination with general or subspecialty pediatrics. In total, approximately two-thirds of the sample (n = 1068, 64.3%) reported holding an academic appointment, including 72.9% (n = 358) of those reporting exclusive PHM practice compared with 56.9% (n = 295) of those also reporting general pediatrics and 63.6% (n = 415) of those also reporting subspecialty care (P < .001). Respondents who reported practicing PHM exclusively most frequently worked at children’s hospitals (64.6%, n = 317), compared with 40.0% (n = 207) and 42.1% (n = 275) of those practicing PHM in combination with general and subspecialty pediatrics, respectively (P < .001).

JHMVol16No11_Leyan06931117e_t1.JPG

Clinical and Nonclinical Roles and Responsibilities

The majority of respondents reported that they spent >75% of their professional time in direct clinical or consultative care, including 62.1% (n = 305) of those reporting PHM exclusively and 77.8% (n = 403) and 66.6% (n = 435) of those reporting PHM with general and subspecialty pediatrics, respectively (P < .001). Overall, <10% reported spending less than 50% of their time proving direct patient care, including 11.2% (n = 55) of those reporting exclusive PHM practice, 11.2% (n = 73) reporting PHM in combination with a subspecialty, and 6% (n = 31) in combination with general pediatrics. The mean proportion of time spent in nonclinical roles was 22.4% (SD, 20.4%), and the mean proportions of time spent in any one area (administration, research, education, or QI) were all <10%.

The proportion of time allocated to inpatient pediatric care, neonatal care, emergency care, and outpatient pediatric care varied substantially across PHM practice groups and settings. Among respondents who practiced at children’s hospitals, the median percentage of clinical time dedicated to inpatient pediatric care was 66.5% (interquartile range [IQR], 15%-100%), with neonatal care being the second most common clinical practice area (Figure, part A; Appendix Table). At community hospitals, the percentage of clinical time dedicated to inpatient pediatric care was lower, with a median of 10% (IQR, 3%-40%) (Figure, part B). Among those reporting exclusive PHM practice, the median proportion of clinical time spent delivering inpatient pediatric care was 100% (IQR, 80%-100%) at children’s hospitals and 40% (IQR, 20%-85%) at community hospitals. At community hospitals, neonatal care accounted for a similar proportion of clinical time as inpatient pediatric care for these respondents (median, 40% [IQR, 0%-70%]). With the exception of emergency room care, we observed significant differences in how clinical time was allocated by respondents reporting exclusive PHM practice compared with those reporting PHM in combination with general or specialty care (all P values < .001, Appendix Table).

JHMVol16No11_Leyan06931117e_f1.JPG

Professional Development Interests

Approximately two-thirds of respondents reported interest in QI leadership or consultation (Table 2), with those reporting exclusive PHM practice significantly more likely to report this (70.3% [n = 345] compared with 57.7% [n = 297] of those practicing PHM with general pediatrics and 66.3% [n = 431] of those practicing PHM with another subspecialty, P < .001). Similarly, 69% (n = 339) of respondents who reported exclusive PHM practice described an intention to take the PHM certifying examination, compared with 20.4% (n = 105) of those practicing PHM and general pediatrics and 17.7% (n = 115) of those practicing PHM and subspeciality pediatrics (P < .001). A total of 82.5% (n = 846) of respondents reported that they were satisfied with the allocation of their professional time; there were no significant differences between those reporting exclusive PHM practice and those reporting PHM in combination with general or subspecialty pediatrics. Of hospitalists reporting exclusive PHM practice, 67.8% (n = 166) reported an intention to maintain more than one ABP certification, compared with 22.1% (n = 78) of those practicing PHM and general pediatrics and 53.9% (n = 230) of those practicing PHM and subspecialty pediatrics (P < .001).

JHMVol16No11_Leyan06931117e_t2.JPG

In multivariate regression analyses, hospitalists reporting exclusive PHM practice had significantly greater odds of reported interest in QI leadership or consultation (adjusted odds ratio [OR], 1.39; 95% CI, 1.09-1.79), intention to take the PHM certifying exam (adjusted OR, 7.10; 95% CI, 5.45-9.25), and intention to maintain more than one ABP certification (adjusted OR, 2.64; 95% CI, 1.89-3.68) than those practicing PHM in combination with general or subspecialty pediatrics (Table 3). There was no significant difference across the three groups in the satisfaction with the allocation of professional time.

JHMVol16No11_Leyan06931117e_t3.JPG

In this national survey of pediatricians seeking MOC from the ABP, 13.1% reported that they practiced hospital medicine, with approximately one-third of these individuals reporting that they practiced PHM exclusively. The distribution of clinical and nonclinical responsibilities differed across those reporting exclusive PHM practice relative to those practicing PHM in combination with general or subspecialty pediatrics. Relative to hospitalists who reported practicing PHM in addition to general or subspecialty care, those reporting exclusive PHM practice were significantly more likely to report an interest in QI leadership or consultation, intention to sit for the PHM board-certification exam, and intention to maintain more than one ABP certification.

These findings offer insight into the evolution of PHM and have important implications for workforce planning. The last nationally representative analysis of the PHM workforce was conducted in 2006, at which time 73% of hospitalists reported working at children’s hospitals.⁶ In the current analysis, less than 50% of hospitalists reported practicing PHM at children’s hospitals only; 10% reported working at both children’s hospitals and community hospitals and 40% at community hospitals alone. This diffusion of PHM from children’s hospitals into community hospitals represents an important development in the field and aligns with the epidemiology of pediatric hospitalization.¹⁰ Pediatric hospitalists who practice at community hospitals experience unique challenges, including a relative paucity of pediatric-specific clinical resources, limited mentorship opportunities and resources for scholarly work, and limited access to data from which to prioritize QI interventions.^11,12 Our findings also illustrate that the scope of practice for hospitalists differs at community hospitals relative to children’s hospitals. Although the PHM fellowship curriculum requires training at a community hospital, the requirement is limited to one 4-week block, which may not provide sufficient preparation for the unique clinical responsibilities in this setting.^13,14

Relative to past analyses of PHM workforce roles and responsibilities, a substantially greater proportion of respondents in the current study reported clinical responsibility for neonatal care, including more than 40% of those self-reporting practicing PHM exclusively and almost three-quarters of those self-reporting PHM in conjunction with general pediatrics.^6,15 Given that more than half of the six million US pediatric hospitalizations that occur each year represent birth hospitalizations,¹⁶ pediatric hospitalists’ responsibilities for newborn care are consistent with these patterns of hospital-based care. Expanding hospitalists’ responsibilities to provide newborn care has also been shown to improve the financial performance of PHM programs with relatively low pediatric volumes, which may further explain this finding, particularly at community hospitals.^17,18 Interestingly, although emergency department care has also been demonstrated as a model to improve the financial stability of PHM programs, relatively few hospitalists reported this as an area of clinical responsibility.^19,20 This finding contrasts with past analyses and may reflect how the scope of PHM clinical responsibilities has changed since these prior studies were conducted.^6,15

Because PHM had not been recognized as a subspecialty prior to 2016, a national count of pediatric hospitalists is lacking. In this study, approximately one in eight pediatricians reported that they practiced PHM, but less than 4% of the survey sample reported practicing PHM exclusively. Based on these results, we estimate that of the 76,214 to 89,608 ABP-certified pediatricians currently practicing in the United States, between 9984 and 11,738 would self-identify as practicing PHM, with between 2945 and 3462 reporting exclusive PHM practice.

Hospitalists who reported practicing PHM exclusively were significantly more likely to report an interest in QI leadership or consultation and plans to take the PHM certifying exam. These findings are consistent with PHM’s focus on QI, as articulated in the application to the ABMS for subspecialty status as well as the PHM Core Competencies and fellowship curriculum.^4,13,21,22 Despite past research questioning the sustainability of some community- and university-based PHM programs and wide variability in workload,^7-9 more than 80% of hospitalists reported satisfaction with the allocation of their professional time, with no significant differences between respondents practicing PHM exclusively or in combination with general or subspecialty care.

This analysis should be interpreted in light of its strengths and limitations. Strengths of this work include its national focus, large sample size, and comprehensive characterization of respondents’ professional roles and characteristics. Study limitations include the fact that respondents were classified as hospitalists based on self-report; we were unable to ascertain if they were classified as hospitalists at their place of employment or if they met the ABP’s eligibility criteria to sit for the PHM subspecialty certifying exam.¹⁹ Additionally, respondents self-reported their allocations of clinical and nonclinical time, and we are unable to correlate this with actual work hours. Respondents’ reported interest in QI leadership or consultation may not be correlated with QI effort in practice; the mean time reportedly dedicated to QI activities was quite low. Additionally, two of our outcomes were available only for respondents who enrolled in MOC in 2017, and the proportion practicing medicine-pediatrics was available only in 2018. Although this analysis represents approximately 40% of all pediatricians enrolling in MOC (2 years of the 5-year MOC cycle), it may not be representative of pediatricians who are not certified by the ABP. Finally, our outcomes related to board certification examined interest and intentions; future study will be needed to determine how many pediatricians take the PHM exam and maintain certification.

In conclusion, the field of PHM has evolved considerably since its inception, with pediatric hospitalists reporting diverse clinical and nonclinical responsibilities. Hospitalists practicing PHM exclusively were more likely to report an interest in QI leadership and intent to sit for the PHM certifying exam than those practicing PHM in combination with general pediatrics or another specialty. Continuing to monitor the evolution of PHM roles and responsibilities over time and across settings will be important to support the professional development needs of the PHM workforce.

As one of the youngest fields of pediatric practice in the United States, pediatric hospital medicine (PHM) has grown rapidly over the past 2 decades. Approximately 10% of recent graduates from pediatric residency programs in the United States have entered PHM, with two-thirds reporting an intention to remain as hospitalists long term.^1,2

In October 2016, the American Board of Medical Specialties (ABMS) approved a petition for PHM to become the newest pediatric subspecialty.³ The application for subspeciality status, led by the Joint Council of Pediatric Hospital Medicine, articulated that subspecialty certification would more clearly define subspecialty hospitalists’ scope of practice, create a “new and larger cadre” of quality improvement (QI) experts, and strengthen opportunities for professional development related to child health safety within healthcare systems.⁴ Approximately 1500 pediatric hospitalists sat for the first PHM board-certification exam in November 2019, illustrating broad interest and commitment to this subspecialty.⁵

Characterizing the current responsibilities, practice settings, and professional interests of pediatric hospitalists is critical to understanding the continued development of the field. However, the most recent national survey of pediatric hospitalists’ roles and responsibilities was conducted more than a decade ago, and shared definitions of what constitutes PHM across institutions are lacking.⁶ Furthermore, studies suggest wide variability in PHM workload.^7-9 We therefore aimed to describe the characteristics, responsibilities, and practice settings of pediatricians who reported practicing PHM in the United States and determine how exclusive PHM practice, compared with PHM practice in combination with primary or subspecialty care, was associated with professional responsibilities and interests. We hypothesized that those reporting exclusive PHM practice would be more likely to report interest in QI leadership and intention to take the PHM certifying exam than those practicing PHM in combination with primary or subspecialty care.

Participants and Survey

Pediatricians enrolling in the American Board of Pediatrics (ABP) Maintenance of Certification (MOC) program in 2017 and 2018 were asked to complete a voluntary survey about their professional roles and scope of practice (Appendix Methods). The survey, offered to all MOC enrollees, included a hospital medicine module administered to those reporting PHM practice, given the ABP’s interest in characterizing PHM roles, responsibilities, practice settings, and interests in QI. Respondents were excluded if they were practicing outside of the United States, if they were unemployed or in a volunteer position, or if they were in fellowship training.

To ascertain areas of clinical practice, respondents were provided with a list of clinical practice areas and asked, “In which of the following areas are you practicing?” Those selecting “hospital medicine” were classified as self-identified hospitalists (hereafter, “hospitalists”). Given variation across institutions in physician roles and responsibilities, we stratified hospitalists into three groups: (1) exclusive PHM practice, representing those who reported PHM as their only area of practice; (2) PHM in combination with general pediatrics, representing those who reported practicing PHM and general pediatrics; and (3) PHM in combination with other subspecialties, representing those who reported practicing PHM in addition to one or more subspecialties. Respondents who reported practicing hospital medicine, general pediatrics, and another subspecialty were classified in the subspecialty group. The ABP’s institutional review board of record deemed the survey exempt from human subjects review.

Hospitalist Characteristics and Clinical Roles

To characterize respondents, we examined their age, gender, medical school location (American medical school or international medical school), and survey year (2017 or 2018). We also examined the following practice characteristics: US Census region, part-time versus full-time employment, academic appointment (yes or no), proportion of time spent providing direct and/or consultative patient care and fulfilling nonclinical responsibilities (research, administration, medical education, and QI), hospital setting (children’s hospital, community hospital, or mix of these hospital types), and work schedule type (shift schedule, on-service work in blocks, or a combination of shift and block schedules).

To examine variation in clinical roles, we determined the proportion of total direct and/or consultative clinical care that was spent in each of the following areas: (1) inpatient pediatric care, defined as inpatient general or subspecialty care in patients up to 21 years of age; (2) neonatal care, defined as labor and delivery, inpatient normal newborn care, and/or neonatal intensive care; (3) outpatient practice, defined as outpatient general or subspecialty care in patients up to 21 years of age; (4) emergency department care; and (5) other, which included pediatric intensive care as well inpatient adult care. Recognizing that scope of practice may differ at community hospitals and children’s hospitals, we stratified this analysis by practice setting (children’s hospital, community hospital).

Dependent Variables

We examined four dependent variables, two that were hypothesis driven and two that were exploratory. To test our hypothesis that respondents practicing PHM exclusively would be more likely to report interest in QI leadership or consultation (given the emphasis on QI in the ABMS application for subspecialty status), we examined the frequency with which respondents endorsed being “somewhat interested” or “very interested” in “serving as a leader or consultant for QI activities.” To test our hypothesis that respondents practicing PHM exclusively would be more likely to report plans to take the PHM certifying exam, we noted the frequency with which respondents reported “yes” to the question, “Do you plan to take a certifying exam in hospitalist medicine when it becomes available?” As an exploratory outcome, we examined satisfaction with allocation of professional time, available on the 2017 survey only; satisfaction was defined as an affirmative response to the question, “Is the allocation of your total professional time approximately what you wanted in your current position?” Finally, intention to maintain more than one ABP certification, also reported only in 2017 and examined as an exploratory outcome, was defined as a reported intention to maintain more than one ABP certification, including general pediatrics, PHM, or any other subspecialty.

Statistical Analysis

We used chi-square tests and analysis of variance as appropriate to examine differences in sociodemographic and professional characteristics among respondents who reported exclusive PHM practice, PHM in combination with general pediatrics, and PHM in combination with another subspecialty. To examine differences across the three PHM groups in their allocation of time to various clinical responsibilities (eg, inpatient care, newborn care), we used Kruskal-Wallis equality-of-population rank tests, stratifying by hospital type. We used multivariable logistic regression to identify associations between exclusive PHM practice and our four dependent variables, adjusting for the sociodemographic and professional characteristics described above. All analyses were conducted using Stata 15 (StataCorp LLC), using two-sided tests, and defining P < .05 as statistically significant.

Study Sample

Of the 19,763 pediatricians enrolling in MOC in 2017 and 2018, 13,839 responded the survey, representing a response rate of 70.0%. There were no significant differences between survey respondents and nonrespondents with respect to gender; differences between respondents and nonrespondents in age, medical school location, and initial year of ABP certification year were small (mean age, 48.1 years and 47.1 years, respectively [P < .01]; 77.0% of respondents were graduates of US medical schools compared with 73.7% of nonrespondents [P < .01]; mean certification year for respondents was 2003 compared with 2004 for nonrespondents [P < .01]). After applying the described exclusion criteria, 1662 of 12,665 respondents self-identified as hospitalists, reflecting 13.1% of the sample and the focus of this analysis (Appendix Figure).

Participant Characteristics and Areas of Practice

Of 1662 self-identified hospitalists, 881 (53.0%) also reported practicing general pediatrics, and 653 (39.3%) also reported practicing at least one subspecialty in addition to PHM. The most frequently reported additional subspecialty practice areas included: (1) neonatology (n = 155, 9.3%); (2) adolescent medicine (n = 138, 8.3%); (3) pediatric critical care (n = 89, 5.4%); (4) pediatric emergency medicine (n = 80, 4.8%); and (5) medicine-pediatrics (n = 30, 4.7%, asked only on the 2018 survey). When stratified into mutually exclusive groups, 491 respondents (29.5%) identified as practicing PHM exclusively, 518 (31.2%) identified as practicing PHM in combination with general pediatrics, and 653 (39.3%) identified as practicing PHM in combination with one or more other subspecialties.

Table 1 summarizes the characteristics of respondents in these three groups. Respondents reporting exclusive PHM practice were, on average, younger, more likely to be female, and more likely to be graduates of US medical schools than those reporting PHM in combination with general or subspecialty pediatrics. In total, approximately two-thirds of the sample (n = 1068, 64.3%) reported holding an academic appointment, including 72.9% (n = 358) of those reporting exclusive PHM practice compared with 56.9% (n = 295) of those also reporting general pediatrics and 63.6% (n = 415) of those also reporting subspecialty care (P < .001). Respondents who reported practicing PHM exclusively most frequently worked at children’s hospitals (64.6%, n = 317), compared with 40.0% (n = 207) and 42.1% (n = 275) of those practicing PHM in combination with general and subspecialty pediatrics, respectively (P < .001).

JHMVol16No11_Leyan06931117e_t1.JPG

Clinical and Nonclinical Roles and Responsibilities

The majority of respondents reported that they spent >75% of their professional time in direct clinical or consultative care, including 62.1% (n = 305) of those reporting PHM exclusively and 77.8% (n = 403) and 66.6% (n = 435) of those reporting PHM with general and subspecialty pediatrics, respectively (P < .001). Overall, <10% reported spending less than 50% of their time proving direct patient care, including 11.2% (n = 55) of those reporting exclusive PHM practice, 11.2% (n = 73) reporting PHM in combination with a subspecialty, and 6% (n = 31) in combination with general pediatrics. The mean proportion of time spent in nonclinical roles was 22.4% (SD, 20.4%), and the mean proportions of time spent in any one area (administration, research, education, or QI) were all <10%.

The proportion of time allocated to inpatient pediatric care, neonatal care, emergency care, and outpatient pediatric care varied substantially across PHM practice groups and settings. Among respondents who practiced at children’s hospitals, the median percentage of clinical time dedicated to inpatient pediatric care was 66.5% (interquartile range [IQR], 15%-100%), with neonatal care being the second most common clinical practice area (Figure, part A; Appendix Table). At community hospitals, the percentage of clinical time dedicated to inpatient pediatric care was lower, with a median of 10% (IQR, 3%-40%) (Figure, part B). Among those reporting exclusive PHM practice, the median proportion of clinical time spent delivering inpatient pediatric care was 100% (IQR, 80%-100%) at children’s hospitals and 40% (IQR, 20%-85%) at community hospitals. At community hospitals, neonatal care accounted for a similar proportion of clinical time as inpatient pediatric care for these respondents (median, 40% [IQR, 0%-70%]). With the exception of emergency room care, we observed significant differences in how clinical time was allocated by respondents reporting exclusive PHM practice compared with those reporting PHM in combination with general or specialty care (all P values < .001, Appendix Table).

JHMVol16No11_Leyan06931117e_f1.JPG

Professional Development Interests

Approximately two-thirds of respondents reported interest in QI leadership or consultation (Table 2), with those reporting exclusive PHM practice significantly more likely to report this (70.3% [n = 345] compared with 57.7% [n = 297] of those practicing PHM with general pediatrics and 66.3% [n = 431] of those practicing PHM with another subspecialty, P < .001). Similarly, 69% (n = 339) of respondents who reported exclusive PHM practice described an intention to take the PHM certifying examination, compared with 20.4% (n = 105) of those practicing PHM and general pediatrics and 17.7% (n = 115) of those practicing PHM and subspeciality pediatrics (P < .001). A total of 82.5% (n = 846) of respondents reported that they were satisfied with the allocation of their professional time; there were no significant differences between those reporting exclusive PHM practice and those reporting PHM in combination with general or subspecialty pediatrics. Of hospitalists reporting exclusive PHM practice, 67.8% (n = 166) reported an intention to maintain more than one ABP certification, compared with 22.1% (n = 78) of those practicing PHM and general pediatrics and 53.9% (n = 230) of those practicing PHM and subspecialty pediatrics (P < .001).

JHMVol16No11_Leyan06931117e_t2.JPG

In multivariate regression analyses, hospitalists reporting exclusive PHM practice had significantly greater odds of reported interest in QI leadership or consultation (adjusted odds ratio [OR], 1.39; 95% CI, 1.09-1.79), intention to take the PHM certifying exam (adjusted OR, 7.10; 95% CI, 5.45-9.25), and intention to maintain more than one ABP certification (adjusted OR, 2.64; 95% CI, 1.89-3.68) than those practicing PHM in combination with general or subspecialty pediatrics (Table 3). There was no significant difference across the three groups in the satisfaction with the allocation of professional time.

JHMVol16No11_Leyan06931117e_t3.JPG

In this national survey of pediatricians seeking MOC from the ABP, 13.1% reported that they practiced hospital medicine, with approximately one-third of these individuals reporting that they practiced PHM exclusively. The distribution of clinical and nonclinical responsibilities differed across those reporting exclusive PHM practice relative to those practicing PHM in combination with general or subspecialty pediatrics. Relative to hospitalists who reported practicing PHM in addition to general or subspecialty care, those reporting exclusive PHM practice were significantly more likely to report an interest in QI leadership or consultation, intention to sit for the PHM board-certification exam, and intention to maintain more than one ABP certification.

These findings offer insight into the evolution of PHM and have important implications for workforce planning. The last nationally representative analysis of the PHM workforce was conducted in 2006, at which time 73% of hospitalists reported working at children’s hospitals.⁶ In the current analysis, less than 50% of hospitalists reported practicing PHM at children’s hospitals only; 10% reported working at both children’s hospitals and community hospitals and 40% at community hospitals alone. This diffusion of PHM from children’s hospitals into community hospitals represents an important development in the field and aligns with the epidemiology of pediatric hospitalization.¹⁰ Pediatric hospitalists who practice at community hospitals experience unique challenges, including a relative paucity of pediatric-specific clinical resources, limited mentorship opportunities and resources for scholarly work, and limited access to data from which to prioritize QI interventions.^11,12 Our findings also illustrate that the scope of practice for hospitalists differs at community hospitals relative to children’s hospitals. Although the PHM fellowship curriculum requires training at a community hospital, the requirement is limited to one 4-week block, which may not provide sufficient preparation for the unique clinical responsibilities in this setting.^13,14

Relative to past analyses of PHM workforce roles and responsibilities, a substantially greater proportion of respondents in the current study reported clinical responsibility for neonatal care, including more than 40% of those self-reporting practicing PHM exclusively and almost three-quarters of those self-reporting PHM in conjunction with general pediatrics.^6,15 Given that more than half of the six million US pediatric hospitalizations that occur each year represent birth hospitalizations,¹⁶ pediatric hospitalists’ responsibilities for newborn care are consistent with these patterns of hospital-based care. Expanding hospitalists’ responsibilities to provide newborn care has also been shown to improve the financial performance of PHM programs with relatively low pediatric volumes, which may further explain this finding, particularly at community hospitals.^17,18 Interestingly, although emergency department care has also been demonstrated as a model to improve the financial stability of PHM programs, relatively few hospitalists reported this as an area of clinical responsibility.^19,20 This finding contrasts with past analyses and may reflect how the scope of PHM clinical responsibilities has changed since these prior studies were conducted.^6,15

Because PHM had not been recognized as a subspecialty prior to 2016, a national count of pediatric hospitalists is lacking. In this study, approximately one in eight pediatricians reported that they practiced PHM, but less than 4% of the survey sample reported practicing PHM exclusively. Based on these results, we estimate that of the 76,214 to 89,608 ABP-certified pediatricians currently practicing in the United States, between 9984 and 11,738 would self-identify as practicing PHM, with between 2945 and 3462 reporting exclusive PHM practice.

Hospitalists who reported practicing PHM exclusively were significantly more likely to report an interest in QI leadership or consultation and plans to take the PHM certifying exam. These findings are consistent with PHM’s focus on QI, as articulated in the application to the ABMS for subspecialty status as well as the PHM Core Competencies and fellowship curriculum.^4,13,21,22 Despite past research questioning the sustainability of some community- and university-based PHM programs and wide variability in workload,^7-9 more than 80% of hospitalists reported satisfaction with the allocation of their professional time, with no significant differences between respondents practicing PHM exclusively or in combination with general or subspecialty care.

This analysis should be interpreted in light of its strengths and limitations. Strengths of this work include its national focus, large sample size, and comprehensive characterization of respondents’ professional roles and characteristics. Study limitations include the fact that respondents were classified as hospitalists based on self-report; we were unable to ascertain if they were classified as hospitalists at their place of employment or if they met the ABP’s eligibility criteria to sit for the PHM subspecialty certifying exam.¹⁹ Additionally, respondents self-reported their allocations of clinical and nonclinical time, and we are unable to correlate this with actual work hours. Respondents’ reported interest in QI leadership or consultation may not be correlated with QI effort in practice; the mean time reportedly dedicated to QI activities was quite low. Additionally, two of our outcomes were available only for respondents who enrolled in MOC in 2017, and the proportion practicing medicine-pediatrics was available only in 2018. Although this analysis represents approximately 40% of all pediatricians enrolling in MOC (2 years of the 5-year MOC cycle), it may not be representative of pediatricians who are not certified by the ABP. Finally, our outcomes related to board certification examined interest and intentions; future study will be needed to determine how many pediatricians take the PHM exam and maintain certification.

In conclusion, the field of PHM has evolved considerably since its inception, with pediatric hospitalists reporting diverse clinical and nonclinical responsibilities. Hospitalists practicing PHM exclusively were more likely to report an interest in QI leadership and intent to sit for the PHM certifying exam than those practicing PHM in combination with general pediatrics or another specialty. Continuing to monitor the evolution of PHM roles and responsibilities over time and across settings will be important to support the professional development needs of the PHM workforce.

Children with medical complexity account for 30% of pediatric hospitalizations and half of all pediatric hospital costs.¹ They frequently experience long lengths of stay (LOS), which are associated with hospital-acquired infections, high costs, and family stress.

In this issue of the Journal of Hospital Medicine, Steuart and colleagues investigate one opportunity to decrease LOS in a subset of children with medical complexity by studying the impact of discharge before patients’ return to their respiratory baseline status.² They examined 632 hospitalizations in children with neurologic impairment who required increased respiratory support for acute respiratory infections. After adjustment for demographic characteristics, clinical complexity, and acute illness severity, there was no difference in the risk of 30-day hospital reutilization (ie, emergency department revisits and readmissions) when comparing the 30% of children discharged before returning to their respiratory baseline with the 70% discharged at baseline (reutilization rates of 32.8% and 31.8%, respectively).

Twenty-six percent required readmission. This rate is four times that reported for children overall, and higher than the rate for children with the top 10 chronic conditions (range, 6%-21%).³ It also exceeds the median 30-day risk-standardized readmission rates for adult conditions targeted by the Centers for Medicare & Medicaid Services (range, 12%-22%).⁴ The high readmission rate demonstrates the vulnerability of this population and their need for support in hospital-to-home transitions.

These results suggest important areas for future research. First, the findings need to be replicated by multicenter studies to better understand their generalizability. Second, we need more information about the respiratory support required at discharge, which was not captured in this study. For example, clinicians and families may be more comfortable with discharge for a patient who needs slightly higher levels of their baseline support rather than a new modality of respiratory support. Third, we need to better understand the home context of patients discharged before return to respiratory baseline. Lack of home nursing, in particular, has been associated with discharge delays and prolonged LOS in this population.

This study prompts reconsideration of discharge criteria for acute respiratory infections, which often include return to respiratory baseline. Discharge before respiratory baseline for healthy children with bronchiolitis who were discharged on home supplemental oxygen has been associated with shorter hospitalizations and lower costs without differences in reutilization.⁵ Steuart and colleagues demonstrate the potential of this approach in children with neurologic impairment. One key question remains: Which children are most appropriate for discharge before return to respiratory baseline? Family engagement in discussions of goals of hospitalization, self-efficacy, and discharge readiness are important.⁶ These conversations provide context that informs discharge decisions. If the patient is stable and both the medical team and family are comfortable with discharge before respiratory baseline, there may be opportunities to engage in shared decision-making around discharge criteria.

The vulnerability of this population, evidenced by their high rates of readmission, reinforces the importance of family engagement, understanding these children’s diverse needs, and further research to identify effective interventions to support safe transitions from hospital to home.

Children with medical complexity account for 30% of pediatric hospitalizations and half of all pediatric hospital costs.¹ They frequently experience long lengths of stay (LOS), which are associated with hospital-acquired infections, high costs, and family stress.

In this issue of the Journal of Hospital Medicine, Steuart and colleagues investigate one opportunity to decrease LOS in a subset of children with medical complexity by studying the impact of discharge before patients’ return to their respiratory baseline status.² They examined 632 hospitalizations in children with neurologic impairment who required increased respiratory support for acute respiratory infections. After adjustment for demographic characteristics, clinical complexity, and acute illness severity, there was no difference in the risk of 30-day hospital reutilization (ie, emergency department revisits and readmissions) when comparing the 30% of children discharged before returning to their respiratory baseline with the 70% discharged at baseline (reutilization rates of 32.8% and 31.8%, respectively).

Twenty-six percent required readmission. This rate is four times that reported for children overall, and higher than the rate for children with the top 10 chronic conditions (range, 6%-21%).³ It also exceeds the median 30-day risk-standardized readmission rates for adult conditions targeted by the Centers for Medicare & Medicaid Services (range, 12%-22%).⁴ The high readmission rate demonstrates the vulnerability of this population and their need for support in hospital-to-home transitions.

These results suggest important areas for future research. First, the findings need to be replicated by multicenter studies to better understand their generalizability. Second, we need more information about the respiratory support required at discharge, which was not captured in this study. For example, clinicians and families may be more comfortable with discharge for a patient who needs slightly higher levels of their baseline support rather than a new modality of respiratory support. Third, we need to better understand the home context of patients discharged before return to respiratory baseline. Lack of home nursing, in particular, has been associated with discharge delays and prolonged LOS in this population.

This study prompts reconsideration of discharge criteria for acute respiratory infections, which often include return to respiratory baseline. Discharge before respiratory baseline for healthy children with bronchiolitis who were discharged on home supplemental oxygen has been associated with shorter hospitalizations and lower costs without differences in reutilization.⁵ Steuart and colleagues demonstrate the potential of this approach in children with neurologic impairment. One key question remains: Which children are most appropriate for discharge before return to respiratory baseline? Family engagement in discussions of goals of hospitalization, self-efficacy, and discharge readiness are important.⁶ These conversations provide context that informs discharge decisions. If the patient is stable and both the medical team and family are comfortable with discharge before respiratory baseline, there may be opportunities to engage in shared decision-making around discharge criteria.

The vulnerability of this population, evidenced by their high rates of readmission, reinforces the importance of family engagement, understanding these children’s diverse needs, and further research to identify effective interventions to support safe transitions from hospital to home.

Children with medical complexity account for 30% of pediatric hospitalizations and half of all pediatric hospital costs.¹ They frequently experience long lengths of stay (LOS), which are associated with hospital-acquired infections, high costs, and family stress.

In this issue of the Journal of Hospital Medicine, Steuart and colleagues investigate one opportunity to decrease LOS in a subset of children with medical complexity by studying the impact of discharge before patients’ return to their respiratory baseline status.² They examined 632 hospitalizations in children with neurologic impairment who required increased respiratory support for acute respiratory infections. After adjustment for demographic characteristics, clinical complexity, and acute illness severity, there was no difference in the risk of 30-day hospital reutilization (ie, emergency department revisits and readmissions) when comparing the 30% of children discharged before returning to their respiratory baseline with the 70% discharged at baseline (reutilization rates of 32.8% and 31.8%, respectively).

Twenty-six percent required readmission. This rate is four times that reported for children overall, and higher than the rate for children with the top 10 chronic conditions (range, 6%-21%).³ It also exceeds the median 30-day risk-standardized readmission rates for adult conditions targeted by the Centers for Medicare & Medicaid Services (range, 12%-22%).⁴ The high readmission rate demonstrates the vulnerability of this population and their need for support in hospital-to-home transitions.

These results suggest important areas for future research. First, the findings need to be replicated by multicenter studies to better understand their generalizability. Second, we need more information about the respiratory support required at discharge, which was not captured in this study. For example, clinicians and families may be more comfortable with discharge for a patient who needs slightly higher levels of their baseline support rather than a new modality of respiratory support. Third, we need to better understand the home context of patients discharged before return to respiratory baseline. Lack of home nursing, in particular, has been associated with discharge delays and prolonged LOS in this population.

This study prompts reconsideration of discharge criteria for acute respiratory infections, which often include return to respiratory baseline. Discharge before respiratory baseline for healthy children with bronchiolitis who were discharged on home supplemental oxygen has been associated with shorter hospitalizations and lower costs without differences in reutilization.⁵ Steuart and colleagues demonstrate the potential of this approach in children with neurologic impairment. One key question remains: Which children are most appropriate for discharge before return to respiratory baseline? Family engagement in discussions of goals of hospitalization, self-efficacy, and discharge readiness are important.⁶ These conversations provide context that informs discharge decisions. If the patient is stable and both the medical team and family are comfortable with discharge before respiratory baseline, there may be opportunities to engage in shared decision-making around discharge criteria.

The vulnerability of this population, evidenced by their high rates of readmission, reinforces the importance of family engagement, understanding these children’s diverse needs, and further research to identify effective interventions to support safe transitions from hospital to home.

Pediatric hospital medicine (PHM) is in the midst of an exciting period of growth. In 2016, the American Board of Medical Specialties approved the petition for PHM to become the newest pediatric subspecialty, taking PHM on a divergent path from the Focused Practice in Hospital Medicine designation established for adult hospitalists. Establishment as a subspecialty has allowed PHM to define the unique skills and qualifications that hospitalists bring to patients and the healthcare system. These skills and qualifications are delineated in the PHM core competencies and national fellowship curriculum.^1,2 In order to realize the vision of PHM to improve care for hospitalized children described by Roberts et al.,³ concerted efforts are needed to train and retain a workforce that is equipped with the skills to catalyze improvements in inpatient pediatric care. We discuss challenges and opportunities facing PHM in workforce development, sustainability of clinical work models, and interhospital collaboration.

The development of PHM as a subspecialty was driven by a number of factors.⁴ The acuity of hospitalized children has increased significantly, with a population comprised of more children with complex chronic conditions and/or technology dependence, serious complications of acute conditions, and acute mental health problems. At the same time, the medical and behavioral conditions seen by outpatient general pediatricians have become more complex and time intensive, with these practitioners less likely to work in inpatient settings. Hospitalist care has positive impacts on healthcare efficiency and value, and both parents and primary care pediatricians report high levels of satisfaction with the healthcare delivered by PHM services.⁴

A national count of the number of pediatric hospitalists is currently lacking. Conservative estimates suggest that at least 3,000 pediatric hospitalists currently practice in the United States.⁵ These hospitalists have highly varied scopes of practice and work across diverse settings—more diverse, perhaps, than any other pediatric subspecialty. Although difficult to quantify, we estimate that approximately one-third of pediatric hospitalists in the US work in community hospitals and the remainder practice at children’s hospitals.⁶ Many of the needs of hospitalized children differ across these settings, and the roles and challenges faced by hospitalists in these settings correspondingly differ. Community hospitalists frequently take active roles in newborn care and emergency department consultation, often without the support of other pediatric subspecialties.⁷ In contrast, hospitalists working at children’s hospitals more frequently care for highly complex patients, often collaborate across multiple specialties and assume nonclinical roles in quality improvement (QI), research, and medical education.

Residents graduating in July 2019 were the last cohort of residents eligible to pursue PHM subspecialty certification via the practice pathway. Accordingly, future residency graduates interested in PHM subspecialty certification will need to complete a PHM fellowship at an accredited program in the US or Canada. Since 2008, PHM fellowship directors have met yearly to collaborate and share best practices,⁸ developing the two-year fellowship curriculum that forms the basis for the American Board of Pediatrics training pathway.² The curriculum allows significant flexibility to meet diverse needs, including tailored content for fellows planning to practice in community settings, fellows planning research careers, medicine-pediatrics hospitalist careers, and those desiring increased training in QI, medical education, or leadership/administration.² In the spring of 2019, Pediatric Research in Inpatient Settings (PRIS) leadership, directors of existing PHM fellowship programs, and national academic society representatives met to develop a fellows’ research curriculum, training resources, and guidelines around scholarship expectations.⁹ This collaboration aims to accelerate the growth of high-quality clinical training and scholarship to benefit hospitalized children across many different settings.

Such collaboration is essential to address an emerging workforce challenge in PHM. Although the number of PHM fellowship positions is expected to grow in the coming years, there is currently a shortage relative to the anticipated demand. With approximately 2,800 US pediatric residents graduating annually and data indicating that 7% of graduating residents enter and remain in PHM for at least five years,^10,11 almost 200 fellowship spots may be needed each year. As of November 2019, 77 fellowship positions were available for residents graduating in 2020,¹² which is less than half of the potential demand. To address this mismatch, the PHM Fellowship Directors’ Council has led an annual training for new and potential fellowship directors, and 18 new programs are under development.¹³ However, this growth may be inadequate to meet the needs of the field. The extent to which limited PHM fellowship positions will adversely affect the pipeline of pediatricians pursuing PHM is unknown.

Efforts to support institutions in creating and expanding fellowship programs will be needed to address the potential shortage of fellowship positions. Continued guidance from the PHM Fellowship Directors’ Council in the many aspects of fellowship program development (eg, curriculum design, assessment) will be crucial in this endeavor. Furthermore, given that fellowships must support fellows to conduct scholarly work and demonstrate evidence of robust faculty scholarly activities to attain accreditation, an essential area of focus is faculty development. Considering barriers such as lack of time, mentorship, and resources, some divisions interested in starting a fellowship may find it challenging to achieve these standards.¹⁴ However, hospitalists are often engaged in areas such as QI and medical education, and there is potential to turn ongoing work into meaningful scholarship with appropriate guidance. Many of our supporting organizations (eg, Academic Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine) provide training programs for faculty in areas such as educational scholarship, research, and QI; however, more may be needed. Leaders of PHM programs will need to be mindful and creative in accessing local, regional, and national resources to invest in faculty development.

As a group, pediatric hospitalists report high levels of satisfaction with their jobs.¹¹ Despite this finding, there are a number of threats to the sustainability of current work models, some of which are unique to pediatrics given the overall lower patient volumes and greater seasonal variation compared with adult hospital medicine. Both university and community-based hospitalist programs report high weekend, overnight, and in-house clinical effort.^7,15 Recent studies reported that a significant proportion of PHM program leaders (50% of division directors at university-affiliated programs and 37% of community program leaders) perceive their program to be unsustainable.^7,15 Among university-affiliated programs, a higher burden of weekend work as well as university employment were associated with perceived unsustainability, while no specific program or employer characteristic was associated with this perception in community programs.

These findings indicate that efforts are needed to address PHM program sustainability and that different work models and interventions may be needed for university-based and community PHM programs. Wide variability exists in the ways that programs address overall clinical burden, with strategies including census caps, seasonal expansion of coverage, and formal back-up systems.^7,15 Additional potential solutions may include differential weighting or financial incentives for nights and weekends, support for nonclinical work, loan repayment programs, and competitive salaries.¹¹ In addition, structuring clinical and nonclinical roles to facilitate career development and advancement may enhance career longevity.¹⁵ Lessons learned from pediatric emergency medicine (PEM), which developed as a field a few decades ahead of PHM, may predict future challenges. A 2015 survey of PEM faculty found that despite a 15% decrease in weekly work hours over a 15-year period, a substantial number of PEM faculty report concerns about burnout, with 40% reporting a plan to decrease their clinical workload and 13% planning to leave the field within five years.¹⁶ Like PEM, the field of PHM may benefit from the development of best practice guidelines to improve well-being and career longevity.¹⁷

The culture of collaboration within PHM places the field in a solid position to address both workforce challenges and barriers to high-quality care for hospitalized children. There are several hospital-based learning networks actively working to strengthen our knowledge base and improve healthcare quality. The PRIS network (www.prisnetwork.org) aims to improve healthcare for children through multihospital studies, boasting 114 sites in the US and Canada. Numerous collaborative projects have linked hospitalists across programs to tackle problems ranging from handoff communication¹⁸ to eliminating monitor overuse.¹⁹ The Value in Inpatient Pediatrics network has similarly leveraged collaborations across multiple children’s and community hospitals to improve transitions of care²⁰ and care for common conditions such as bronchiolitis, febrile infants, and asthma.²¹ These networks serve as models of effective collaboration between children’s hospitals and community hospitals, more of which is needed to increase research and QI initiatives in community hospitals, where the majority of US children receive their hospital-based care.^6,22

With the rapid growth of scholarly networks in research, QI, and education, PHM has a solid infrastructure on which to base continued development as a subspeciality. Building on this infrastructure will be essential in order to address current challenges in workforce development, fellowship training, and program sustainability. Ultimately, achieving a strong, stable, and skilled workforce will enable PHM to fulfill its promise of improving the care of children across the diversity of settings where they receive their hospital-based care.

Disclosures

Dr. Leyenaar provides consultative services to the American Board of Pediatrics Foundation, which is not associated with this manuscript. Drs. Wang and Shaughnessy have no disclosures

Pediatric hospital medicine (PHM) is in the midst of an exciting period of growth. In 2016, the American Board of Medical Specialties approved the petition for PHM to become the newest pediatric subspecialty, taking PHM on a divergent path from the Focused Practice in Hospital Medicine designation established for adult hospitalists. Establishment as a subspecialty has allowed PHM to define the unique skills and qualifications that hospitalists bring to patients and the healthcare system. These skills and qualifications are delineated in the PHM core competencies and national fellowship curriculum.^1,2 In order to realize the vision of PHM to improve care for hospitalized children described by Roberts et al.,³ concerted efforts are needed to train and retain a workforce that is equipped with the skills to catalyze improvements in inpatient pediatric care. We discuss challenges and opportunities facing PHM in workforce development, sustainability of clinical work models, and interhospital collaboration.

The development of PHM as a subspecialty was driven by a number of factors.⁴ The acuity of hospitalized children has increased significantly, with a population comprised of more children with complex chronic conditions and/or technology dependence, serious complications of acute conditions, and acute mental health problems. At the same time, the medical and behavioral conditions seen by outpatient general pediatricians have become more complex and time intensive, with these practitioners less likely to work in inpatient settings. Hospitalist care has positive impacts on healthcare efficiency and value, and both parents and primary care pediatricians report high levels of satisfaction with the healthcare delivered by PHM services.⁴

A national count of the number of pediatric hospitalists is currently lacking. Conservative estimates suggest that at least 3,000 pediatric hospitalists currently practice in the United States.⁵ These hospitalists have highly varied scopes of practice and work across diverse settings—more diverse, perhaps, than any other pediatric subspecialty. Although difficult to quantify, we estimate that approximately one-third of pediatric hospitalists in the US work in community hospitals and the remainder practice at children’s hospitals.⁶ Many of the needs of hospitalized children differ across these settings, and the roles and challenges faced by hospitalists in these settings correspondingly differ. Community hospitalists frequently take active roles in newborn care and emergency department consultation, often without the support of other pediatric subspecialties.⁷ In contrast, hospitalists working at children’s hospitals more frequently care for highly complex patients, often collaborate across multiple specialties and assume nonclinical roles in quality improvement (QI), research, and medical education.

Residents graduating in July 2019 were the last cohort of residents eligible to pursue PHM subspecialty certification via the practice pathway. Accordingly, future residency graduates interested in PHM subspecialty certification will need to complete a PHM fellowship at an accredited program in the US or Canada. Since 2008, PHM fellowship directors have met yearly to collaborate and share best practices,⁸ developing the two-year fellowship curriculum that forms the basis for the American Board of Pediatrics training pathway.² The curriculum allows significant flexibility to meet diverse needs, including tailored content for fellows planning to practice in community settings, fellows planning research careers, medicine-pediatrics hospitalist careers, and those desiring increased training in QI, medical education, or leadership/administration.² In the spring of 2019, Pediatric Research in Inpatient Settings (PRIS) leadership, directors of existing PHM fellowship programs, and national academic society representatives met to develop a fellows’ research curriculum, training resources, and guidelines around scholarship expectations.⁹ This collaboration aims to accelerate the growth of high-quality clinical training and scholarship to benefit hospitalized children across many different settings.

Such collaboration is essential to address an emerging workforce challenge in PHM. Although the number of PHM fellowship positions is expected to grow in the coming years, there is currently a shortage relative to the anticipated demand. With approximately 2,800 US pediatric residents graduating annually and data indicating that 7% of graduating residents enter and remain in PHM for at least five years,^10,11 almost 200 fellowship spots may be needed each year. As of November 2019, 77 fellowship positions were available for residents graduating in 2020,¹² which is less than half of the potential demand. To address this mismatch, the PHM Fellowship Directors’ Council has led an annual training for new and potential fellowship directors, and 18 new programs are under development.¹³ However, this growth may be inadequate to meet the needs of the field. The extent to which limited PHM fellowship positions will adversely affect the pipeline of pediatricians pursuing PHM is unknown.

Efforts to support institutions in creating and expanding fellowship programs will be needed to address the potential shortage of fellowship positions. Continued guidance from the PHM Fellowship Directors’ Council in the many aspects of fellowship program development (eg, curriculum design, assessment) will be crucial in this endeavor. Furthermore, given that fellowships must support fellows to conduct scholarly work and demonstrate evidence of robust faculty scholarly activities to attain accreditation, an essential area of focus is faculty development. Considering barriers such as lack of time, mentorship, and resources, some divisions interested in starting a fellowship may find it challenging to achieve these standards.¹⁴ However, hospitalists are often engaged in areas such as QI and medical education, and there is potential to turn ongoing work into meaningful scholarship with appropriate guidance. Many of our supporting organizations (eg, Academic Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine) provide training programs for faculty in areas such as educational scholarship, research, and QI; however, more may be needed. Leaders of PHM programs will need to be mindful and creative in accessing local, regional, and national resources to invest in faculty development.

As a group, pediatric hospitalists report high levels of satisfaction with their jobs.¹¹ Despite this finding, there are a number of threats to the sustainability of current work models, some of which are unique to pediatrics given the overall lower patient volumes and greater seasonal variation compared with adult hospital medicine. Both university and community-based hospitalist programs report high weekend, overnight, and in-house clinical effort.^7,15 Recent studies reported that a significant proportion of PHM program leaders (50% of division directors at university-affiliated programs and 37% of community program leaders) perceive their program to be unsustainable.^7,15 Among university-affiliated programs, a higher burden of weekend work as well as university employment were associated with perceived unsustainability, while no specific program or employer characteristic was associated with this perception in community programs.

These findings indicate that efforts are needed to address PHM program sustainability and that different work models and interventions may be needed for university-based and community PHM programs. Wide variability exists in the ways that programs address overall clinical burden, with strategies including census caps, seasonal expansion of coverage, and formal back-up systems.^7,15 Additional potential solutions may include differential weighting or financial incentives for nights and weekends, support for nonclinical work, loan repayment programs, and competitive salaries.¹¹ In addition, structuring clinical and nonclinical roles to facilitate career development and advancement may enhance career longevity.¹⁵ Lessons learned from pediatric emergency medicine (PEM), which developed as a field a few decades ahead of PHM, may predict future challenges. A 2015 survey of PEM faculty found that despite a 15% decrease in weekly work hours over a 15-year period, a substantial number of PEM faculty report concerns about burnout, with 40% reporting a plan to decrease their clinical workload and 13% planning to leave the field within five years.¹⁶ Like PEM, the field of PHM may benefit from the development of best practice guidelines to improve well-being and career longevity.¹⁷

The culture of collaboration within PHM places the field in a solid position to address both workforce challenges and barriers to high-quality care for hospitalized children. There are several hospital-based learning networks actively working to strengthen our knowledge base and improve healthcare quality. The PRIS network (www.prisnetwork.org) aims to improve healthcare for children through multihospital studies, boasting 114 sites in the US and Canada. Numerous collaborative projects have linked hospitalists across programs to tackle problems ranging from handoff communication¹⁸ to eliminating monitor overuse.¹⁹ The Value in Inpatient Pediatrics network has similarly leveraged collaborations across multiple children’s and community hospitals to improve transitions of care²⁰ and care for common conditions such as bronchiolitis, febrile infants, and asthma.²¹ These networks serve as models of effective collaboration between children’s hospitals and community hospitals, more of which is needed to increase research and QI initiatives in community hospitals, where the majority of US children receive their hospital-based care.^6,22

With the rapid growth of scholarly networks in research, QI, and education, PHM has a solid infrastructure on which to base continued development as a subspeciality. Building on this infrastructure will be essential in order to address current challenges in workforce development, fellowship training, and program sustainability. Ultimately, achieving a strong, stable, and skilled workforce will enable PHM to fulfill its promise of improving the care of children across the diversity of settings where they receive their hospital-based care.

Disclosures

Dr. Leyenaar provides consultative services to the American Board of Pediatrics Foundation, which is not associated with this manuscript. Drs. Wang and Shaughnessy have no disclosures

Pediatric hospital medicine (PHM) is in the midst of an exciting period of growth. In 2016, the American Board of Medical Specialties approved the petition for PHM to become the newest pediatric subspecialty, taking PHM on a divergent path from the Focused Practice in Hospital Medicine designation established for adult hospitalists. Establishment as a subspecialty has allowed PHM to define the unique skills and qualifications that hospitalists bring to patients and the healthcare system. These skills and qualifications are delineated in the PHM core competencies and national fellowship curriculum.^1,2 In order to realize the vision of PHM to improve care for hospitalized children described by Roberts et al.,³ concerted efforts are needed to train and retain a workforce that is equipped with the skills to catalyze improvements in inpatient pediatric care. We discuss challenges and opportunities facing PHM in workforce development, sustainability of clinical work models, and interhospital collaboration.

The development of PHM as a subspecialty was driven by a number of factors.⁴ The acuity of hospitalized children has increased significantly, with a population comprised of more children with complex chronic conditions and/or technology dependence, serious complications of acute conditions, and acute mental health problems. At the same time, the medical and behavioral conditions seen by outpatient general pediatricians have become more complex and time intensive, with these practitioners less likely to work in inpatient settings. Hospitalist care has positive impacts on healthcare efficiency and value, and both parents and primary care pediatricians report high levels of satisfaction with the healthcare delivered by PHM services.⁴

A national count of the number of pediatric hospitalists is currently lacking. Conservative estimates suggest that at least 3,000 pediatric hospitalists currently practice in the United States.⁵ These hospitalists have highly varied scopes of practice and work across diverse settings—more diverse, perhaps, than any other pediatric subspecialty. Although difficult to quantify, we estimate that approximately one-third of pediatric hospitalists in the US work in community hospitals and the remainder practice at children’s hospitals.⁶ Many of the needs of hospitalized children differ across these settings, and the roles and challenges faced by hospitalists in these settings correspondingly differ. Community hospitalists frequently take active roles in newborn care and emergency department consultation, often without the support of other pediatric subspecialties.⁷ In contrast, hospitalists working at children’s hospitals more frequently care for highly complex patients, often collaborate across multiple specialties and assume nonclinical roles in quality improvement (QI), research, and medical education.

Residents graduating in July 2019 were the last cohort of residents eligible to pursue PHM subspecialty certification via the practice pathway. Accordingly, future residency graduates interested in PHM subspecialty certification will need to complete a PHM fellowship at an accredited program in the US or Canada. Since 2008, PHM fellowship directors have met yearly to collaborate and share best practices,⁸ developing the two-year fellowship curriculum that forms the basis for the American Board of Pediatrics training pathway.² The curriculum allows significant flexibility to meet diverse needs, including tailored content for fellows planning to practice in community settings, fellows planning research careers, medicine-pediatrics hospitalist careers, and those desiring increased training in QI, medical education, or leadership/administration.² In the spring of 2019, Pediatric Research in Inpatient Settings (PRIS) leadership, directors of existing PHM fellowship programs, and national academic society representatives met to develop a fellows’ research curriculum, training resources, and guidelines around scholarship expectations.⁹ This collaboration aims to accelerate the growth of high-quality clinical training and scholarship to benefit hospitalized children across many different settings.

Such collaboration is essential to address an emerging workforce challenge in PHM. Although the number of PHM fellowship positions is expected to grow in the coming years, there is currently a shortage relative to the anticipated demand. With approximately 2,800 US pediatric residents graduating annually and data indicating that 7% of graduating residents enter and remain in PHM for at least five years,^10,11 almost 200 fellowship spots may be needed each year. As of November 2019, 77 fellowship positions were available for residents graduating in 2020,¹² which is less than half of the potential demand. To address this mismatch, the PHM Fellowship Directors’ Council has led an annual training for new and potential fellowship directors, and 18 new programs are under development.¹³ However, this growth may be inadequate to meet the needs of the field. The extent to which limited PHM fellowship positions will adversely affect the pipeline of pediatricians pursuing PHM is unknown.

Efforts to support institutions in creating and expanding fellowship programs will be needed to address the potential shortage of fellowship positions. Continued guidance from the PHM Fellowship Directors’ Council in the many aspects of fellowship program development (eg, curriculum design, assessment) will be crucial in this endeavor. Furthermore, given that fellowships must support fellows to conduct scholarly work and demonstrate evidence of robust faculty scholarly activities to attain accreditation, an essential area of focus is faculty development. Considering barriers such as lack of time, mentorship, and resources, some divisions interested in starting a fellowship may find it challenging to achieve these standards.¹⁴ However, hospitalists are often engaged in areas such as QI and medical education, and there is potential to turn ongoing work into meaningful scholarship with appropriate guidance. Many of our supporting organizations (eg, Academic Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine) provide training programs for faculty in areas such as educational scholarship, research, and QI; however, more may be needed. Leaders of PHM programs will need to be mindful and creative in accessing local, regional, and national resources to invest in faculty development.

As a group, pediatric hospitalists report high levels of satisfaction with their jobs.¹¹ Despite this finding, there are a number of threats to the sustainability of current work models, some of which are unique to pediatrics given the overall lower patient volumes and greater seasonal variation compared with adult hospital medicine. Both university and community-based hospitalist programs report high weekend, overnight, and in-house clinical effort.^7,15 Recent studies reported that a significant proportion of PHM program leaders (50% of division directors at university-affiliated programs and 37% of community program leaders) perceive their program to be unsustainable.^7,15 Among university-affiliated programs, a higher burden of weekend work as well as university employment were associated with perceived unsustainability, while no specific program or employer characteristic was associated with this perception in community programs.

These findings indicate that efforts are needed to address PHM program sustainability and that different work models and interventions may be needed for university-based and community PHM programs. Wide variability exists in the ways that programs address overall clinical burden, with strategies including census caps, seasonal expansion of coverage, and formal back-up systems.^7,15 Additional potential solutions may include differential weighting or financial incentives for nights and weekends, support for nonclinical work, loan repayment programs, and competitive salaries.¹¹ In addition, structuring clinical and nonclinical roles to facilitate career development and advancement may enhance career longevity.¹⁵ Lessons learned from pediatric emergency medicine (PEM), which developed as a field a few decades ahead of PHM, may predict future challenges. A 2015 survey of PEM faculty found that despite a 15% decrease in weekly work hours over a 15-year period, a substantial number of PEM faculty report concerns about burnout, with 40% reporting a plan to decrease their clinical workload and 13% planning to leave the field within five years.¹⁶ Like PEM, the field of PHM may benefit from the development of best practice guidelines to improve well-being and career longevity.¹⁷

The culture of collaboration within PHM places the field in a solid position to address both workforce challenges and barriers to high-quality care for hospitalized children. There are several hospital-based learning networks actively working to strengthen our knowledge base and improve healthcare quality. The PRIS network (www.prisnetwork.org) aims to improve healthcare for children through multihospital studies, boasting 114 sites in the US and Canada. Numerous collaborative projects have linked hospitalists across programs to tackle problems ranging from handoff communication¹⁸ to eliminating monitor overuse.¹⁹ The Value in Inpatient Pediatrics network has similarly leveraged collaborations across multiple children’s and community hospitals to improve transitions of care²⁰ and care for common conditions such as bronchiolitis, febrile infants, and asthma.²¹ These networks serve as models of effective collaboration between children’s hospitals and community hospitals, more of which is needed to increase research and QI initiatives in community hospitals, where the majority of US children receive their hospital-based care.^6,22

With the rapid growth of scholarly networks in research, QI, and education, PHM has a solid infrastructure on which to base continued development as a subspeciality. Building on this infrastructure will be essential in order to address current challenges in workforce development, fellowship training, and program sustainability. Ultimately, achieving a strong, stable, and skilled workforce will enable PHM to fulfill its promise of improving the care of children across the diversity of settings where they receive their hospital-based care.

Disclosures

Dr. Leyenaar provides consultative services to the American Board of Pediatrics Foundation, which is not associated with this manuscript. Drs. Wang and Shaughnessy have no disclosures