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Board Certification Requirements Changes
In 2005, we conducted a study of the prevalence of board certification requirements for hospital privileging of pediatricians.[1] Since that time, there have been many changes in the landscape of both physician and healthcare‐system quality assessment. New developments include greater utilization of physician quality‐of‐care assessment tools, a change from recertification for time‐limited board certification to Maintenance of Certification (MOC) in 2010, and an increasing commitment on the part of hospitals and state licensing officials to patient safety and quality‐of‐care issues, due in part to the continued interest by governmental and private payors and the public on external measurement of healthcare quality.[2, 3, 4, 5, 6]
MOC is an ongoing process of lifelong learning and self‐assessment to continuously improve knowledge and clinical performance. It has been adopted by all 24 member boards of the American Boards of Medical Specialties. MOC is focused on the 6 core competencies of quality medical care as outlined by the Accreditation Council for Graduate Medical Education (ACGME): (1) patient care, (2) medical knowledge, (3) practice‐based learning, (4) systems‐based practice, (5) professionalism, and (6) interpersonal and communication skills. To address, these competencies, MOC involves a 4‐part process for continuous learning that is required to keep certification current: (1) licensure and professional standing, (2) lifelong learning and self‐assessment, (3) cognitive expertise, and (4) practice performance assessment.[7, 8]
Our previous study found that many hospitals utilize specialty certification as a marker of quality for privileging.[1] To explore changes in the policies of hospitals regarding requirements for board certification and the incorporation of MOC into those requirements, we conducted a 5‐year follow‐up study of a national random sample of hospitals in 2010.
METHODS
Sample
All hospitals identified in the American Hospital Association's 2009 Annual Survey of Hospitals as providing care to pediatric patients were included in the sampling frame (N=2136). We then selected a stratified random sample of 10% of the total (N=220) hospitals weighted to provide nationally representative estimates. The sample was stratified by Council of Teaching Hospitals (COTH) designation (teaching vs nonteaching) and National Association of Children's Hospitals and Related Institutions (NACHRI) membership. In contrast to our previous study, in this study we did not stratify according to the designation of freestanding children's hospital (vs part of a hospital system) or metropolitan statistical area size (urban vs rural), as comparisons across these designations were not found to be significant in 2005.
Hospitals were sampled with varying probabilities from each stratum. Weights were applied to create a representative sample of the overall hospital population. The total sampling weight (TSW) calculated for each hospital was based on the probability of selection into the study (P) and the response rate (RR). The following formula was used: TSW: (1/P) (1/RR).
Survey Instrument
In collaboration with the American Board of Pediatrics Research Advisory Committee, we developed a 24‐item, fixed‐choice, structured questionnaire to be administered by phone. The survey was designed to be completed in 15 minutes or less and focused on board certification requirements at initial privileging, recredentialing, and MOC requirements.
The survey focused on the following descriptive research questions: Do hospitals require board certification for pediatricians at the time of initial privileging? Do they ever require board certification for privileging? Are there different certification requirements for generalists vs subspecialists? Are pediatricians with permanent certificates required to enroll in MOC?
Other questions focused on such issues such as whether the hospital was familiar with the requirements of MOC, whether MOC was required of all pediatricians, and whether the institution of MOC changed certification requirements at the hospital.
The instrument was pilot tested for clarity and ease of use with representatives from a convenience sample of hospitals within the state of Michigan and revised to clarify potentially ambiguous questions. Pilot surveys were not included in the analyses.
Questionnaire Administration
Data collection took place between April 2010 and June 2010. Interviewers requested to speak with the department responsible for credentialing or privileging at the hospital, typically the Medical Staff Office, the Office of Clinical Affairs, or the Credentialing or Privileging Department. When the appropriate person was identified and located, interviewers explained the purpose of the study and obtained verbal consent to participate.
Data Analysis
Initially, frequency distributions were calculated for all survey items to create descriptive statistics. Next, we performed a cross‐tabulation of responses by the specific hospital classifications listed above (COTH and NACHRI status) and computed the 2 statistics. Finally, we conducted bivariate analyses on the 2005 and 2010 results. SAS version 9.1 (SAS Institute Inc., Cary, NC) was used for all statistical analyses. P<0.05 was considered statistically significant.
Although this study is similar to the study that was completed in 2005,[1] we have reanalyzed those data to more specifically assess certification policy. All results are now weighted in contrast to the 2005 study, which only weighted the results by hospital classification. Thus, the numbers in some cases may be slightly different from those reported in 2006. We believe that this has resulted in a more robust analysis of hospital use of board certification in privileging.
Comparisons
Where possible, results were compared with those found in a 2005 study of hospital privileging.[1] The sampling frame for that study was identical to the current study, but the specific hospitals may or may not be included in the current study.
The study was approved by the University of Michigan Medical School Institutional Review Board.
RESULTS
Response Rate and Respondent Demographics
Of the 220 hospitals surveyed, 23 were ineligible because they did not have at least 1 pediatrician on staff. Of the remaining 197 hospitals, 154 completed the survey, resulting in a 78% participation rate.
Response rates did not differ significantly by NACHRI or COTH hospital status; therefore, there was no impact on the analytic power of the weighting. Approximately half (54%, n=82) of the respondents were NACHRI member hospitals, and 49% (n=75) were COTH hospitals.
Because not every hospital responded to every question, the total number for each question response may differ slightly.
2005 VS 2010 COMPARISONS
Board Certification Requirements
Compared with our findings in 2005, in 2010 a greater proportion of hospitals now require board certification for general pediatricians (80% vs 67%, P=0.141). Among these hospitals, a much larger proportion (24% vs 4%) now require board certification for all pediatricians at the point of initial privileging (Table 1). Similarly, a greater proportion of hospitals now require board certification for pediatric subspecialists (86% vs 71%, P=0.048). The percentage of hospitals that require subspecialists to be board certified at the point of initial privileging also increased from 10% in 2005 to 34% in 2010.
| General Pediatricians | Pediatric Subspecialists | |||
|---|---|---|---|---|
| 2005 (N=159) | 2010 (N=154) | 2005 (N=153) | 2010 (N=147) | |
| ||||
| Certification never required | 33%a | 20%a | 29%b | 14%b |
| Certification ever required | 67%a | 80%a | 71%b | 86%b |
| At time of initial privileging for all pediatricians | 4% | 24% | 10% | 34% |
| Within a specified time frame of initial privileging | 50% | 29% | 41% | 32% |
| At time of initial privileging but only for some pediatricians | 11% | 24% | 16% | 17% |
| Only recertification required | 2% | 3% | 4% | 3% |
The proportion of teaching (COTH) hospitals that require general pediatricians to be board certified at some point in time increased from 63% in 2005 to 89% in 2010 (P=0.001), and the percentage that require board certification for all pediatricians at initial privileging increased from 2% in 2005 to 25% in 2010. Similarly, the proportion of teaching hospitals that require pediatric subspecialists to be board certified increased from 66% in 2005 to 89% in 2010 (P=0.003).
There were small changes between 2005 and 2010 in the proportion of nonteaching (68% vs 79%, P=0.231), NACHRI‐member (76% vs 82%, P=0.366), and non‐NACHRI member (67% vs 80%, P=0.156) hospitals that require pediatricians to be board certified at some point in time. The proportion of nonteaching (4% vs 24%), NACHRI‐member (5% vs 32%), and non‐NACHRI (4% vs 23%) hospitals that require board certification at the point of initial privileging also increased between 2005 and 2010.
Certification Policies at Initial Privileging
Although in 2010, a greater proportion of hospitals reported that they require board certification for general pediatricians and pediatric subspecialists at the point of initial privileging, a much larger proportion of hospitals reported that they make exceptions to their board certification policies for both general pediatricians (99% vs 41%) (Table 2) and pediatric subspecialists (98% vs 14%) (Table 3). Among hospitals that do not require board certification at the point of initial privileging, only small differences were seen in requirements around completion of residency or fellowship training and time frame after which certification must be achieved (Tables 2 and 3).
| 2005 (N=159) | 2010 (N=154) | |
|---|---|---|
| Certification required at initial privileging | ||
| Yes | 4% | 24% |
| Mixed policy | 11% | 24% |
| No | 85% | 52% |
| If hospital required certification at initial privileging: | ||
| Allowed exceptions to policy at initial privileging | 41% | 99% |
| Required certification to be current | 99% | 99% |
| If hospital did not require certification at initial privileging: | ||
| Required to complete residency | 85% | 84% |
| Established time frame after which certification must be achieved | 48% | 51% |
| 2005 (N=153) | 2010 (N=147) | |
|---|---|---|
| Certification required at initial privileging | ||
| Yes | 10% | 34% |
| Mixed policy | 5% | 17% |
| No | 85% | 49% |
| If hospital required certification at initial privileging: | ||
| Allowed exceptions to policy at initial privileging | 14% | 98% |
| Required certification to be current | 83% | 100% |
| If hospital did not require certification at initial privileging: | ||
| Required to complete fellowship | 86% | 86% |
| Established time frame after which certification must be achieved | 47% | 52% |
There were no meaningful differences between board certification policies for general pediatricians and pediatric subspecialists in 2010.
Comparing Recertification and MOC Policies
Few hospitals required permanent certificate holders to recertify (2005) or enroll in MOC (2010) in 2005 (5%) or 2010 (6%). The proportion of hospitals that required recertification or MOC enrollment for general pediatricians increased from 33% in 2005 to 42% in 2010. Similarly, the percentage of hospitals that required recertification or MOC enrollment for pediatric subspecialists increased from 25% in 2005 to 35% in 2010.
Between 2005 and 2010, there was no significant change in the proportion of hospitals that reported revoking or denying privileges to a pediatrician due to failure to recertify or enroll in MOC (3% vs 6%).
SPECIFIC MAINTENANCE OF CERTIFICATION POLICIES IN 2010
Board Certification Requirements
Respondents from 29% of hospitals reported that they were not at all familiar with the American Board of Pediatrics' (ABP) MOC program. Most respondents (58%) were familiar with MOC, with 37% reporting that they were somewhat familiar, and 12% reporting that they were very familiar with the program.
Three‐fourths of hospitals (76%) reported that their MOC requirements do not differ from their recertification requirements held prior to the institution of MOC, and 14% reported that their hospital had not yet established specific MOC requirements.
The majority of respondents (62%) had verified the board certification of some physicians since the institution of the ABP's MOC program on January 1, 2010. A majority (53%) of hospitals track MOC data for all pediatricians, whereas 3% of respondents track MOC data only for those pediatricians whose initial certification was time limited.
Of those hospitals that require pediatricians with permanent certificates to enroll in MOC, 9% allow them to retain their privileges for a period of time if they are not meeting the requirements for MOC. Among hospitals that require pediatricians with time‐limited certificates to enroll in MOC, fewer than half allow general pediatricians (37%) and pediatric subspecialists (40%) to retain their privileges if they are not meeting the requirements for MOC.
The majority of respondents (89%) reported that the initiation of MOC had not changed board certification requirements at their hospital. However, respondents from over one‐quarter of hospitals (27%) reported that they expect changes in their hospital's certification or MOC requirements in the next 2 years. Those hospitals that reported changes moved to more stringent requirements for certification at initial privileging and requirements for permanent certificate holders to meet MOC requirements.
DISCUSSION
In the 5 years since our previous study, a larger proportion of hospitals now require pediatricians to become board certified to obtain hospital privileges. Of note is that a larger proportion of hospitals also now require board certification at the time of initial privileging for both generalist and subspecialist pediatricians.
Hospitals face increasing pressure to differentiate themselves from their peers through better patient outcomes.[9, 10] The increase from 67% to 80% of hospitals requiring board certification may be a result of hospitals utilizing certification as a proxy for assessment of physician quality or as a way to engage physicians in quality improvement through the MOC program.[11] Hospitals may also be responding to greater interest in MOC from regulatory agencies such as the Centers for Medicare and Medicaid Services Maintenance of Certification Program Incentive, which rewards physicians with an additional incentive payment beyond the Physician Quality Reporting System incentive for their participation in the MOC program.[12]
Interestingly, although a greater proportion of hospitals reported that they require certification, a much larger proportion of hospitals make exceptions to the policy. The exceptions could include grandfathering physicians who had hospital privileges prior to the policy change, or giving recent graduates additional time to obtain board certification. It is unknown whether or not all of these physicians would be required to obtain board certification or participate in MOC after some provisional time frame.
Hospitals in our study appear to be incorporating the MOC program into their policies. However, fewer than half of the hospitals studied require pediatricians with time‐limited certificates to enroll in MOC if their certificates have expired. In addition, some hospitals are still establishing their MOC requirements for those pediatricians with time‐limited and permanent certificates. It is likely that the majority of hospitals retained their previous board certification requirements, and that the current flux in hospital requirements is not unique to pediatrics, as all American Board of Medical Specialties' specialties have recently implemented MOC requirements.[13] Hospitals will likely adjust their credentialing policies as their familiarity and experience with MOC grows.
The primary purpose of the specialty certification process is to provide to the public, which includes both individual consumers and regulatory agencies, an assessment of the competency of individual physicians. Self‐regulation through certification is a privilege of trust granted to the medical profession by the public. This is an essential concept that underlies the concept of specialty certification.[14] As the public has continued to adopt a greater focus, and additional demands, on safety and quality assessment in healthcare, the medical profession must in turn be responsive.[13, 15, 16, 17] Failure in this regard would run the risk of losing that trust with the public, with the resultant loss of the ability to self‐regulate.
Studies have indicated a positive relationship between board certification and quality of care, yet this area remains hampered by a paucity of data.[18, 19, 20, 21, 22] Pham et al. found that board certified physicians were more likely to provide preventative care services to Medicare patients.[22] In 2008, Turchin et al. showed that recertification made a small, yet meaningful, difference in physician treatment of hypertension.[18] This area of research is especially important, as the MOC program is more comprehensive and utilizes an ongoing system of assessment and physician engagement. As such, it has been criticized by some for being complicated, burdensome, and irrelevant to the manner in which physicians actually practice.[23, 24] However, previous methods of certification were limited to assessing physicians at 1 point in time during their entire careers (eg, permanent certification) or at specific intervals (eg, time‐limited certification). With recent increased attention to improving the quality of patient care, these methods were unable to assure the public that physicians maintained their knowledge and skills over time in an environment of increasing rapid incorporation of new knowledge into clinical practice. Recent reports have also shown that (years of) practice does not make perfect with regard to physician performance. In fact, there may be deterioration of performance over long periods of practice.[25] Furthermore, although physicians commonly believe they are able to assess their own performance, available evidence does not support that contention.[26, 27] Thus, there is a need for an objective ongoing assessment of physician performance that also has the capacity to continuously improve the quality of care provided.
The comprehensive nature of the MOC program is a result of efforts to meaningfully incorporate the 6 competencies defined by the ACGME into the certification process. Although MOC is still relatively new and maturing, a growing body of evidence is demonstrating effectiveness of specific components of the program.[28, 29, 30, 31] In the field of pediatrics, several programs approved for MOC credit have already demonstrated their effectiveness in improving the quality of care in clinical practice.[32, 33, 34, 35, 36] However, additional efforts are needed to evaluate more of the part 4 (Assessment of Practice Performance) modules to assess their impact on patient care. The continued commitment to quality of care and quality improvement in hospitals will likely result in a further adoption of MOC requirements as the process matures and demonstrable impacts on patient outcomes are assessed. Furthermore, greater coordination of MOC with quality assessments in health plans and in the changes taking place in the process of licensure will likely help to streamline the paperwork and documentation burden placed on physicians by multiple assessment efforts.
This study has several limitations. Because the MOC program was initiated by the ABP in January 2010, there may be a lag in uptake of this particular requirement by hospitals. In some cases, this may have been the first time that members of the credentialing staff had considered the MOC program. It is probable that staff awareness will increase over time, as hospital policies are further developed and greater exposure to the specifics of the MOC program occurs. Additionally, although we compared stratified random samples of hospitals in 2005 and 2010, we did not follow the same group of hospitals over time.
As with all changes to the certification program over the years, there is a period of time required for new requirements to be understood and accepted by both those in regulatory positions and those in the medical profession. The demands of the public for increasingly comprehensive assessments of healthcare quality will continue into the future.
Acknowledgments
Disclosures: Funding was provided by a grant from the American Board of Pediatrics Foundation. The authors have no other disclosures or conflicts of interest to report.
- , , , , , . Policies and practices related to the role of board certification and recertification of pediatricians in hospital privileging. JAMA. 2006;295(8):905–912.
- American Board of Pediatrics. Maintenance of Certification: MOC requirements. 2011. Available at: https://www.abp.org/ABPWeb Static/#murl%3D%2FABPWebStatic%2Fmoc.html%26surl%3D%2 Fabpwebsite%2Fmoc%2Fphysicianrequirements%2Fphysreq.htm. Accessed May 23, 2011.
- , , , , , . Maintenance of licensure: protecting the public, promoting quality health care. J Med Regul. 2010;96(2):13–20.
- , , , , . Setting a fair performance standard for physicians' quality of patient care. J Gen Intern Med. 2011;26(5):467–473.
- , . Payer trend: “tiering” physicians and “steering” patients. Fam Pract Manag. 2007;14(10):24–26.
- , , , et al. Association between maintenance of certification examination scores and quality of care for medicare beneficiaries. Arch Intern Med. 2008;168(13):1396–1403.
- American Board of Medical Specialties. ABMS Maintenance of Certification. Available at: http://www.abms.org/Maintenance_of_Certification/ABMS_MOC.aspx. Accessed January 23, 2012.
- American Board of Medical Specialties. ABMS Maintenance of Certification. Available at: http://www.abms.org/maintenance_of_certification/MOC_competencies.aspx. Accessed January 24, 2012.
- , , . Hospital performance reports: impact on quality, market share, and reputation. Health Aff (Millwood). 2005;24(4):1150–1160.
- , , , et al. Impact of public reporting of coronary artery bypass graft surgery performance data on market share, mortality, and patient selection. Med Care. 2011;49(12):1118–1125.
- , , . Hospital strategies to engage physicians in quality improvement. Available at: www.hschange.org/CONTENT/1087. Accessed June 4, 2012.
- The Physician Quality Reporting System Maintenance of Certification Program Incentive Requirements of Self‐Nomination for 2012. http://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instru ments/PQRS/downloads/2012_MaintenanceofCertificationProgram_ mmrvsd01162012.pdf. Accessed June 4, 2012.
- , , . Maintenance of Certification, maintenance of public trust. Plast Reconstr Surg. 2011;127(2):967–973.
- , . Credentialing and public accountability: a central role for board certification. JAMA. 2006;295(8):939–940.
- , , , . Perspectives and preferences among the general public regarding physician selection and board certification. J Pediatr. 2010;156(5):841–845, 845.e1.
- , . Public perceptions of quality care and provider profiling in New York: implications for improving quality care and public health. J Public Health Manag Pract. 2004;10(3):241–250.
- . Future of board certification in a new era of public accountability. J Am Board Fam Med. 2010;23(suppl 1):S32–S39.
- , , , , . Effect of board certification on antihypertensive treatment intensification in patients with diabetes mellitus. Circulation. 2008;117(5):623–628.
- , , , , . Physician board certification and the care and outcomes of elderly patients with acute myocardial infarction. J Gen Intern Med. 2006;21(3):238–244.
- , , . Certifying examination performance and patient outcomes following acute myocardial infarction. Med Educ. 2002;36(9):853–859.
- , , , , . Specialty board certification and clinical outcomes: the missing link. Acad Med. 2002;77(6):534–542.
- , , , . Delivery of preventive services to older adults by primary care physicians. JAMA. 2005;294(4):473–481.
- . Are you ready for maintenance of certification? Fam Pract Manag. 2005;12(1):42–48.
- , , , , . Clinical decisions. American Board of Internal Medicine maintenance of certification program. N Engl J Med. 2010;362(10):948–952.
- . As doctors age, worries about their abilities grow. New York Times. January 24, 2011:D.1.
- , , . Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005;142(4):260–273.
- , , , , , . Accuracy of physician self‐assessment compared with observed measures of competence: a systematic review. JAMA. 2006;296(9):1094–1102.
- , , . The impact of a preventive cardiology quality improvement intervention on residents and clinics: a qualitative exploration. Am J Med Qual. 2009;24(2):99–107.
- , , , , , . Promoting physicians' self‐assessment and quality improvement: the ABIM diabetes practice improvement module. J Contin Educ Health Prof. 2006;26(2):109–119.
- , , , et al. Self‐assessment of practice performance: development of the ABIM Practice Improvement Module (PIM). J Contin Educ Health Prof. 2008;28(1):38–46.
- , , , , , . Variation in internal medicine residency clinic practices: assessing practice environments and quality of care. J Gen Intern Med. 2008;23(7):914–920.
- , , , et al. Statewide NICU central‐line‐associated bloodstream infection rates decline after bundles and checklists. Pediatrics. 2011;127(3):436–444.
- , , , et al. ImproveCareNow: the development of a pediatric inflammatory bowel disease improvement network. Inflamm Bowel Dis. 2011;17(1):450–457.
- , . Pay for performance alone cannot drive quality. Arch Pediatr Adolesc Med. 2007;161(7):650–655.
- , , , et al. National pediatric cardiology quality improvement collaborative: lessons learned from development and early years. Prog Pediatr Cardiol. 2011;32(2):103–109.
- , , , et al. Reducing PICU central line‐associated bloodstream infections: 3‐year results. Pediatrics. 2011;128(5):e1077–e1083.
In 2005, we conducted a study of the prevalence of board certification requirements for hospital privileging of pediatricians.[1] Since that time, there have been many changes in the landscape of both physician and healthcare‐system quality assessment. New developments include greater utilization of physician quality‐of‐care assessment tools, a change from recertification for time‐limited board certification to Maintenance of Certification (MOC) in 2010, and an increasing commitment on the part of hospitals and state licensing officials to patient safety and quality‐of‐care issues, due in part to the continued interest by governmental and private payors and the public on external measurement of healthcare quality.[2, 3, 4, 5, 6]
MOC is an ongoing process of lifelong learning and self‐assessment to continuously improve knowledge and clinical performance. It has been adopted by all 24 member boards of the American Boards of Medical Specialties. MOC is focused on the 6 core competencies of quality medical care as outlined by the Accreditation Council for Graduate Medical Education (ACGME): (1) patient care, (2) medical knowledge, (3) practice‐based learning, (4) systems‐based practice, (5) professionalism, and (6) interpersonal and communication skills. To address, these competencies, MOC involves a 4‐part process for continuous learning that is required to keep certification current: (1) licensure and professional standing, (2) lifelong learning and self‐assessment, (3) cognitive expertise, and (4) practice performance assessment.[7, 8]
Our previous study found that many hospitals utilize specialty certification as a marker of quality for privileging.[1] To explore changes in the policies of hospitals regarding requirements for board certification and the incorporation of MOC into those requirements, we conducted a 5‐year follow‐up study of a national random sample of hospitals in 2010.
METHODS
Sample
All hospitals identified in the American Hospital Association's 2009 Annual Survey of Hospitals as providing care to pediatric patients were included in the sampling frame (N=2136). We then selected a stratified random sample of 10% of the total (N=220) hospitals weighted to provide nationally representative estimates. The sample was stratified by Council of Teaching Hospitals (COTH) designation (teaching vs nonteaching) and National Association of Children's Hospitals and Related Institutions (NACHRI) membership. In contrast to our previous study, in this study we did not stratify according to the designation of freestanding children's hospital (vs part of a hospital system) or metropolitan statistical area size (urban vs rural), as comparisons across these designations were not found to be significant in 2005.
Hospitals were sampled with varying probabilities from each stratum. Weights were applied to create a representative sample of the overall hospital population. The total sampling weight (TSW) calculated for each hospital was based on the probability of selection into the study (P) and the response rate (RR). The following formula was used: TSW: (1/P) (1/RR).
Survey Instrument
In collaboration with the American Board of Pediatrics Research Advisory Committee, we developed a 24‐item, fixed‐choice, structured questionnaire to be administered by phone. The survey was designed to be completed in 15 minutes or less and focused on board certification requirements at initial privileging, recredentialing, and MOC requirements.
The survey focused on the following descriptive research questions: Do hospitals require board certification for pediatricians at the time of initial privileging? Do they ever require board certification for privileging? Are there different certification requirements for generalists vs subspecialists? Are pediatricians with permanent certificates required to enroll in MOC?
Other questions focused on such issues such as whether the hospital was familiar with the requirements of MOC, whether MOC was required of all pediatricians, and whether the institution of MOC changed certification requirements at the hospital.
The instrument was pilot tested for clarity and ease of use with representatives from a convenience sample of hospitals within the state of Michigan and revised to clarify potentially ambiguous questions. Pilot surveys were not included in the analyses.
Questionnaire Administration
Data collection took place between April 2010 and June 2010. Interviewers requested to speak with the department responsible for credentialing or privileging at the hospital, typically the Medical Staff Office, the Office of Clinical Affairs, or the Credentialing or Privileging Department. When the appropriate person was identified and located, interviewers explained the purpose of the study and obtained verbal consent to participate.
Data Analysis
Initially, frequency distributions were calculated for all survey items to create descriptive statistics. Next, we performed a cross‐tabulation of responses by the specific hospital classifications listed above (COTH and NACHRI status) and computed the 2 statistics. Finally, we conducted bivariate analyses on the 2005 and 2010 results. SAS version 9.1 (SAS Institute Inc., Cary, NC) was used for all statistical analyses. P<0.05 was considered statistically significant.
Although this study is similar to the study that was completed in 2005,[1] we have reanalyzed those data to more specifically assess certification policy. All results are now weighted in contrast to the 2005 study, which only weighted the results by hospital classification. Thus, the numbers in some cases may be slightly different from those reported in 2006. We believe that this has resulted in a more robust analysis of hospital use of board certification in privileging.
Comparisons
Where possible, results were compared with those found in a 2005 study of hospital privileging.[1] The sampling frame for that study was identical to the current study, but the specific hospitals may or may not be included in the current study.
The study was approved by the University of Michigan Medical School Institutional Review Board.
RESULTS
Response Rate and Respondent Demographics
Of the 220 hospitals surveyed, 23 were ineligible because they did not have at least 1 pediatrician on staff. Of the remaining 197 hospitals, 154 completed the survey, resulting in a 78% participation rate.
Response rates did not differ significantly by NACHRI or COTH hospital status; therefore, there was no impact on the analytic power of the weighting. Approximately half (54%, n=82) of the respondents were NACHRI member hospitals, and 49% (n=75) were COTH hospitals.
Because not every hospital responded to every question, the total number for each question response may differ slightly.
2005 VS 2010 COMPARISONS
Board Certification Requirements
Compared with our findings in 2005, in 2010 a greater proportion of hospitals now require board certification for general pediatricians (80% vs 67%, P=0.141). Among these hospitals, a much larger proportion (24% vs 4%) now require board certification for all pediatricians at the point of initial privileging (Table 1). Similarly, a greater proportion of hospitals now require board certification for pediatric subspecialists (86% vs 71%, P=0.048). The percentage of hospitals that require subspecialists to be board certified at the point of initial privileging also increased from 10% in 2005 to 34% in 2010.
| General Pediatricians | Pediatric Subspecialists | |||
|---|---|---|---|---|
| 2005 (N=159) | 2010 (N=154) | 2005 (N=153) | 2010 (N=147) | |
| ||||
| Certification never required | 33%a | 20%a | 29%b | 14%b |
| Certification ever required | 67%a | 80%a | 71%b | 86%b |
| At time of initial privileging for all pediatricians | 4% | 24% | 10% | 34% |
| Within a specified time frame of initial privileging | 50% | 29% | 41% | 32% |
| At time of initial privileging but only for some pediatricians | 11% | 24% | 16% | 17% |
| Only recertification required | 2% | 3% | 4% | 3% |
The proportion of teaching (COTH) hospitals that require general pediatricians to be board certified at some point in time increased from 63% in 2005 to 89% in 2010 (P=0.001), and the percentage that require board certification for all pediatricians at initial privileging increased from 2% in 2005 to 25% in 2010. Similarly, the proportion of teaching hospitals that require pediatric subspecialists to be board certified increased from 66% in 2005 to 89% in 2010 (P=0.003).
There were small changes between 2005 and 2010 in the proportion of nonteaching (68% vs 79%, P=0.231), NACHRI‐member (76% vs 82%, P=0.366), and non‐NACHRI member (67% vs 80%, P=0.156) hospitals that require pediatricians to be board certified at some point in time. The proportion of nonteaching (4% vs 24%), NACHRI‐member (5% vs 32%), and non‐NACHRI (4% vs 23%) hospitals that require board certification at the point of initial privileging also increased between 2005 and 2010.
Certification Policies at Initial Privileging
Although in 2010, a greater proportion of hospitals reported that they require board certification for general pediatricians and pediatric subspecialists at the point of initial privileging, a much larger proportion of hospitals reported that they make exceptions to their board certification policies for both general pediatricians (99% vs 41%) (Table 2) and pediatric subspecialists (98% vs 14%) (Table 3). Among hospitals that do not require board certification at the point of initial privileging, only small differences were seen in requirements around completion of residency or fellowship training and time frame after which certification must be achieved (Tables 2 and 3).
| 2005 (N=159) | 2010 (N=154) | |
|---|---|---|
| Certification required at initial privileging | ||
| Yes | 4% | 24% |
| Mixed policy | 11% | 24% |
| No | 85% | 52% |
| If hospital required certification at initial privileging: | ||
| Allowed exceptions to policy at initial privileging | 41% | 99% |
| Required certification to be current | 99% | 99% |
| If hospital did not require certification at initial privileging: | ||
| Required to complete residency | 85% | 84% |
| Established time frame after which certification must be achieved | 48% | 51% |
| 2005 (N=153) | 2010 (N=147) | |
|---|---|---|
| Certification required at initial privileging | ||
| Yes | 10% | 34% |
| Mixed policy | 5% | 17% |
| No | 85% | 49% |
| If hospital required certification at initial privileging: | ||
| Allowed exceptions to policy at initial privileging | 14% | 98% |
| Required certification to be current | 83% | 100% |
| If hospital did not require certification at initial privileging: | ||
| Required to complete fellowship | 86% | 86% |
| Established time frame after which certification must be achieved | 47% | 52% |
There were no meaningful differences between board certification policies for general pediatricians and pediatric subspecialists in 2010.
Comparing Recertification and MOC Policies
Few hospitals required permanent certificate holders to recertify (2005) or enroll in MOC (2010) in 2005 (5%) or 2010 (6%). The proportion of hospitals that required recertification or MOC enrollment for general pediatricians increased from 33% in 2005 to 42% in 2010. Similarly, the percentage of hospitals that required recertification or MOC enrollment for pediatric subspecialists increased from 25% in 2005 to 35% in 2010.
Between 2005 and 2010, there was no significant change in the proportion of hospitals that reported revoking or denying privileges to a pediatrician due to failure to recertify or enroll in MOC (3% vs 6%).
SPECIFIC MAINTENANCE OF CERTIFICATION POLICIES IN 2010
Board Certification Requirements
Respondents from 29% of hospitals reported that they were not at all familiar with the American Board of Pediatrics' (ABP) MOC program. Most respondents (58%) were familiar with MOC, with 37% reporting that they were somewhat familiar, and 12% reporting that they were very familiar with the program.
Three‐fourths of hospitals (76%) reported that their MOC requirements do not differ from their recertification requirements held prior to the institution of MOC, and 14% reported that their hospital had not yet established specific MOC requirements.
The majority of respondents (62%) had verified the board certification of some physicians since the institution of the ABP's MOC program on January 1, 2010. A majority (53%) of hospitals track MOC data for all pediatricians, whereas 3% of respondents track MOC data only for those pediatricians whose initial certification was time limited.
Of those hospitals that require pediatricians with permanent certificates to enroll in MOC, 9% allow them to retain their privileges for a period of time if they are not meeting the requirements for MOC. Among hospitals that require pediatricians with time‐limited certificates to enroll in MOC, fewer than half allow general pediatricians (37%) and pediatric subspecialists (40%) to retain their privileges if they are not meeting the requirements for MOC.
The majority of respondents (89%) reported that the initiation of MOC had not changed board certification requirements at their hospital. However, respondents from over one‐quarter of hospitals (27%) reported that they expect changes in their hospital's certification or MOC requirements in the next 2 years. Those hospitals that reported changes moved to more stringent requirements for certification at initial privileging and requirements for permanent certificate holders to meet MOC requirements.
DISCUSSION
In the 5 years since our previous study, a larger proportion of hospitals now require pediatricians to become board certified to obtain hospital privileges. Of note is that a larger proportion of hospitals also now require board certification at the time of initial privileging for both generalist and subspecialist pediatricians.
Hospitals face increasing pressure to differentiate themselves from their peers through better patient outcomes.[9, 10] The increase from 67% to 80% of hospitals requiring board certification may be a result of hospitals utilizing certification as a proxy for assessment of physician quality or as a way to engage physicians in quality improvement through the MOC program.[11] Hospitals may also be responding to greater interest in MOC from regulatory agencies such as the Centers for Medicare and Medicaid Services Maintenance of Certification Program Incentive, which rewards physicians with an additional incentive payment beyond the Physician Quality Reporting System incentive for their participation in the MOC program.[12]
Interestingly, although a greater proportion of hospitals reported that they require certification, a much larger proportion of hospitals make exceptions to the policy. The exceptions could include grandfathering physicians who had hospital privileges prior to the policy change, or giving recent graduates additional time to obtain board certification. It is unknown whether or not all of these physicians would be required to obtain board certification or participate in MOC after some provisional time frame.
Hospitals in our study appear to be incorporating the MOC program into their policies. However, fewer than half of the hospitals studied require pediatricians with time‐limited certificates to enroll in MOC if their certificates have expired. In addition, some hospitals are still establishing their MOC requirements for those pediatricians with time‐limited and permanent certificates. It is likely that the majority of hospitals retained their previous board certification requirements, and that the current flux in hospital requirements is not unique to pediatrics, as all American Board of Medical Specialties' specialties have recently implemented MOC requirements.[13] Hospitals will likely adjust their credentialing policies as their familiarity and experience with MOC grows.
The primary purpose of the specialty certification process is to provide to the public, which includes both individual consumers and regulatory agencies, an assessment of the competency of individual physicians. Self‐regulation through certification is a privilege of trust granted to the medical profession by the public. This is an essential concept that underlies the concept of specialty certification.[14] As the public has continued to adopt a greater focus, and additional demands, on safety and quality assessment in healthcare, the medical profession must in turn be responsive.[13, 15, 16, 17] Failure in this regard would run the risk of losing that trust with the public, with the resultant loss of the ability to self‐regulate.
Studies have indicated a positive relationship between board certification and quality of care, yet this area remains hampered by a paucity of data.[18, 19, 20, 21, 22] Pham et al. found that board certified physicians were more likely to provide preventative care services to Medicare patients.[22] In 2008, Turchin et al. showed that recertification made a small, yet meaningful, difference in physician treatment of hypertension.[18] This area of research is especially important, as the MOC program is more comprehensive and utilizes an ongoing system of assessment and physician engagement. As such, it has been criticized by some for being complicated, burdensome, and irrelevant to the manner in which physicians actually practice.[23, 24] However, previous methods of certification were limited to assessing physicians at 1 point in time during their entire careers (eg, permanent certification) or at specific intervals (eg, time‐limited certification). With recent increased attention to improving the quality of patient care, these methods were unable to assure the public that physicians maintained their knowledge and skills over time in an environment of increasing rapid incorporation of new knowledge into clinical practice. Recent reports have also shown that (years of) practice does not make perfect with regard to physician performance. In fact, there may be deterioration of performance over long periods of practice.[25] Furthermore, although physicians commonly believe they are able to assess their own performance, available evidence does not support that contention.[26, 27] Thus, there is a need for an objective ongoing assessment of physician performance that also has the capacity to continuously improve the quality of care provided.
The comprehensive nature of the MOC program is a result of efforts to meaningfully incorporate the 6 competencies defined by the ACGME into the certification process. Although MOC is still relatively new and maturing, a growing body of evidence is demonstrating effectiveness of specific components of the program.[28, 29, 30, 31] In the field of pediatrics, several programs approved for MOC credit have already demonstrated their effectiveness in improving the quality of care in clinical practice.[32, 33, 34, 35, 36] However, additional efforts are needed to evaluate more of the part 4 (Assessment of Practice Performance) modules to assess their impact on patient care. The continued commitment to quality of care and quality improvement in hospitals will likely result in a further adoption of MOC requirements as the process matures and demonstrable impacts on patient outcomes are assessed. Furthermore, greater coordination of MOC with quality assessments in health plans and in the changes taking place in the process of licensure will likely help to streamline the paperwork and documentation burden placed on physicians by multiple assessment efforts.
This study has several limitations. Because the MOC program was initiated by the ABP in January 2010, there may be a lag in uptake of this particular requirement by hospitals. In some cases, this may have been the first time that members of the credentialing staff had considered the MOC program. It is probable that staff awareness will increase over time, as hospital policies are further developed and greater exposure to the specifics of the MOC program occurs. Additionally, although we compared stratified random samples of hospitals in 2005 and 2010, we did not follow the same group of hospitals over time.
As with all changes to the certification program over the years, there is a period of time required for new requirements to be understood and accepted by both those in regulatory positions and those in the medical profession. The demands of the public for increasingly comprehensive assessments of healthcare quality will continue into the future.
Acknowledgments
Disclosures: Funding was provided by a grant from the American Board of Pediatrics Foundation. The authors have no other disclosures or conflicts of interest to report.
In 2005, we conducted a study of the prevalence of board certification requirements for hospital privileging of pediatricians.[1] Since that time, there have been many changes in the landscape of both physician and healthcare‐system quality assessment. New developments include greater utilization of physician quality‐of‐care assessment tools, a change from recertification for time‐limited board certification to Maintenance of Certification (MOC) in 2010, and an increasing commitment on the part of hospitals and state licensing officials to patient safety and quality‐of‐care issues, due in part to the continued interest by governmental and private payors and the public on external measurement of healthcare quality.[2, 3, 4, 5, 6]
MOC is an ongoing process of lifelong learning and self‐assessment to continuously improve knowledge and clinical performance. It has been adopted by all 24 member boards of the American Boards of Medical Specialties. MOC is focused on the 6 core competencies of quality medical care as outlined by the Accreditation Council for Graduate Medical Education (ACGME): (1) patient care, (2) medical knowledge, (3) practice‐based learning, (4) systems‐based practice, (5) professionalism, and (6) interpersonal and communication skills. To address, these competencies, MOC involves a 4‐part process for continuous learning that is required to keep certification current: (1) licensure and professional standing, (2) lifelong learning and self‐assessment, (3) cognitive expertise, and (4) practice performance assessment.[7, 8]
Our previous study found that many hospitals utilize specialty certification as a marker of quality for privileging.[1] To explore changes in the policies of hospitals regarding requirements for board certification and the incorporation of MOC into those requirements, we conducted a 5‐year follow‐up study of a national random sample of hospitals in 2010.
METHODS
Sample
All hospitals identified in the American Hospital Association's 2009 Annual Survey of Hospitals as providing care to pediatric patients were included in the sampling frame (N=2136). We then selected a stratified random sample of 10% of the total (N=220) hospitals weighted to provide nationally representative estimates. The sample was stratified by Council of Teaching Hospitals (COTH) designation (teaching vs nonteaching) and National Association of Children's Hospitals and Related Institutions (NACHRI) membership. In contrast to our previous study, in this study we did not stratify according to the designation of freestanding children's hospital (vs part of a hospital system) or metropolitan statistical area size (urban vs rural), as comparisons across these designations were not found to be significant in 2005.
Hospitals were sampled with varying probabilities from each stratum. Weights were applied to create a representative sample of the overall hospital population. The total sampling weight (TSW) calculated for each hospital was based on the probability of selection into the study (P) and the response rate (RR). The following formula was used: TSW: (1/P) (1/RR).
Survey Instrument
In collaboration with the American Board of Pediatrics Research Advisory Committee, we developed a 24‐item, fixed‐choice, structured questionnaire to be administered by phone. The survey was designed to be completed in 15 minutes or less and focused on board certification requirements at initial privileging, recredentialing, and MOC requirements.
The survey focused on the following descriptive research questions: Do hospitals require board certification for pediatricians at the time of initial privileging? Do they ever require board certification for privileging? Are there different certification requirements for generalists vs subspecialists? Are pediatricians with permanent certificates required to enroll in MOC?
Other questions focused on such issues such as whether the hospital was familiar with the requirements of MOC, whether MOC was required of all pediatricians, and whether the institution of MOC changed certification requirements at the hospital.
The instrument was pilot tested for clarity and ease of use with representatives from a convenience sample of hospitals within the state of Michigan and revised to clarify potentially ambiguous questions. Pilot surveys were not included in the analyses.
Questionnaire Administration
Data collection took place between April 2010 and June 2010. Interviewers requested to speak with the department responsible for credentialing or privileging at the hospital, typically the Medical Staff Office, the Office of Clinical Affairs, or the Credentialing or Privileging Department. When the appropriate person was identified and located, interviewers explained the purpose of the study and obtained verbal consent to participate.
Data Analysis
Initially, frequency distributions were calculated for all survey items to create descriptive statistics. Next, we performed a cross‐tabulation of responses by the specific hospital classifications listed above (COTH and NACHRI status) and computed the 2 statistics. Finally, we conducted bivariate analyses on the 2005 and 2010 results. SAS version 9.1 (SAS Institute Inc., Cary, NC) was used for all statistical analyses. P<0.05 was considered statistically significant.
Although this study is similar to the study that was completed in 2005,[1] we have reanalyzed those data to more specifically assess certification policy. All results are now weighted in contrast to the 2005 study, which only weighted the results by hospital classification. Thus, the numbers in some cases may be slightly different from those reported in 2006. We believe that this has resulted in a more robust analysis of hospital use of board certification in privileging.
Comparisons
Where possible, results were compared with those found in a 2005 study of hospital privileging.[1] The sampling frame for that study was identical to the current study, but the specific hospitals may or may not be included in the current study.
The study was approved by the University of Michigan Medical School Institutional Review Board.
RESULTS
Response Rate and Respondent Demographics
Of the 220 hospitals surveyed, 23 were ineligible because they did not have at least 1 pediatrician on staff. Of the remaining 197 hospitals, 154 completed the survey, resulting in a 78% participation rate.
Response rates did not differ significantly by NACHRI or COTH hospital status; therefore, there was no impact on the analytic power of the weighting. Approximately half (54%, n=82) of the respondents were NACHRI member hospitals, and 49% (n=75) were COTH hospitals.
Because not every hospital responded to every question, the total number for each question response may differ slightly.
2005 VS 2010 COMPARISONS
Board Certification Requirements
Compared with our findings in 2005, in 2010 a greater proportion of hospitals now require board certification for general pediatricians (80% vs 67%, P=0.141). Among these hospitals, a much larger proportion (24% vs 4%) now require board certification for all pediatricians at the point of initial privileging (Table 1). Similarly, a greater proportion of hospitals now require board certification for pediatric subspecialists (86% vs 71%, P=0.048). The percentage of hospitals that require subspecialists to be board certified at the point of initial privileging also increased from 10% in 2005 to 34% in 2010.
| General Pediatricians | Pediatric Subspecialists | |||
|---|---|---|---|---|
| 2005 (N=159) | 2010 (N=154) | 2005 (N=153) | 2010 (N=147) | |
| ||||
| Certification never required | 33%a | 20%a | 29%b | 14%b |
| Certification ever required | 67%a | 80%a | 71%b | 86%b |
| At time of initial privileging for all pediatricians | 4% | 24% | 10% | 34% |
| Within a specified time frame of initial privileging | 50% | 29% | 41% | 32% |
| At time of initial privileging but only for some pediatricians | 11% | 24% | 16% | 17% |
| Only recertification required | 2% | 3% | 4% | 3% |
The proportion of teaching (COTH) hospitals that require general pediatricians to be board certified at some point in time increased from 63% in 2005 to 89% in 2010 (P=0.001), and the percentage that require board certification for all pediatricians at initial privileging increased from 2% in 2005 to 25% in 2010. Similarly, the proportion of teaching hospitals that require pediatric subspecialists to be board certified increased from 66% in 2005 to 89% in 2010 (P=0.003).
There were small changes between 2005 and 2010 in the proportion of nonteaching (68% vs 79%, P=0.231), NACHRI‐member (76% vs 82%, P=0.366), and non‐NACHRI member (67% vs 80%, P=0.156) hospitals that require pediatricians to be board certified at some point in time. The proportion of nonteaching (4% vs 24%), NACHRI‐member (5% vs 32%), and non‐NACHRI (4% vs 23%) hospitals that require board certification at the point of initial privileging also increased between 2005 and 2010.
Certification Policies at Initial Privileging
Although in 2010, a greater proportion of hospitals reported that they require board certification for general pediatricians and pediatric subspecialists at the point of initial privileging, a much larger proportion of hospitals reported that they make exceptions to their board certification policies for both general pediatricians (99% vs 41%) (Table 2) and pediatric subspecialists (98% vs 14%) (Table 3). Among hospitals that do not require board certification at the point of initial privileging, only small differences were seen in requirements around completion of residency or fellowship training and time frame after which certification must be achieved (Tables 2 and 3).
| 2005 (N=159) | 2010 (N=154) | |
|---|---|---|
| Certification required at initial privileging | ||
| Yes | 4% | 24% |
| Mixed policy | 11% | 24% |
| No | 85% | 52% |
| If hospital required certification at initial privileging: | ||
| Allowed exceptions to policy at initial privileging | 41% | 99% |
| Required certification to be current | 99% | 99% |
| If hospital did not require certification at initial privileging: | ||
| Required to complete residency | 85% | 84% |
| Established time frame after which certification must be achieved | 48% | 51% |
| 2005 (N=153) | 2010 (N=147) | |
|---|---|---|
| Certification required at initial privileging | ||
| Yes | 10% | 34% |
| Mixed policy | 5% | 17% |
| No | 85% | 49% |
| If hospital required certification at initial privileging: | ||
| Allowed exceptions to policy at initial privileging | 14% | 98% |
| Required certification to be current | 83% | 100% |
| If hospital did not require certification at initial privileging: | ||
| Required to complete fellowship | 86% | 86% |
| Established time frame after which certification must be achieved | 47% | 52% |
There were no meaningful differences between board certification policies for general pediatricians and pediatric subspecialists in 2010.
Comparing Recertification and MOC Policies
Few hospitals required permanent certificate holders to recertify (2005) or enroll in MOC (2010) in 2005 (5%) or 2010 (6%). The proportion of hospitals that required recertification or MOC enrollment for general pediatricians increased from 33% in 2005 to 42% in 2010. Similarly, the percentage of hospitals that required recertification or MOC enrollment for pediatric subspecialists increased from 25% in 2005 to 35% in 2010.
Between 2005 and 2010, there was no significant change in the proportion of hospitals that reported revoking or denying privileges to a pediatrician due to failure to recertify or enroll in MOC (3% vs 6%).
SPECIFIC MAINTENANCE OF CERTIFICATION POLICIES IN 2010
Board Certification Requirements
Respondents from 29% of hospitals reported that they were not at all familiar with the American Board of Pediatrics' (ABP) MOC program. Most respondents (58%) were familiar with MOC, with 37% reporting that they were somewhat familiar, and 12% reporting that they were very familiar with the program.
Three‐fourths of hospitals (76%) reported that their MOC requirements do not differ from their recertification requirements held prior to the institution of MOC, and 14% reported that their hospital had not yet established specific MOC requirements.
The majority of respondents (62%) had verified the board certification of some physicians since the institution of the ABP's MOC program on January 1, 2010. A majority (53%) of hospitals track MOC data for all pediatricians, whereas 3% of respondents track MOC data only for those pediatricians whose initial certification was time limited.
Of those hospitals that require pediatricians with permanent certificates to enroll in MOC, 9% allow them to retain their privileges for a period of time if they are not meeting the requirements for MOC. Among hospitals that require pediatricians with time‐limited certificates to enroll in MOC, fewer than half allow general pediatricians (37%) and pediatric subspecialists (40%) to retain their privileges if they are not meeting the requirements for MOC.
The majority of respondents (89%) reported that the initiation of MOC had not changed board certification requirements at their hospital. However, respondents from over one‐quarter of hospitals (27%) reported that they expect changes in their hospital's certification or MOC requirements in the next 2 years. Those hospitals that reported changes moved to more stringent requirements for certification at initial privileging and requirements for permanent certificate holders to meet MOC requirements.
DISCUSSION
In the 5 years since our previous study, a larger proportion of hospitals now require pediatricians to become board certified to obtain hospital privileges. Of note is that a larger proportion of hospitals also now require board certification at the time of initial privileging for both generalist and subspecialist pediatricians.
Hospitals face increasing pressure to differentiate themselves from their peers through better patient outcomes.[9, 10] The increase from 67% to 80% of hospitals requiring board certification may be a result of hospitals utilizing certification as a proxy for assessment of physician quality or as a way to engage physicians in quality improvement through the MOC program.[11] Hospitals may also be responding to greater interest in MOC from regulatory agencies such as the Centers for Medicare and Medicaid Services Maintenance of Certification Program Incentive, which rewards physicians with an additional incentive payment beyond the Physician Quality Reporting System incentive for their participation in the MOC program.[12]
Interestingly, although a greater proportion of hospitals reported that they require certification, a much larger proportion of hospitals make exceptions to the policy. The exceptions could include grandfathering physicians who had hospital privileges prior to the policy change, or giving recent graduates additional time to obtain board certification. It is unknown whether or not all of these physicians would be required to obtain board certification or participate in MOC after some provisional time frame.
Hospitals in our study appear to be incorporating the MOC program into their policies. However, fewer than half of the hospitals studied require pediatricians with time‐limited certificates to enroll in MOC if their certificates have expired. In addition, some hospitals are still establishing their MOC requirements for those pediatricians with time‐limited and permanent certificates. It is likely that the majority of hospitals retained their previous board certification requirements, and that the current flux in hospital requirements is not unique to pediatrics, as all American Board of Medical Specialties' specialties have recently implemented MOC requirements.[13] Hospitals will likely adjust their credentialing policies as their familiarity and experience with MOC grows.
The primary purpose of the specialty certification process is to provide to the public, which includes both individual consumers and regulatory agencies, an assessment of the competency of individual physicians. Self‐regulation through certification is a privilege of trust granted to the medical profession by the public. This is an essential concept that underlies the concept of specialty certification.[14] As the public has continued to adopt a greater focus, and additional demands, on safety and quality assessment in healthcare, the medical profession must in turn be responsive.[13, 15, 16, 17] Failure in this regard would run the risk of losing that trust with the public, with the resultant loss of the ability to self‐regulate.
Studies have indicated a positive relationship between board certification and quality of care, yet this area remains hampered by a paucity of data.[18, 19, 20, 21, 22] Pham et al. found that board certified physicians were more likely to provide preventative care services to Medicare patients.[22] In 2008, Turchin et al. showed that recertification made a small, yet meaningful, difference in physician treatment of hypertension.[18] This area of research is especially important, as the MOC program is more comprehensive and utilizes an ongoing system of assessment and physician engagement. As such, it has been criticized by some for being complicated, burdensome, and irrelevant to the manner in which physicians actually practice.[23, 24] However, previous methods of certification were limited to assessing physicians at 1 point in time during their entire careers (eg, permanent certification) or at specific intervals (eg, time‐limited certification). With recent increased attention to improving the quality of patient care, these methods were unable to assure the public that physicians maintained their knowledge and skills over time in an environment of increasing rapid incorporation of new knowledge into clinical practice. Recent reports have also shown that (years of) practice does not make perfect with regard to physician performance. In fact, there may be deterioration of performance over long periods of practice.[25] Furthermore, although physicians commonly believe they are able to assess their own performance, available evidence does not support that contention.[26, 27] Thus, there is a need for an objective ongoing assessment of physician performance that also has the capacity to continuously improve the quality of care provided.
The comprehensive nature of the MOC program is a result of efforts to meaningfully incorporate the 6 competencies defined by the ACGME into the certification process. Although MOC is still relatively new and maturing, a growing body of evidence is demonstrating effectiveness of specific components of the program.[28, 29, 30, 31] In the field of pediatrics, several programs approved for MOC credit have already demonstrated their effectiveness in improving the quality of care in clinical practice.[32, 33, 34, 35, 36] However, additional efforts are needed to evaluate more of the part 4 (Assessment of Practice Performance) modules to assess their impact on patient care. The continued commitment to quality of care and quality improvement in hospitals will likely result in a further adoption of MOC requirements as the process matures and demonstrable impacts on patient outcomes are assessed. Furthermore, greater coordination of MOC with quality assessments in health plans and in the changes taking place in the process of licensure will likely help to streamline the paperwork and documentation burden placed on physicians by multiple assessment efforts.
This study has several limitations. Because the MOC program was initiated by the ABP in January 2010, there may be a lag in uptake of this particular requirement by hospitals. In some cases, this may have been the first time that members of the credentialing staff had considered the MOC program. It is probable that staff awareness will increase over time, as hospital policies are further developed and greater exposure to the specifics of the MOC program occurs. Additionally, although we compared stratified random samples of hospitals in 2005 and 2010, we did not follow the same group of hospitals over time.
As with all changes to the certification program over the years, there is a period of time required for new requirements to be understood and accepted by both those in regulatory positions and those in the medical profession. The demands of the public for increasingly comprehensive assessments of healthcare quality will continue into the future.
Acknowledgments
Disclosures: Funding was provided by a grant from the American Board of Pediatrics Foundation. The authors have no other disclosures or conflicts of interest to report.
- , , , , , . Policies and practices related to the role of board certification and recertification of pediatricians in hospital privileging. JAMA. 2006;295(8):905–912.
- American Board of Pediatrics. Maintenance of Certification: MOC requirements. 2011. Available at: https://www.abp.org/ABPWeb Static/#murl%3D%2FABPWebStatic%2Fmoc.html%26surl%3D%2 Fabpwebsite%2Fmoc%2Fphysicianrequirements%2Fphysreq.htm. Accessed May 23, 2011.
- , , , , , . Maintenance of licensure: protecting the public, promoting quality health care. J Med Regul. 2010;96(2):13–20.
- , , , , . Setting a fair performance standard for physicians' quality of patient care. J Gen Intern Med. 2011;26(5):467–473.
- , . Payer trend: “tiering” physicians and “steering” patients. Fam Pract Manag. 2007;14(10):24–26.
- , , , et al. Association between maintenance of certification examination scores and quality of care for medicare beneficiaries. Arch Intern Med. 2008;168(13):1396–1403.
- American Board of Medical Specialties. ABMS Maintenance of Certification. Available at: http://www.abms.org/Maintenance_of_Certification/ABMS_MOC.aspx. Accessed January 23, 2012.
- American Board of Medical Specialties. ABMS Maintenance of Certification. Available at: http://www.abms.org/maintenance_of_certification/MOC_competencies.aspx. Accessed January 24, 2012.
- , , . Hospital performance reports: impact on quality, market share, and reputation. Health Aff (Millwood). 2005;24(4):1150–1160.
- , , , et al. Impact of public reporting of coronary artery bypass graft surgery performance data on market share, mortality, and patient selection. Med Care. 2011;49(12):1118–1125.
- , , . Hospital strategies to engage physicians in quality improvement. Available at: www.hschange.org/CONTENT/1087. Accessed June 4, 2012.
- The Physician Quality Reporting System Maintenance of Certification Program Incentive Requirements of Self‐Nomination for 2012. http://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instru ments/PQRS/downloads/2012_MaintenanceofCertificationProgram_ mmrvsd01162012.pdf. Accessed June 4, 2012.
- , , . Maintenance of Certification, maintenance of public trust. Plast Reconstr Surg. 2011;127(2):967–973.
- , . Credentialing and public accountability: a central role for board certification. JAMA. 2006;295(8):939–940.
- , , , . Perspectives and preferences among the general public regarding physician selection and board certification. J Pediatr. 2010;156(5):841–845, 845.e1.
- , . Public perceptions of quality care and provider profiling in New York: implications for improving quality care and public health. J Public Health Manag Pract. 2004;10(3):241–250.
- . Future of board certification in a new era of public accountability. J Am Board Fam Med. 2010;23(suppl 1):S32–S39.
- , , , , . Effect of board certification on antihypertensive treatment intensification in patients with diabetes mellitus. Circulation. 2008;117(5):623–628.
- , , , , . Physician board certification and the care and outcomes of elderly patients with acute myocardial infarction. J Gen Intern Med. 2006;21(3):238–244.
- , , . Certifying examination performance and patient outcomes following acute myocardial infarction. Med Educ. 2002;36(9):853–859.
- , , , , . Specialty board certification and clinical outcomes: the missing link. Acad Med. 2002;77(6):534–542.
- , , , . Delivery of preventive services to older adults by primary care physicians. JAMA. 2005;294(4):473–481.
- . Are you ready for maintenance of certification? Fam Pract Manag. 2005;12(1):42–48.
- , , , , . Clinical decisions. American Board of Internal Medicine maintenance of certification program. N Engl J Med. 2010;362(10):948–952.
- . As doctors age, worries about their abilities grow. New York Times. January 24, 2011:D.1.
- , , . Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005;142(4):260–273.
- , , , , , . Accuracy of physician self‐assessment compared with observed measures of competence: a systematic review. JAMA. 2006;296(9):1094–1102.
- , , . The impact of a preventive cardiology quality improvement intervention on residents and clinics: a qualitative exploration. Am J Med Qual. 2009;24(2):99–107.
- , , , , , . Promoting physicians' self‐assessment and quality improvement: the ABIM diabetes practice improvement module. J Contin Educ Health Prof. 2006;26(2):109–119.
- , , , et al. Self‐assessment of practice performance: development of the ABIM Practice Improvement Module (PIM). J Contin Educ Health Prof. 2008;28(1):38–46.
- , , , , , . Variation in internal medicine residency clinic practices: assessing practice environments and quality of care. J Gen Intern Med. 2008;23(7):914–920.
- , , , et al. Statewide NICU central‐line‐associated bloodstream infection rates decline after bundles and checklists. Pediatrics. 2011;127(3):436–444.
- , , , et al. ImproveCareNow: the development of a pediatric inflammatory bowel disease improvement network. Inflamm Bowel Dis. 2011;17(1):450–457.
- , . Pay for performance alone cannot drive quality. Arch Pediatr Adolesc Med. 2007;161(7):650–655.
- , , , et al. National pediatric cardiology quality improvement collaborative: lessons learned from development and early years. Prog Pediatr Cardiol. 2011;32(2):103–109.
- , , , et al. Reducing PICU central line‐associated bloodstream infections: 3‐year results. Pediatrics. 2011;128(5):e1077–e1083.
- , , , , , . Policies and practices related to the role of board certification and recertification of pediatricians in hospital privileging. JAMA. 2006;295(8):905–912.
- American Board of Pediatrics. Maintenance of Certification: MOC requirements. 2011. Available at: https://www.abp.org/ABPWeb Static/#murl%3D%2FABPWebStatic%2Fmoc.html%26surl%3D%2 Fabpwebsite%2Fmoc%2Fphysicianrequirements%2Fphysreq.htm. Accessed May 23, 2011.
- , , , , , . Maintenance of licensure: protecting the public, promoting quality health care. J Med Regul. 2010;96(2):13–20.
- , , , , . Setting a fair performance standard for physicians' quality of patient care. J Gen Intern Med. 2011;26(5):467–473.
- , . Payer trend: “tiering” physicians and “steering” patients. Fam Pract Manag. 2007;14(10):24–26.
- , , , et al. Association between maintenance of certification examination scores and quality of care for medicare beneficiaries. Arch Intern Med. 2008;168(13):1396–1403.
- American Board of Medical Specialties. ABMS Maintenance of Certification. Available at: http://www.abms.org/Maintenance_of_Certification/ABMS_MOC.aspx. Accessed January 23, 2012.
- American Board of Medical Specialties. ABMS Maintenance of Certification. Available at: http://www.abms.org/maintenance_of_certification/MOC_competencies.aspx. Accessed January 24, 2012.
- , , . Hospital performance reports: impact on quality, market share, and reputation. Health Aff (Millwood). 2005;24(4):1150–1160.
- , , , et al. Impact of public reporting of coronary artery bypass graft surgery performance data on market share, mortality, and patient selection. Med Care. 2011;49(12):1118–1125.
- , , . Hospital strategies to engage physicians in quality improvement. Available at: www.hschange.org/CONTENT/1087. Accessed June 4, 2012.
- The Physician Quality Reporting System Maintenance of Certification Program Incentive Requirements of Self‐Nomination for 2012. http://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instru ments/PQRS/downloads/2012_MaintenanceofCertificationProgram_ mmrvsd01162012.pdf. Accessed June 4, 2012.
- , , . Maintenance of Certification, maintenance of public trust. Plast Reconstr Surg. 2011;127(2):967–973.
- , . Credentialing and public accountability: a central role for board certification. JAMA. 2006;295(8):939–940.
- , , , . Perspectives and preferences among the general public regarding physician selection and board certification. J Pediatr. 2010;156(5):841–845, 845.e1.
- , . Public perceptions of quality care and provider profiling in New York: implications for improving quality care and public health. J Public Health Manag Pract. 2004;10(3):241–250.
- . Future of board certification in a new era of public accountability. J Am Board Fam Med. 2010;23(suppl 1):S32–S39.
- , , , , . Effect of board certification on antihypertensive treatment intensification in patients with diabetes mellitus. Circulation. 2008;117(5):623–628.
- , , , , . Physician board certification and the care and outcomes of elderly patients with acute myocardial infarction. J Gen Intern Med. 2006;21(3):238–244.
- , , . Certifying examination performance and patient outcomes following acute myocardial infarction. Med Educ. 2002;36(9):853–859.
- , , , , . Specialty board certification and clinical outcomes: the missing link. Acad Med. 2002;77(6):534–542.
- , , , . Delivery of preventive services to older adults by primary care physicians. JAMA. 2005;294(4):473–481.
- . Are you ready for maintenance of certification? Fam Pract Manag. 2005;12(1):42–48.
- , , , , . Clinical decisions. American Board of Internal Medicine maintenance of certification program. N Engl J Med. 2010;362(10):948–952.
- . As doctors age, worries about their abilities grow. New York Times. January 24, 2011:D.1.
- , , . Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005;142(4):260–273.
- , , , , , . Accuracy of physician self‐assessment compared with observed measures of competence: a systematic review. JAMA. 2006;296(9):1094–1102.
- , , . The impact of a preventive cardiology quality improvement intervention on residents and clinics: a qualitative exploration. Am J Med Qual. 2009;24(2):99–107.
- , , , , , . Promoting physicians' self‐assessment and quality improvement: the ABIM diabetes practice improvement module. J Contin Educ Health Prof. 2006;26(2):109–119.
- , , , et al. Self‐assessment of practice performance: development of the ABIM Practice Improvement Module (PIM). J Contin Educ Health Prof. 2008;28(1):38–46.
- , , , , , . Variation in internal medicine residency clinic practices: assessing practice environments and quality of care. J Gen Intern Med. 2008;23(7):914–920.
- , , , et al. Statewide NICU central‐line‐associated bloodstream infection rates decline after bundles and checklists. Pediatrics. 2011;127(3):436–444.
- , , , et al. ImproveCareNow: the development of a pediatric inflammatory bowel disease improvement network. Inflamm Bowel Dis. 2011;17(1):450–457.
- , . Pay for performance alone cannot drive quality. Arch Pediatr Adolesc Med. 2007;161(7):650–655.
- , , , et al. National pediatric cardiology quality improvement collaborative: lessons learned from development and early years. Prog Pediatr Cardiol. 2011;32(2):103–109.
- , , , et al. Reducing PICU central line‐associated bloodstream infections: 3‐year results. Pediatrics. 2011;128(5):e1077–e1083.
Copyright © 2013 Society of Hospital Medicine
Pediatric Hospitalists
There has been marked recent growth in the employment and utilization of both pediatric and adult hospitalists. Recent data demonstrate that approximately 25% of current pediatric hospitalist programs are less than 2 years old.1 Some have posited that this growth is due to increasing pressure from the public and payors to deliver cost‐effective and high‐quality care.2 However, little is known about the mechanisms by which those who deliver care in this framework are trained, nor the scope of clinical practice they provide.37 One study has shown that among those who direct pediatric hospitalist services there is a great degree of variability in the description of the roles, work patterns, and employment characteristics of hospitalists.1 That study provided only 1 perspective on the roles and career trajectories of those in the field. To better understand both the range and frequency of experiences, clinical and nonclinical roles, training, work expectations, and career plans, we conducted a national survey study of practicing pediatric hospitalists.
METHODS
Sample
We identified all 761 hospitals in the American Hospital Association (AHA)'s 2005 Annual Survey of Hospitals that reported to have both a hospitalist service (adult and/or pediatric) and pediatric beds. From these 761 hospitals, we selected a random sample of 213, stratified by:
Council of Teaching Hospital (COTH) designation
National Association of Children's Hospitals & Related Institutions (NACHRI) membership
Freestanding children's hospitals
Metropolitan Statistical Area (MSA) (urban versus rural location)
Hospital size (small: <250 total beds versus large: 250 total beds)
Some hospitals are included in more than 1 category. Thus, there is some overlap of hospitals in the analysis. Of these 213 hospitals, 97 were removed from the sample because they did not have at least 1 pediatric hospitalist. In a separate study, we surveyed hospitalist program directors at 112 of the remaining 116 hospitals from June through September 2006. These results have been published.1
Pediatric hospitalist program directors at these 112 participating hospitals were asked to provide the names of all practicing pediatric hospitalists in their respective programs. Ninety‐five of these program directors provided a list of hospitalists at their institutions, representing 85% of the hospitals in our previous study. A total of 530 practicing pediatric hospitalists were identified to us in this manner. Of these 530 hospitalists, 67% (N = 338) were from teaching hospitals, 71% (N = 374) were from children's hospitals, 43% (N = 230) were from freestanding children's hospitals, and 69% (N = 354) were from hospitals with 250 beds. These are not mutually exclusive categories.
Survey Instrument
We developed a structured questionnaire to be administered by mail. The survey contained 25 items and was designed to be completed in 10 minutes or less. The survey focused on exploring the characteristics of hospitalist clinical and nonclinical practice, service schedule, training, and career goals. The questionnaire was comprised of a mixture of fixed‐choice, Likert‐scale, and open‐ended questions.
Questionnaire Administration
In October 2006, the first mailing of questionnaires was sent via priority mail. The survey packet contained a personalized cover letter signed by the principal investigator (G.L.F.), the instrument, a business reply mail envelope, and a $5 bill as an incentive. Two additional mailings were sent to nonrespondents in November 2006 and January 2007.
Data Analysis
First, frequency distributions were calculated for all survey items. Next, comparisons were made between respondents indicating they held an academic appointment and those who did not. For the purposes of this analysis, academic pediatric hospitalists were defined as those respondents holding a full‐time or part‐time academic appointment. Nonacademic pediatric hospitalists were defined as respondents holding an adjunct or volunteer faculty position, or no academic appointment. Finally, chi‐square statistics were used to compare pediatric hospitalist responses by hospital demographics such as teaching status, children's hospital status, NACHRI freestanding hospital designation, and hospital bed size.
The study was approved by the University of Michigan Medical Institutional Review Board.
RESULTS
Response Rate
Of the initial 530 survey packets mailed, 18 were returned as undeliverable by the postal service and 431 physicians returned the survey. This yielded an overall response rate of 84%. Of the 431 respondents, 40 physicians were ineligible because they no longer provided inpatient care to children or did not consider themselves to be hospitalists. Thus, the final sample for analysis was 391.
Hospitalist Employment Characteristics
Demographics of Hospital Worksite
Of the 391 respondents, 61% (N = 237) were from teaching hospitals, 73% (N = 287) from children's hospitals, 47% (N = 182) from freestanding children's hospitals, and 66% (N = 258) from hospitals with more than 250 beds.
Physician Demographics
The mean age of respondents was 39 years and 59% were female. The majority were employed by a hospital or health system (56%), 20% were employed by a university, and 4% were employed by both. Eight percent reported employment by a general physician medical group, 7% were employed by a hospitalist‐only group, and 4% reported other sources of employment. Half of respondents (N = 196) reported holding a full‐time (40%) or part‐time (10%) academic appointment. Approximately half the respondents (N = 194) were considered nonacademic hospitalists.
More than half of respondents (54%; N = 211) had been practicing as hospitalists for at least 3 years. Reported time as a practicing hospitalist ranged from <1 year to 26 years, while the average length of time was 63 months (Table 1). These figures may be skewed because those hospitalists with higher turnover rates might have left their position during the period of time from when they were selected into the sample until the time of survey administration.
| Length of Time as Hospitalist | % (N) |
|---|---|
| |
| 12 months | 13 (51) |
| 13‐24 months | 18 (71) |
| 25‐36 months | 14 (56) |
| 37‐60 months | 17 (67) |
| >61 months | 37 (144) |
Clinical Practice
Most respondents reported that the pediatric inpatient unit (94%) and inpatient consultation service (51%) were a part of their regular clinical assignment (Table 2). A majority did not provide service in the normal newborn nursery (58%), subspecialty inpatient service (52%), pediatric intensive care unit (ICU) (70%), neonatal ICU (77%), transports (85%), outpatient clinics (66%), or as part of an emergency response team (53%).
| Part of Regular Clinical Assignment % (N) | Occasionally % (N) | Never % (N) | |
|---|---|---|---|
| |||
| Pediatric inpatient unit | 94 (368) | 3 (13) | 2 (9) |
| Inpatient consultation service | 51 (199) | 40 (155) | 9 (35) |
| Normal newborn nursery | 29 (110) | 13 (50) | 58 (223) |
| Emergency department | 25 (95) | 28 (108) | 47 (178) |
| Subspecialty inpatient service | 25 (92) | 23 (86) | 52 (196) |
| Emergency response team | 23 (87) | 24 (91) | 53 (201) |
| Outpatient/outreach clinics | 18 (68) | 16 (61) | 66 (253) |
| Pediatric ICU | 14 (54) | 16 (59) | 70 (268) |
| Neonatal ICU | 12 (44) | 11 (42) | 77 (294) |
| Transports | 9 (33) | 6 (23) | 85 (319) |
With regard to procedures, many (53%) respondents reported that they routinely perform or supervise lumbar punctures. Several services are never performed or never supervised by the majority of pediatric hospitalists, including infusion services (57%), peripherally inserted central catheter (PICC) placement (76%), central line placement (67%), and circumcision (85%).
Professional Roles and Parameters
Respondents reported that they participate in a variety of nonclinical activities. Ninety‐four percent of hospitalists were involved in education, and 45% reported having a leadership role in that area. The majority of respondents participated in quality improvement (QI) initiatives (84%) and practice guideline development (81%), with one‐quarter of hospitalists reporting a leadership role in each of these activities. Slightly more than half of respondents reported involvement in hospital administration (52%) and utilization review (55%) (Table 3).
| Participation | No Involvement % (N) | ||
|---|---|---|---|
| Participation of Any Type % (N) | Leadership Role % (N) | ||
| |||
| Education (students, house staff) | 94 (368) | 45 (177) | 6 (22) |
| Quality improvement initiatives | 84 (330) | 25 (99) | 16 (61) |
| Practice guideline development | 81 (313) | 26 (101) | 19 (74) |
| Utilization review | 55 (213) | 11 (41) | 45 (172) |
| Hospital administration | 52 (202) | 16 (60) | 48 (184) |
On average, hospitalists reported spending 61% of their time providing inpatient care (excluding clinical teaching) and 16% of their time providing clinical teaching or supervising residents. More than one‐third of respondents (38%) spent more than 75% of their time providing direct inpatient care. Research (3%), administrative duties (8%), and nonclinical teaching (3%) were reported to be a small part of hospitalist professional time.
Pediatric Hospitalist Service Schedule
The majority of respondents reported that their assigned clinical schedule was a combination of shift and call (61%).
When on service, over half of responding pediatric hospitalists (58%) reported that they spend 40 to 60 hours onsite per week. Less than one‐fifth of respondents (19%) reported that they provide <40 hours of onsite coverage when on service. Most (97%) provide some type of night coverage, including taking calls from home or providing onsite coverage.
Hospitalist Training and Continuing Education
Only 51 of the 391 respondents (13%) had received some type of fellowship training, mostly in general pediatrics or the pediatric subspecialties. Only 5 respondents had received fellowship training in hospital medicine.
Fifty‐eight percent of respondents reported that they had received no hospitalist‐specific training. One‐fifth reported that they received training through a workshop at a professional meeting, while fewer respondents had received hospitalist training though a continuing medical education (CME) course (16%) or a mentoring program (17%).
Respondents were asked to rate the adequacy of their respective training in preparing them for their work as hospitalists. The vast majority rated their training in general clinical skills (94%) and communication (85%) as fully adequate. However, respondents found their training for some of the nonclinical aspects of their positions to be deficient. Many respondents rated training for QI projects (38%) and hospital administrative duties (46%) as inadequate (Table 4).
| Fully Adequate % (N) | Somewhat Adequate % (N) | Not Adequate % (N) | NA % (N) | |
|---|---|---|---|---|
| ||||
| General clinical skills | 94 (367) | 5 (21) | 0 (0) | 0 (1) |
| Communication skills | 85 (330) | 14 (53) | 1 (5) | 0 (1) |
| Coordination of care | 73 (284) | 23 (89) | 4 (15) | 0 (1) |
| Clinical procedure experience | 67 (258) | 32 (123) | 1 (5) | 1 (2) |
| Teaching skills (resident and medical student teaching) | 64 (248) | 31 (120) | 3 (13) | 2 (8) |
| Attending newborn deliveries | 60 (233) | 18 (70) | 4 (14) | 19 (72) |
| Running resuscitation (codes) | 45 (173) | 46 (177) | 5 (21) | 5 (18) |
| Quality improvement projects | 14 (55) | 42 (162) | 38 (148) | 6 (22) |
| Hospital administrative duties | 10 (37) | 37 (144) | 46 (177) | 8 (31) |
Survey respondents were asked to indicate the extent to which they agreed or disagreed with 3 statements regarding hospitalist training. The majority of respondents believed that hospitalists need training in QI methods (70%). However, most pediatric hospitalists (73%) did not believe that additional training beyond residency should be required. Only one‐third (36%) of respondents agreed that current CME offerings are adequate for their needs as a pediatric hospitalist.
Career Goals and Expectations
Respondents were asked to select 1 or more reasons why they became pediatric hospitalists. The top factors influencing respondents' decision to become a hospitalist were reported to be a preference for the inpatient setting (73%), clinical variety (72%), enjoyment of teaching in the inpatient setting (58%), and a flexible schedule (52%) (Table 5).
| Factor | % (N) |
|---|---|
| |
| Prefer inpatient setting | 73 (284) |
| Clinical variety | 72 (281) |
| Enjoy teaching in inpatient setting | 58 (225) |
| Flexible schedule | 52 (202) |
| Defined hours | 41 (161) |
| Attractive career opportunities | 21 (80) |
| Salary | 18 (70) |
| Unsure of long‐term career direction | 13 (51) |
| Other | 7 (28) |
| Needed short‐term employment | 4 (15) |
| Only position available | 3 (10) |
The majority (85%) were satisfied with their position as a pediatric hospitalist, with 37% reporting that they were extremely satisfied. Over one‐half (61%) expected to remain a hospitalist for the duration of their career.
RESULTS BY ACADEMIC STATUS
Only significant differences between academic and nonacademic hospitalists are presented.
Clinical Practice by Academic Status
Nonacademic respondents were more likely than academic respondents to report regular service in the normal newborn nursery, pediatric ICU, neonatal ICU, transports, emergency department, and as part of an emergency response team. Academic respondents were more likely to report regular service in outpatient clinics. Nonacademic respondents were more likely than academic respondents to perform or supervise lumbar punctures, sedation services, PICC or central line insertions, and circumcisions (Table 6).
| Academic* (N = 196) | Nonacademic (N = 194) | P Value | |
|---|---|---|---|
| |||
| Regularly provides service | |||
| Normal newborn nursery | 16% | 42% | <0.0001 |
| Pediatric ICU | 9% | 20% | 0.0065 |
| Neonatal ICU | 4% | 20% | <0.0001 |
| Transports | 3% | 15% | <0.0001 |
| Emergency department | 16% | 34% | <0.0001 |
| Emergency response team | 17% | 29% | <0.0001 |
| Outpatient clinic | 23% | 13% | 0.0168 |
| Performs or supervises procedures | |||
| Lumbar puncture | 84% | 92% | 0.0152 |
| Sedation services | 50% | 64% | 0.0055 |
| PICC insertion | 8% | 18% | 0.0031 |
| Central line insertion | 11% | 23% | 0.0018 |
| Circumcision | 5% | 16% | 0.0002 |
| Holds leadership roles | |||
| Education (student or house staff) | 63% | 27% | <0.0001 |
| Hospital administration | 21% | 10% | <0.0001 |
| Quality improvement initiatives | 33% | 18% | 0.0005 |
Professional Roles and Parameters by Academic Status
Responding academic pediatric hospitalists were twice as likely as nonacademic respondents to have a leadership role in the education of students and house staff and to hold a leadership position in hospital administration. The academic respondents were also more likely to report a leadership role in QI initiatives (Table 6).
Clinical and Educational Activities by Academic Status
Academic pediatric hospitalist respondents reported spending on average 52% of their time providing inpatient care (excluding teaching), in contrast to the nonacademic hospitalist respondents who reported 71% of their time was spent providing inpatient care (P < 0.0001). Academic respondents also reported that 19% of their time was spent providing inpatient teaching or supervising residents, compared to 12% of nonacademic respondents (P < 0.0001). Responding academic pediatric hospitalists reported spending a greater proportion of time participating in nonclinical teaching activities (5% versus 2%; P < 0.0001), administrative duties (11% versus 5%; P < 0.0001), and research (4% versus 1%; P < 0.0001) compared to the nonacademic respondents.
Nonacademic respondents were more likely than academic respondents to report no hospitalist‐specific training (64% versus 54%; P = 0.0324).
RESULTS BY HOSPITAL CHARACTERISTICS
For each hospital characteristic, only significant differences between dichotomized groups are presented.
Children's Hospitals versus Other Hospitals
Clinical Practice
Pediatric hospitalist respondents practicing in NACHRI hospitals were more likely to report that they provide regular service for general pediatric inpatients (98% versus 86%; P < 0.0001) as well as subspecialty inpatients (27% versus 17%; P = 0.044). Non‐NACHRI pediatric hospitalist respondents were twice as likely to report the provision of regular service in the normal newborn nursery (49% versus 22%; P < 0.0001), the neonatal ICU (21% versus 8%, P = 0.002), and the emergency department (38% versus 20%; P < 0.0001).
Among respondents, pediatric hospitalists who were not working at a children's hospital were more likely to report that they sometimes or routinely performed lumbar punctures (93% versus 85%; P = 0.037), infusion services (36% versus 21%; P = 0.003), and were twice as likely to perform circumcision (16% versus 8%; P = 0.041) compared to those working at children's hospitals.
Professional Roles and Parameters
Respondents working in children's hospitals were twice as likely to hold a leadership position in utilization review (12% versus 6%; P = 0.012), though respondents from non‐NACHRI hospitals were more likely to at least participate in utilization review (58% versus 40%; P = 0.004).
Hospitalist Training
Respondents from non‐NACHRI hospitals were more likely to report that they had received no hospitalist‐specific training (68% versus 56%; P = 0.029). Those at NACHRI hospitals were twice as likely to have received hospitalist training through a mentoring program (20% versus 9%; P = 0.009).
Freestanding versus Nonfreestanding Children's Hospitals
Clinical Practice
Pediatric hospitalist respondents employed at institutions that are not freestanding children's hospitals were more likely to report that they provided regular service in the normal newborn nursery (42% versus 14%; P < 0.0001), pediatric ICU (22% versus 5%), emergency department (32% versus 17%; P < 0.0001), and outpatient clinics (23% versus 12%; P = 0.0068). They were also more likely to perform or supervise sedation services (63% versus 50%; P = 0.0116), infusion services (32% versus 17%; P = 0.0006), PICC insertions (19% versus 6%; P = 0.0002), central line insertions (23% versus 11%; P = 0.0024), and circumcisions (16% versus 3%; P < 0.0001).
Professional Roles and Parameters
Among respondents, pediatric hospitalists employed by nonfreestanding children's hospitals were more likely to report participation in utilization review (51% versus 38%; P = 0.02).
Hospital Size
Clinical Practice
Pediatric hospitalist respondents working at large hospitals were twice as likely to report that they regularly provided service in the pediatric ICU (18% versus 7%; P = 0.0072) and were more likely to regularly perform circumcisions (13% versus 5%; P = 0.0069). Respondents from small hospitals were more likely to provide regular service in the neonatal ICU (20% versus 7%; P = 0.0013).
COTH Status: Teaching versus Nonteaching Hospitals
Clinical Practice
Among survey respondents, pediatric hospitalists employed by COTH hospitals were more likely to provide regular service in the neonatal ICU, compared to their peers in nonteaching hospitals (15% versus 6%; P = 0.0109). Those employed by non‐COTH hospitals were more likely to provide service in subspecialty inpatient service (38% versus 16%; P < 0.0001), transports (14% versus 6%; P = 0.0227), inpatient consultation (61% versus 45%; P = 0.0086), and the emergency response team (29% versus 19%; P = 0.0021).
Professional Roles and Parameters
Respondents from COTH hospitals were more likely to have no involvement in utilization review, compared to their peers at non‐COTH hospitals (49% versus 37%; P = 0.0220).
DISCUSSION
This study provides the most comprehensive information available regarding the clinical and nonclinical roles, training, work expectations, and career plans of pediatric hospitalists. Among the most important of our findings is the distribution of the length of time that pediatric hospitalists had served in their roles. While over one‐third (37%) reported having been practicing as hospitalists for over 5 years, 45% of our respondents had been in practice for fewer than 3 years. This is consistent with both the perceptions of rapid growth of the field and with significant turnover of hospitalists.1, 8 It is important to note that our findings may actually overestimate the proportion of hospitalists with longer durations of employment as our sampling strategy would have been less likely to include those who left the field within the first 12 to 18 months of practice. Nevertheless, over half (61%) of our respondents expected to remain a hospitalist for the duration of their career and few reported choosing to become a hospitalist as a short‐term employment option. This finding has important implications for the future stability of the hospitalist workforce and the potential development of specific expertise among this cadre of clinicians.6
The demographic profile of pediatric hospitalists was also consistent with these findings. The mean age of 39 years for our respondents is indicative of a significant proportion of this group of physicians recently having completed their residency training. Further, the gender distribution approximates that of current pediatric residency graduates, thus indicating that that this is not a clinical choice for which there would be a skewed distribution as is the case in some pediatric subspecialties.9
Our findings were similar to the 2004 Ottolini et al.10 findings on the roles of pediatric hospitalists. Respondents in our study reported spending less time providing inpatient care (61% versus 75%), providing clinical teaching or supervising residents (16% versus 26%), performing administrative duties (8% versus 19%), and conducting research (3% versus 9%) compared with the respondents in the Ottolini et al.10 survey.
At this point in time, fewer than half of our respondents reported any hospitalist‐specific training, including workshops at professional meetings or CME coursework. As there are a paucity of fellowships offering postresidency training in pediatric hospital medicine, and most of the existing programs are newly established, few in practice have completed such programs.11 In addition, most respondents reported that current CME offerings do not meet their needs, and that they could have used additional QI training to prepare them for their role as pediatric hospitalists. However, almost three‐quarters of respondents (73%) do not believe any additional training beyond residency should be required. As such, it is unclear if a defined, unique body of knowledge specific to hospitalists is either needed or desired by those currently in the field.
Although there are a broad range of potential clinical roles within hospital medicine, and this clinical variety influenced most respondents' decisions to become hospitalists, the current scope of an individual hospitalist tends to become somewhat focused.12, 13 While we found almost all provided service on the pediatric inpatient unit, many fewer provided inpatient consultation and normal newborn care, or were involved in interhospital transport or as part of an emergency response team. There is also wide variation in the types of procedures performed or supervised by hospitalists at different institutions. More than half never perform or supervise infusion services, PICC or central line placement, or circumcision. The variation seen among hospitalists practicing in different hospital settings likely is a result, at least in part, of different needs in teaching hospitals for both service and for clinical experience of trainees. For example, our results demonstrate that pediatric hospitalists in nonteaching and non‐children's hospitals are more likely to have a broader scope of clinical care provision. Another potential issue is that some hospitalists may be employed by institutions which have no pediatric ICU, neonatal ICU, or other specialty unit. As such, these hospitalists would not have the opportunity to work in such settings.
Further, those without academic appointments are also more likely to have expanded clinical roles compared with their academic counterparts. This may be due to the fact that there is likely a greater number of subspecialty‐trained pediatric providers in academic centers and thus the need for hospitalists to cover specific services or perform specific procedures is lessened. There may also be a desire to prevent competition among care providers within the same institution. In contrast, hospitalists with academic appointments are more likely (though still uncommonly) to have taken leadership roles in hospital administration and QI initiatives. Thus, the nature of their efforts appears to expand into nonclinical delivery areas.
Clearly, hospitalists report they have assumed a significant role in the clinical teaching of trainees at all levels, with 94% of our respondents maintaining at least some involvement in education. On average, they spend 16% of their time in educational efforts. However, there are few data on the impact of their work in this area.5, 13 Studies in pediatrics to date have been limited to a few institutions,3, 5 and have not addressed the issue from the perspective of residency program directors or those who are in charge of inpatient curricula.
This study, like the majority of studies related to pediatric hospitalists, is hampered by the difficulty of identifying pediatric hospitalists. Rather than utilizing a hospital medicine membership list, which would be potentially biased by self‐selection, we attempted to obtain a more representative sample through utilization of the AHA database.
CONCLUSIONS
Findings from this study provide an additional perspective regarding pediatric hospitalists to add to our previous study of hospitalist program directors.1 However, the field is currently a moving target. Our data demonstrate that there is significant flux in the hospitalist workforce, uncertainty regarding turnover, and variation in the roles of these professionals in their clinical and nonclinical work environment. Moreover, additional studies of the educational impact of hospitalists on residency and medical student education are needed. Questions regarding the nature and degree of resident autonomy and experience conducting procedures in the hospitalist environment have been raised. These must be assessed through studies of residency program directors, their expectations of residents, and the curricula they have developed.
As with any new phenomenon, it will take time to understand the impact of hospitalists in a variety of domains. Additional research will be helpful in following the development of this field and the manner in which it will interface with existing medical practice and educational programs.
- ,,,; The Research Advisory Committee of the American Board of Pediatrics.Characteristics of the pediatric hospitalist workforce: its roles and work environment.Pediatrics.2007;120:33–39.
- .The evolution of the hospitalist model in the United States.Med Clin North Am.2002;86:687–706.
- ,.Hospitalists in children's hospitals: what we know now and what we need to know.J Pediatr.2006;148:296–299.
- ,.Hospitalists: the new model of inpatient medical care in the United States.Eur J Intern Med.2003;14:65–70.
- ,,,,,.Effect of a pediatric hospitalist system on housestaff education and experience.Arch Pediatr Adolesc Med.2002;156:877–883.
- ,,,.Hospitalists' perceptions of their residency training needs: results of a national survey.Am J Med.2001;111:247–254.
- ,,,,,.Pediatric hospitalists in Canada and the United States: a survey of pediatric academic department chairs.Ambul Pediatr.2001;1:338–339.
- .Hospitalists in the United States: mission accomplished or work in progress?N Engl J Med.2004;350:1935–1936.
- ,.Pediatric workforce: a look at general pediatrics data from the American Board of Pediatrics.J Pediatr.2006;148:166–169.
- ,,,,PRIS survey: pediatric hospitalist roles and training needs [Abstr].Pediatr Res.2004;55:360A.
- ,,,.Hospital medicine fellowships: works in progress.Am J Med.2006;119:1.e1–1.e7.
- ,,.How hospitalists spend their time: insights on efficiency and safety.J Hosp Med.2006;1:88–93.
- ,,.Pediatric hospitalists fill varied roles in the care of newborns.Pediatr Ann.2003;32:802–810.
There has been marked recent growth in the employment and utilization of both pediatric and adult hospitalists. Recent data demonstrate that approximately 25% of current pediatric hospitalist programs are less than 2 years old.1 Some have posited that this growth is due to increasing pressure from the public and payors to deliver cost‐effective and high‐quality care.2 However, little is known about the mechanisms by which those who deliver care in this framework are trained, nor the scope of clinical practice they provide.37 One study has shown that among those who direct pediatric hospitalist services there is a great degree of variability in the description of the roles, work patterns, and employment characteristics of hospitalists.1 That study provided only 1 perspective on the roles and career trajectories of those in the field. To better understand both the range and frequency of experiences, clinical and nonclinical roles, training, work expectations, and career plans, we conducted a national survey study of practicing pediatric hospitalists.
METHODS
Sample
We identified all 761 hospitals in the American Hospital Association (AHA)'s 2005 Annual Survey of Hospitals that reported to have both a hospitalist service (adult and/or pediatric) and pediatric beds. From these 761 hospitals, we selected a random sample of 213, stratified by:
Council of Teaching Hospital (COTH) designation
National Association of Children's Hospitals & Related Institutions (NACHRI) membership
Freestanding children's hospitals
Metropolitan Statistical Area (MSA) (urban versus rural location)
Hospital size (small: <250 total beds versus large: 250 total beds)
Some hospitals are included in more than 1 category. Thus, there is some overlap of hospitals in the analysis. Of these 213 hospitals, 97 were removed from the sample because they did not have at least 1 pediatric hospitalist. In a separate study, we surveyed hospitalist program directors at 112 of the remaining 116 hospitals from June through September 2006. These results have been published.1
Pediatric hospitalist program directors at these 112 participating hospitals were asked to provide the names of all practicing pediatric hospitalists in their respective programs. Ninety‐five of these program directors provided a list of hospitalists at their institutions, representing 85% of the hospitals in our previous study. A total of 530 practicing pediatric hospitalists were identified to us in this manner. Of these 530 hospitalists, 67% (N = 338) were from teaching hospitals, 71% (N = 374) were from children's hospitals, 43% (N = 230) were from freestanding children's hospitals, and 69% (N = 354) were from hospitals with 250 beds. These are not mutually exclusive categories.
Survey Instrument
We developed a structured questionnaire to be administered by mail. The survey contained 25 items and was designed to be completed in 10 minutes or less. The survey focused on exploring the characteristics of hospitalist clinical and nonclinical practice, service schedule, training, and career goals. The questionnaire was comprised of a mixture of fixed‐choice, Likert‐scale, and open‐ended questions.
Questionnaire Administration
In October 2006, the first mailing of questionnaires was sent via priority mail. The survey packet contained a personalized cover letter signed by the principal investigator (G.L.F.), the instrument, a business reply mail envelope, and a $5 bill as an incentive. Two additional mailings were sent to nonrespondents in November 2006 and January 2007.
Data Analysis
First, frequency distributions were calculated for all survey items. Next, comparisons were made between respondents indicating they held an academic appointment and those who did not. For the purposes of this analysis, academic pediatric hospitalists were defined as those respondents holding a full‐time or part‐time academic appointment. Nonacademic pediatric hospitalists were defined as respondents holding an adjunct or volunteer faculty position, or no academic appointment. Finally, chi‐square statistics were used to compare pediatric hospitalist responses by hospital demographics such as teaching status, children's hospital status, NACHRI freestanding hospital designation, and hospital bed size.
The study was approved by the University of Michigan Medical Institutional Review Board.
RESULTS
Response Rate
Of the initial 530 survey packets mailed, 18 were returned as undeliverable by the postal service and 431 physicians returned the survey. This yielded an overall response rate of 84%. Of the 431 respondents, 40 physicians were ineligible because they no longer provided inpatient care to children or did not consider themselves to be hospitalists. Thus, the final sample for analysis was 391.
Hospitalist Employment Characteristics
Demographics of Hospital Worksite
Of the 391 respondents, 61% (N = 237) were from teaching hospitals, 73% (N = 287) from children's hospitals, 47% (N = 182) from freestanding children's hospitals, and 66% (N = 258) from hospitals with more than 250 beds.
Physician Demographics
The mean age of respondents was 39 years and 59% were female. The majority were employed by a hospital or health system (56%), 20% were employed by a university, and 4% were employed by both. Eight percent reported employment by a general physician medical group, 7% were employed by a hospitalist‐only group, and 4% reported other sources of employment. Half of respondents (N = 196) reported holding a full‐time (40%) or part‐time (10%) academic appointment. Approximately half the respondents (N = 194) were considered nonacademic hospitalists.
More than half of respondents (54%; N = 211) had been practicing as hospitalists for at least 3 years. Reported time as a practicing hospitalist ranged from <1 year to 26 years, while the average length of time was 63 months (Table 1). These figures may be skewed because those hospitalists with higher turnover rates might have left their position during the period of time from when they were selected into the sample until the time of survey administration.
| Length of Time as Hospitalist | % (N) |
|---|---|
| |
| 12 months | 13 (51) |
| 13‐24 months | 18 (71) |
| 25‐36 months | 14 (56) |
| 37‐60 months | 17 (67) |
| >61 months | 37 (144) |
Clinical Practice
Most respondents reported that the pediatric inpatient unit (94%) and inpatient consultation service (51%) were a part of their regular clinical assignment (Table 2). A majority did not provide service in the normal newborn nursery (58%), subspecialty inpatient service (52%), pediatric intensive care unit (ICU) (70%), neonatal ICU (77%), transports (85%), outpatient clinics (66%), or as part of an emergency response team (53%).
| Part of Regular Clinical Assignment % (N) | Occasionally % (N) | Never % (N) | |
|---|---|---|---|
| |||
| Pediatric inpatient unit | 94 (368) | 3 (13) | 2 (9) |
| Inpatient consultation service | 51 (199) | 40 (155) | 9 (35) |
| Normal newborn nursery | 29 (110) | 13 (50) | 58 (223) |
| Emergency department | 25 (95) | 28 (108) | 47 (178) |
| Subspecialty inpatient service | 25 (92) | 23 (86) | 52 (196) |
| Emergency response team | 23 (87) | 24 (91) | 53 (201) |
| Outpatient/outreach clinics | 18 (68) | 16 (61) | 66 (253) |
| Pediatric ICU | 14 (54) | 16 (59) | 70 (268) |
| Neonatal ICU | 12 (44) | 11 (42) | 77 (294) |
| Transports | 9 (33) | 6 (23) | 85 (319) |
With regard to procedures, many (53%) respondents reported that they routinely perform or supervise lumbar punctures. Several services are never performed or never supervised by the majority of pediatric hospitalists, including infusion services (57%), peripherally inserted central catheter (PICC) placement (76%), central line placement (67%), and circumcision (85%).
Professional Roles and Parameters
Respondents reported that they participate in a variety of nonclinical activities. Ninety‐four percent of hospitalists were involved in education, and 45% reported having a leadership role in that area. The majority of respondents participated in quality improvement (QI) initiatives (84%) and practice guideline development (81%), with one‐quarter of hospitalists reporting a leadership role in each of these activities. Slightly more than half of respondents reported involvement in hospital administration (52%) and utilization review (55%) (Table 3).
| Participation | No Involvement % (N) | ||
|---|---|---|---|
| Participation of Any Type % (N) | Leadership Role % (N) | ||
| |||
| Education (students, house staff) | 94 (368) | 45 (177) | 6 (22) |
| Quality improvement initiatives | 84 (330) | 25 (99) | 16 (61) |
| Practice guideline development | 81 (313) | 26 (101) | 19 (74) |
| Utilization review | 55 (213) | 11 (41) | 45 (172) |
| Hospital administration | 52 (202) | 16 (60) | 48 (184) |
On average, hospitalists reported spending 61% of their time providing inpatient care (excluding clinical teaching) and 16% of their time providing clinical teaching or supervising residents. More than one‐third of respondents (38%) spent more than 75% of their time providing direct inpatient care. Research (3%), administrative duties (8%), and nonclinical teaching (3%) were reported to be a small part of hospitalist professional time.
Pediatric Hospitalist Service Schedule
The majority of respondents reported that their assigned clinical schedule was a combination of shift and call (61%).
When on service, over half of responding pediatric hospitalists (58%) reported that they spend 40 to 60 hours onsite per week. Less than one‐fifth of respondents (19%) reported that they provide <40 hours of onsite coverage when on service. Most (97%) provide some type of night coverage, including taking calls from home or providing onsite coverage.
Hospitalist Training and Continuing Education
Only 51 of the 391 respondents (13%) had received some type of fellowship training, mostly in general pediatrics or the pediatric subspecialties. Only 5 respondents had received fellowship training in hospital medicine.
Fifty‐eight percent of respondents reported that they had received no hospitalist‐specific training. One‐fifth reported that they received training through a workshop at a professional meeting, while fewer respondents had received hospitalist training though a continuing medical education (CME) course (16%) or a mentoring program (17%).
Respondents were asked to rate the adequacy of their respective training in preparing them for their work as hospitalists. The vast majority rated their training in general clinical skills (94%) and communication (85%) as fully adequate. However, respondents found their training for some of the nonclinical aspects of their positions to be deficient. Many respondents rated training for QI projects (38%) and hospital administrative duties (46%) as inadequate (Table 4).
| Fully Adequate % (N) | Somewhat Adequate % (N) | Not Adequate % (N) | NA % (N) | |
|---|---|---|---|---|
| ||||
| General clinical skills | 94 (367) | 5 (21) | 0 (0) | 0 (1) |
| Communication skills | 85 (330) | 14 (53) | 1 (5) | 0 (1) |
| Coordination of care | 73 (284) | 23 (89) | 4 (15) | 0 (1) |
| Clinical procedure experience | 67 (258) | 32 (123) | 1 (5) | 1 (2) |
| Teaching skills (resident and medical student teaching) | 64 (248) | 31 (120) | 3 (13) | 2 (8) |
| Attending newborn deliveries | 60 (233) | 18 (70) | 4 (14) | 19 (72) |
| Running resuscitation (codes) | 45 (173) | 46 (177) | 5 (21) | 5 (18) |
| Quality improvement projects | 14 (55) | 42 (162) | 38 (148) | 6 (22) |
| Hospital administrative duties | 10 (37) | 37 (144) | 46 (177) | 8 (31) |
Survey respondents were asked to indicate the extent to which they agreed or disagreed with 3 statements regarding hospitalist training. The majority of respondents believed that hospitalists need training in QI methods (70%). However, most pediatric hospitalists (73%) did not believe that additional training beyond residency should be required. Only one‐third (36%) of respondents agreed that current CME offerings are adequate for their needs as a pediatric hospitalist.
Career Goals and Expectations
Respondents were asked to select 1 or more reasons why they became pediatric hospitalists. The top factors influencing respondents' decision to become a hospitalist were reported to be a preference for the inpatient setting (73%), clinical variety (72%), enjoyment of teaching in the inpatient setting (58%), and a flexible schedule (52%) (Table 5).
| Factor | % (N) |
|---|---|
| |
| Prefer inpatient setting | 73 (284) |
| Clinical variety | 72 (281) |
| Enjoy teaching in inpatient setting | 58 (225) |
| Flexible schedule | 52 (202) |
| Defined hours | 41 (161) |
| Attractive career opportunities | 21 (80) |
| Salary | 18 (70) |
| Unsure of long‐term career direction | 13 (51) |
| Other | 7 (28) |
| Needed short‐term employment | 4 (15) |
| Only position available | 3 (10) |
The majority (85%) were satisfied with their position as a pediatric hospitalist, with 37% reporting that they were extremely satisfied. Over one‐half (61%) expected to remain a hospitalist for the duration of their career.
RESULTS BY ACADEMIC STATUS
Only significant differences between academic and nonacademic hospitalists are presented.
Clinical Practice by Academic Status
Nonacademic respondents were more likely than academic respondents to report regular service in the normal newborn nursery, pediatric ICU, neonatal ICU, transports, emergency department, and as part of an emergency response team. Academic respondents were more likely to report regular service in outpatient clinics. Nonacademic respondents were more likely than academic respondents to perform or supervise lumbar punctures, sedation services, PICC or central line insertions, and circumcisions (Table 6).
| Academic* (N = 196) | Nonacademic (N = 194) | P Value | |
|---|---|---|---|
| |||
| Regularly provides service | |||
| Normal newborn nursery | 16% | 42% | <0.0001 |
| Pediatric ICU | 9% | 20% | 0.0065 |
| Neonatal ICU | 4% | 20% | <0.0001 |
| Transports | 3% | 15% | <0.0001 |
| Emergency department | 16% | 34% | <0.0001 |
| Emergency response team | 17% | 29% | <0.0001 |
| Outpatient clinic | 23% | 13% | 0.0168 |
| Performs or supervises procedures | |||
| Lumbar puncture | 84% | 92% | 0.0152 |
| Sedation services | 50% | 64% | 0.0055 |
| PICC insertion | 8% | 18% | 0.0031 |
| Central line insertion | 11% | 23% | 0.0018 |
| Circumcision | 5% | 16% | 0.0002 |
| Holds leadership roles | |||
| Education (student or house staff) | 63% | 27% | <0.0001 |
| Hospital administration | 21% | 10% | <0.0001 |
| Quality improvement initiatives | 33% | 18% | 0.0005 |
Professional Roles and Parameters by Academic Status
Responding academic pediatric hospitalists were twice as likely as nonacademic respondents to have a leadership role in the education of students and house staff and to hold a leadership position in hospital administration. The academic respondents were also more likely to report a leadership role in QI initiatives (Table 6).
Clinical and Educational Activities by Academic Status
Academic pediatric hospitalist respondents reported spending on average 52% of their time providing inpatient care (excluding teaching), in contrast to the nonacademic hospitalist respondents who reported 71% of their time was spent providing inpatient care (P < 0.0001). Academic respondents also reported that 19% of their time was spent providing inpatient teaching or supervising residents, compared to 12% of nonacademic respondents (P < 0.0001). Responding academic pediatric hospitalists reported spending a greater proportion of time participating in nonclinical teaching activities (5% versus 2%; P < 0.0001), administrative duties (11% versus 5%; P < 0.0001), and research (4% versus 1%; P < 0.0001) compared to the nonacademic respondents.
Nonacademic respondents were more likely than academic respondents to report no hospitalist‐specific training (64% versus 54%; P = 0.0324).
RESULTS BY HOSPITAL CHARACTERISTICS
For each hospital characteristic, only significant differences between dichotomized groups are presented.
Children's Hospitals versus Other Hospitals
Clinical Practice
Pediatric hospitalist respondents practicing in NACHRI hospitals were more likely to report that they provide regular service for general pediatric inpatients (98% versus 86%; P < 0.0001) as well as subspecialty inpatients (27% versus 17%; P = 0.044). Non‐NACHRI pediatric hospitalist respondents were twice as likely to report the provision of regular service in the normal newborn nursery (49% versus 22%; P < 0.0001), the neonatal ICU (21% versus 8%, P = 0.002), and the emergency department (38% versus 20%; P < 0.0001).
Among respondents, pediatric hospitalists who were not working at a children's hospital were more likely to report that they sometimes or routinely performed lumbar punctures (93% versus 85%; P = 0.037), infusion services (36% versus 21%; P = 0.003), and were twice as likely to perform circumcision (16% versus 8%; P = 0.041) compared to those working at children's hospitals.
Professional Roles and Parameters
Respondents working in children's hospitals were twice as likely to hold a leadership position in utilization review (12% versus 6%; P = 0.012), though respondents from non‐NACHRI hospitals were more likely to at least participate in utilization review (58% versus 40%; P = 0.004).
Hospitalist Training
Respondents from non‐NACHRI hospitals were more likely to report that they had received no hospitalist‐specific training (68% versus 56%; P = 0.029). Those at NACHRI hospitals were twice as likely to have received hospitalist training through a mentoring program (20% versus 9%; P = 0.009).
Freestanding versus Nonfreestanding Children's Hospitals
Clinical Practice
Pediatric hospitalist respondents employed at institutions that are not freestanding children's hospitals were more likely to report that they provided regular service in the normal newborn nursery (42% versus 14%; P < 0.0001), pediatric ICU (22% versus 5%), emergency department (32% versus 17%; P < 0.0001), and outpatient clinics (23% versus 12%; P = 0.0068). They were also more likely to perform or supervise sedation services (63% versus 50%; P = 0.0116), infusion services (32% versus 17%; P = 0.0006), PICC insertions (19% versus 6%; P = 0.0002), central line insertions (23% versus 11%; P = 0.0024), and circumcisions (16% versus 3%; P < 0.0001).
Professional Roles and Parameters
Among respondents, pediatric hospitalists employed by nonfreestanding children's hospitals were more likely to report participation in utilization review (51% versus 38%; P = 0.02).
Hospital Size
Clinical Practice
Pediatric hospitalist respondents working at large hospitals were twice as likely to report that they regularly provided service in the pediatric ICU (18% versus 7%; P = 0.0072) and were more likely to regularly perform circumcisions (13% versus 5%; P = 0.0069). Respondents from small hospitals were more likely to provide regular service in the neonatal ICU (20% versus 7%; P = 0.0013).
COTH Status: Teaching versus Nonteaching Hospitals
Clinical Practice
Among survey respondents, pediatric hospitalists employed by COTH hospitals were more likely to provide regular service in the neonatal ICU, compared to their peers in nonteaching hospitals (15% versus 6%; P = 0.0109). Those employed by non‐COTH hospitals were more likely to provide service in subspecialty inpatient service (38% versus 16%; P < 0.0001), transports (14% versus 6%; P = 0.0227), inpatient consultation (61% versus 45%; P = 0.0086), and the emergency response team (29% versus 19%; P = 0.0021).
Professional Roles and Parameters
Respondents from COTH hospitals were more likely to have no involvement in utilization review, compared to their peers at non‐COTH hospitals (49% versus 37%; P = 0.0220).
DISCUSSION
This study provides the most comprehensive information available regarding the clinical and nonclinical roles, training, work expectations, and career plans of pediatric hospitalists. Among the most important of our findings is the distribution of the length of time that pediatric hospitalists had served in their roles. While over one‐third (37%) reported having been practicing as hospitalists for over 5 years, 45% of our respondents had been in practice for fewer than 3 years. This is consistent with both the perceptions of rapid growth of the field and with significant turnover of hospitalists.1, 8 It is important to note that our findings may actually overestimate the proportion of hospitalists with longer durations of employment as our sampling strategy would have been less likely to include those who left the field within the first 12 to 18 months of practice. Nevertheless, over half (61%) of our respondents expected to remain a hospitalist for the duration of their career and few reported choosing to become a hospitalist as a short‐term employment option. This finding has important implications for the future stability of the hospitalist workforce and the potential development of specific expertise among this cadre of clinicians.6
The demographic profile of pediatric hospitalists was also consistent with these findings. The mean age of 39 years for our respondents is indicative of a significant proportion of this group of physicians recently having completed their residency training. Further, the gender distribution approximates that of current pediatric residency graduates, thus indicating that that this is not a clinical choice for which there would be a skewed distribution as is the case in some pediatric subspecialties.9
Our findings were similar to the 2004 Ottolini et al.10 findings on the roles of pediatric hospitalists. Respondents in our study reported spending less time providing inpatient care (61% versus 75%), providing clinical teaching or supervising residents (16% versus 26%), performing administrative duties (8% versus 19%), and conducting research (3% versus 9%) compared with the respondents in the Ottolini et al.10 survey.
At this point in time, fewer than half of our respondents reported any hospitalist‐specific training, including workshops at professional meetings or CME coursework. As there are a paucity of fellowships offering postresidency training in pediatric hospital medicine, and most of the existing programs are newly established, few in practice have completed such programs.11 In addition, most respondents reported that current CME offerings do not meet their needs, and that they could have used additional QI training to prepare them for their role as pediatric hospitalists. However, almost three‐quarters of respondents (73%) do not believe any additional training beyond residency should be required. As such, it is unclear if a defined, unique body of knowledge specific to hospitalists is either needed or desired by those currently in the field.
Although there are a broad range of potential clinical roles within hospital medicine, and this clinical variety influenced most respondents' decisions to become hospitalists, the current scope of an individual hospitalist tends to become somewhat focused.12, 13 While we found almost all provided service on the pediatric inpatient unit, many fewer provided inpatient consultation and normal newborn care, or were involved in interhospital transport or as part of an emergency response team. There is also wide variation in the types of procedures performed or supervised by hospitalists at different institutions. More than half never perform or supervise infusion services, PICC or central line placement, or circumcision. The variation seen among hospitalists practicing in different hospital settings likely is a result, at least in part, of different needs in teaching hospitals for both service and for clinical experience of trainees. For example, our results demonstrate that pediatric hospitalists in nonteaching and non‐children's hospitals are more likely to have a broader scope of clinical care provision. Another potential issue is that some hospitalists may be employed by institutions which have no pediatric ICU, neonatal ICU, or other specialty unit. As such, these hospitalists would not have the opportunity to work in such settings.
Further, those without academic appointments are also more likely to have expanded clinical roles compared with their academic counterparts. This may be due to the fact that there is likely a greater number of subspecialty‐trained pediatric providers in academic centers and thus the need for hospitalists to cover specific services or perform specific procedures is lessened. There may also be a desire to prevent competition among care providers within the same institution. In contrast, hospitalists with academic appointments are more likely (though still uncommonly) to have taken leadership roles in hospital administration and QI initiatives. Thus, the nature of their efforts appears to expand into nonclinical delivery areas.
Clearly, hospitalists report they have assumed a significant role in the clinical teaching of trainees at all levels, with 94% of our respondents maintaining at least some involvement in education. On average, they spend 16% of their time in educational efforts. However, there are few data on the impact of their work in this area.5, 13 Studies in pediatrics to date have been limited to a few institutions,3, 5 and have not addressed the issue from the perspective of residency program directors or those who are in charge of inpatient curricula.
This study, like the majority of studies related to pediatric hospitalists, is hampered by the difficulty of identifying pediatric hospitalists. Rather than utilizing a hospital medicine membership list, which would be potentially biased by self‐selection, we attempted to obtain a more representative sample through utilization of the AHA database.
CONCLUSIONS
Findings from this study provide an additional perspective regarding pediatric hospitalists to add to our previous study of hospitalist program directors.1 However, the field is currently a moving target. Our data demonstrate that there is significant flux in the hospitalist workforce, uncertainty regarding turnover, and variation in the roles of these professionals in their clinical and nonclinical work environment. Moreover, additional studies of the educational impact of hospitalists on residency and medical student education are needed. Questions regarding the nature and degree of resident autonomy and experience conducting procedures in the hospitalist environment have been raised. These must be assessed through studies of residency program directors, their expectations of residents, and the curricula they have developed.
As with any new phenomenon, it will take time to understand the impact of hospitalists in a variety of domains. Additional research will be helpful in following the development of this field and the manner in which it will interface with existing medical practice and educational programs.
There has been marked recent growth in the employment and utilization of both pediatric and adult hospitalists. Recent data demonstrate that approximately 25% of current pediatric hospitalist programs are less than 2 years old.1 Some have posited that this growth is due to increasing pressure from the public and payors to deliver cost‐effective and high‐quality care.2 However, little is known about the mechanisms by which those who deliver care in this framework are trained, nor the scope of clinical practice they provide.37 One study has shown that among those who direct pediatric hospitalist services there is a great degree of variability in the description of the roles, work patterns, and employment characteristics of hospitalists.1 That study provided only 1 perspective on the roles and career trajectories of those in the field. To better understand both the range and frequency of experiences, clinical and nonclinical roles, training, work expectations, and career plans, we conducted a national survey study of practicing pediatric hospitalists.
METHODS
Sample
We identified all 761 hospitals in the American Hospital Association (AHA)'s 2005 Annual Survey of Hospitals that reported to have both a hospitalist service (adult and/or pediatric) and pediatric beds. From these 761 hospitals, we selected a random sample of 213, stratified by:
Council of Teaching Hospital (COTH) designation
National Association of Children's Hospitals & Related Institutions (NACHRI) membership
Freestanding children's hospitals
Metropolitan Statistical Area (MSA) (urban versus rural location)
Hospital size (small: <250 total beds versus large: 250 total beds)
Some hospitals are included in more than 1 category. Thus, there is some overlap of hospitals in the analysis. Of these 213 hospitals, 97 were removed from the sample because they did not have at least 1 pediatric hospitalist. In a separate study, we surveyed hospitalist program directors at 112 of the remaining 116 hospitals from June through September 2006. These results have been published.1
Pediatric hospitalist program directors at these 112 participating hospitals were asked to provide the names of all practicing pediatric hospitalists in their respective programs. Ninety‐five of these program directors provided a list of hospitalists at their institutions, representing 85% of the hospitals in our previous study. A total of 530 practicing pediatric hospitalists were identified to us in this manner. Of these 530 hospitalists, 67% (N = 338) were from teaching hospitals, 71% (N = 374) were from children's hospitals, 43% (N = 230) were from freestanding children's hospitals, and 69% (N = 354) were from hospitals with 250 beds. These are not mutually exclusive categories.
Survey Instrument
We developed a structured questionnaire to be administered by mail. The survey contained 25 items and was designed to be completed in 10 minutes or less. The survey focused on exploring the characteristics of hospitalist clinical and nonclinical practice, service schedule, training, and career goals. The questionnaire was comprised of a mixture of fixed‐choice, Likert‐scale, and open‐ended questions.
Questionnaire Administration
In October 2006, the first mailing of questionnaires was sent via priority mail. The survey packet contained a personalized cover letter signed by the principal investigator (G.L.F.), the instrument, a business reply mail envelope, and a $5 bill as an incentive. Two additional mailings were sent to nonrespondents in November 2006 and January 2007.
Data Analysis
First, frequency distributions were calculated for all survey items. Next, comparisons were made between respondents indicating they held an academic appointment and those who did not. For the purposes of this analysis, academic pediatric hospitalists were defined as those respondents holding a full‐time or part‐time academic appointment. Nonacademic pediatric hospitalists were defined as respondents holding an adjunct or volunteer faculty position, or no academic appointment. Finally, chi‐square statistics were used to compare pediatric hospitalist responses by hospital demographics such as teaching status, children's hospital status, NACHRI freestanding hospital designation, and hospital bed size.
The study was approved by the University of Michigan Medical Institutional Review Board.
RESULTS
Response Rate
Of the initial 530 survey packets mailed, 18 were returned as undeliverable by the postal service and 431 physicians returned the survey. This yielded an overall response rate of 84%. Of the 431 respondents, 40 physicians were ineligible because they no longer provided inpatient care to children or did not consider themselves to be hospitalists. Thus, the final sample for analysis was 391.
Hospitalist Employment Characteristics
Demographics of Hospital Worksite
Of the 391 respondents, 61% (N = 237) were from teaching hospitals, 73% (N = 287) from children's hospitals, 47% (N = 182) from freestanding children's hospitals, and 66% (N = 258) from hospitals with more than 250 beds.
Physician Demographics
The mean age of respondents was 39 years and 59% were female. The majority were employed by a hospital or health system (56%), 20% were employed by a university, and 4% were employed by both. Eight percent reported employment by a general physician medical group, 7% were employed by a hospitalist‐only group, and 4% reported other sources of employment. Half of respondents (N = 196) reported holding a full‐time (40%) or part‐time (10%) academic appointment. Approximately half the respondents (N = 194) were considered nonacademic hospitalists.
More than half of respondents (54%; N = 211) had been practicing as hospitalists for at least 3 years. Reported time as a practicing hospitalist ranged from <1 year to 26 years, while the average length of time was 63 months (Table 1). These figures may be skewed because those hospitalists with higher turnover rates might have left their position during the period of time from when they were selected into the sample until the time of survey administration.
| Length of Time as Hospitalist | % (N) |
|---|---|
| |
| 12 months | 13 (51) |
| 13‐24 months | 18 (71) |
| 25‐36 months | 14 (56) |
| 37‐60 months | 17 (67) |
| >61 months | 37 (144) |
Clinical Practice
Most respondents reported that the pediatric inpatient unit (94%) and inpatient consultation service (51%) were a part of their regular clinical assignment (Table 2). A majority did not provide service in the normal newborn nursery (58%), subspecialty inpatient service (52%), pediatric intensive care unit (ICU) (70%), neonatal ICU (77%), transports (85%), outpatient clinics (66%), or as part of an emergency response team (53%).
| Part of Regular Clinical Assignment % (N) | Occasionally % (N) | Never % (N) | |
|---|---|---|---|
| |||
| Pediatric inpatient unit | 94 (368) | 3 (13) | 2 (9) |
| Inpatient consultation service | 51 (199) | 40 (155) | 9 (35) |
| Normal newborn nursery | 29 (110) | 13 (50) | 58 (223) |
| Emergency department | 25 (95) | 28 (108) | 47 (178) |
| Subspecialty inpatient service | 25 (92) | 23 (86) | 52 (196) |
| Emergency response team | 23 (87) | 24 (91) | 53 (201) |
| Outpatient/outreach clinics | 18 (68) | 16 (61) | 66 (253) |
| Pediatric ICU | 14 (54) | 16 (59) | 70 (268) |
| Neonatal ICU | 12 (44) | 11 (42) | 77 (294) |
| Transports | 9 (33) | 6 (23) | 85 (319) |
With regard to procedures, many (53%) respondents reported that they routinely perform or supervise lumbar punctures. Several services are never performed or never supervised by the majority of pediatric hospitalists, including infusion services (57%), peripherally inserted central catheter (PICC) placement (76%), central line placement (67%), and circumcision (85%).
Professional Roles and Parameters
Respondents reported that they participate in a variety of nonclinical activities. Ninety‐four percent of hospitalists were involved in education, and 45% reported having a leadership role in that area. The majority of respondents participated in quality improvement (QI) initiatives (84%) and practice guideline development (81%), with one‐quarter of hospitalists reporting a leadership role in each of these activities. Slightly more than half of respondents reported involvement in hospital administration (52%) and utilization review (55%) (Table 3).
| Participation | No Involvement % (N) | ||
|---|---|---|---|
| Participation of Any Type % (N) | Leadership Role % (N) | ||
| |||
| Education (students, house staff) | 94 (368) | 45 (177) | 6 (22) |
| Quality improvement initiatives | 84 (330) | 25 (99) | 16 (61) |
| Practice guideline development | 81 (313) | 26 (101) | 19 (74) |
| Utilization review | 55 (213) | 11 (41) | 45 (172) |
| Hospital administration | 52 (202) | 16 (60) | 48 (184) |
On average, hospitalists reported spending 61% of their time providing inpatient care (excluding clinical teaching) and 16% of their time providing clinical teaching or supervising residents. More than one‐third of respondents (38%) spent more than 75% of their time providing direct inpatient care. Research (3%), administrative duties (8%), and nonclinical teaching (3%) were reported to be a small part of hospitalist professional time.
Pediatric Hospitalist Service Schedule
The majority of respondents reported that their assigned clinical schedule was a combination of shift and call (61%).
When on service, over half of responding pediatric hospitalists (58%) reported that they spend 40 to 60 hours onsite per week. Less than one‐fifth of respondents (19%) reported that they provide <40 hours of onsite coverage when on service. Most (97%) provide some type of night coverage, including taking calls from home or providing onsite coverage.
Hospitalist Training and Continuing Education
Only 51 of the 391 respondents (13%) had received some type of fellowship training, mostly in general pediatrics or the pediatric subspecialties. Only 5 respondents had received fellowship training in hospital medicine.
Fifty‐eight percent of respondents reported that they had received no hospitalist‐specific training. One‐fifth reported that they received training through a workshop at a professional meeting, while fewer respondents had received hospitalist training though a continuing medical education (CME) course (16%) or a mentoring program (17%).
Respondents were asked to rate the adequacy of their respective training in preparing them for their work as hospitalists. The vast majority rated their training in general clinical skills (94%) and communication (85%) as fully adequate. However, respondents found their training for some of the nonclinical aspects of their positions to be deficient. Many respondents rated training for QI projects (38%) and hospital administrative duties (46%) as inadequate (Table 4).
| Fully Adequate % (N) | Somewhat Adequate % (N) | Not Adequate % (N) | NA % (N) | |
|---|---|---|---|---|
| ||||
| General clinical skills | 94 (367) | 5 (21) | 0 (0) | 0 (1) |
| Communication skills | 85 (330) | 14 (53) | 1 (5) | 0 (1) |
| Coordination of care | 73 (284) | 23 (89) | 4 (15) | 0 (1) |
| Clinical procedure experience | 67 (258) | 32 (123) | 1 (5) | 1 (2) |
| Teaching skills (resident and medical student teaching) | 64 (248) | 31 (120) | 3 (13) | 2 (8) |
| Attending newborn deliveries | 60 (233) | 18 (70) | 4 (14) | 19 (72) |
| Running resuscitation (codes) | 45 (173) | 46 (177) | 5 (21) | 5 (18) |
| Quality improvement projects | 14 (55) | 42 (162) | 38 (148) | 6 (22) |
| Hospital administrative duties | 10 (37) | 37 (144) | 46 (177) | 8 (31) |
Survey respondents were asked to indicate the extent to which they agreed or disagreed with 3 statements regarding hospitalist training. The majority of respondents believed that hospitalists need training in QI methods (70%). However, most pediatric hospitalists (73%) did not believe that additional training beyond residency should be required. Only one‐third (36%) of respondents agreed that current CME offerings are adequate for their needs as a pediatric hospitalist.
Career Goals and Expectations
Respondents were asked to select 1 or more reasons why they became pediatric hospitalists. The top factors influencing respondents' decision to become a hospitalist were reported to be a preference for the inpatient setting (73%), clinical variety (72%), enjoyment of teaching in the inpatient setting (58%), and a flexible schedule (52%) (Table 5).
| Factor | % (N) |
|---|---|
| |
| Prefer inpatient setting | 73 (284) |
| Clinical variety | 72 (281) |
| Enjoy teaching in inpatient setting | 58 (225) |
| Flexible schedule | 52 (202) |
| Defined hours | 41 (161) |
| Attractive career opportunities | 21 (80) |
| Salary | 18 (70) |
| Unsure of long‐term career direction | 13 (51) |
| Other | 7 (28) |
| Needed short‐term employment | 4 (15) |
| Only position available | 3 (10) |
The majority (85%) were satisfied with their position as a pediatric hospitalist, with 37% reporting that they were extremely satisfied. Over one‐half (61%) expected to remain a hospitalist for the duration of their career.
RESULTS BY ACADEMIC STATUS
Only significant differences between academic and nonacademic hospitalists are presented.
Clinical Practice by Academic Status
Nonacademic respondents were more likely than academic respondents to report regular service in the normal newborn nursery, pediatric ICU, neonatal ICU, transports, emergency department, and as part of an emergency response team. Academic respondents were more likely to report regular service in outpatient clinics. Nonacademic respondents were more likely than academic respondents to perform or supervise lumbar punctures, sedation services, PICC or central line insertions, and circumcisions (Table 6).
| Academic* (N = 196) | Nonacademic (N = 194) | P Value | |
|---|---|---|---|
| |||
| Regularly provides service | |||
| Normal newborn nursery | 16% | 42% | <0.0001 |
| Pediatric ICU | 9% | 20% | 0.0065 |
| Neonatal ICU | 4% | 20% | <0.0001 |
| Transports | 3% | 15% | <0.0001 |
| Emergency department | 16% | 34% | <0.0001 |
| Emergency response team | 17% | 29% | <0.0001 |
| Outpatient clinic | 23% | 13% | 0.0168 |
| Performs or supervises procedures | |||
| Lumbar puncture | 84% | 92% | 0.0152 |
| Sedation services | 50% | 64% | 0.0055 |
| PICC insertion | 8% | 18% | 0.0031 |
| Central line insertion | 11% | 23% | 0.0018 |
| Circumcision | 5% | 16% | 0.0002 |
| Holds leadership roles | |||
| Education (student or house staff) | 63% | 27% | <0.0001 |
| Hospital administration | 21% | 10% | <0.0001 |
| Quality improvement initiatives | 33% | 18% | 0.0005 |
Professional Roles and Parameters by Academic Status
Responding academic pediatric hospitalists were twice as likely as nonacademic respondents to have a leadership role in the education of students and house staff and to hold a leadership position in hospital administration. The academic respondents were also more likely to report a leadership role in QI initiatives (Table 6).
Clinical and Educational Activities by Academic Status
Academic pediatric hospitalist respondents reported spending on average 52% of their time providing inpatient care (excluding teaching), in contrast to the nonacademic hospitalist respondents who reported 71% of their time was spent providing inpatient care (P < 0.0001). Academic respondents also reported that 19% of their time was spent providing inpatient teaching or supervising residents, compared to 12% of nonacademic respondents (P < 0.0001). Responding academic pediatric hospitalists reported spending a greater proportion of time participating in nonclinical teaching activities (5% versus 2%; P < 0.0001), administrative duties (11% versus 5%; P < 0.0001), and research (4% versus 1%; P < 0.0001) compared to the nonacademic respondents.
Nonacademic respondents were more likely than academic respondents to report no hospitalist‐specific training (64% versus 54%; P = 0.0324).
RESULTS BY HOSPITAL CHARACTERISTICS
For each hospital characteristic, only significant differences between dichotomized groups are presented.
Children's Hospitals versus Other Hospitals
Clinical Practice
Pediatric hospitalist respondents practicing in NACHRI hospitals were more likely to report that they provide regular service for general pediatric inpatients (98% versus 86%; P < 0.0001) as well as subspecialty inpatients (27% versus 17%; P = 0.044). Non‐NACHRI pediatric hospitalist respondents were twice as likely to report the provision of regular service in the normal newborn nursery (49% versus 22%; P < 0.0001), the neonatal ICU (21% versus 8%, P = 0.002), and the emergency department (38% versus 20%; P < 0.0001).
Among respondents, pediatric hospitalists who were not working at a children's hospital were more likely to report that they sometimes or routinely performed lumbar punctures (93% versus 85%; P = 0.037), infusion services (36% versus 21%; P = 0.003), and were twice as likely to perform circumcision (16% versus 8%; P = 0.041) compared to those working at children's hospitals.
Professional Roles and Parameters
Respondents working in children's hospitals were twice as likely to hold a leadership position in utilization review (12% versus 6%; P = 0.012), though respondents from non‐NACHRI hospitals were more likely to at least participate in utilization review (58% versus 40%; P = 0.004).
Hospitalist Training
Respondents from non‐NACHRI hospitals were more likely to report that they had received no hospitalist‐specific training (68% versus 56%; P = 0.029). Those at NACHRI hospitals were twice as likely to have received hospitalist training through a mentoring program (20% versus 9%; P = 0.009).
Freestanding versus Nonfreestanding Children's Hospitals
Clinical Practice
Pediatric hospitalist respondents employed at institutions that are not freestanding children's hospitals were more likely to report that they provided regular service in the normal newborn nursery (42% versus 14%; P < 0.0001), pediatric ICU (22% versus 5%), emergency department (32% versus 17%; P < 0.0001), and outpatient clinics (23% versus 12%; P = 0.0068). They were also more likely to perform or supervise sedation services (63% versus 50%; P = 0.0116), infusion services (32% versus 17%; P = 0.0006), PICC insertions (19% versus 6%; P = 0.0002), central line insertions (23% versus 11%; P = 0.0024), and circumcisions (16% versus 3%; P < 0.0001).
Professional Roles and Parameters
Among respondents, pediatric hospitalists employed by nonfreestanding children's hospitals were more likely to report participation in utilization review (51% versus 38%; P = 0.02).
Hospital Size
Clinical Practice
Pediatric hospitalist respondents working at large hospitals were twice as likely to report that they regularly provided service in the pediatric ICU (18% versus 7%; P = 0.0072) and were more likely to regularly perform circumcisions (13% versus 5%; P = 0.0069). Respondents from small hospitals were more likely to provide regular service in the neonatal ICU (20% versus 7%; P = 0.0013).
COTH Status: Teaching versus Nonteaching Hospitals
Clinical Practice
Among survey respondents, pediatric hospitalists employed by COTH hospitals were more likely to provide regular service in the neonatal ICU, compared to their peers in nonteaching hospitals (15% versus 6%; P = 0.0109). Those employed by non‐COTH hospitals were more likely to provide service in subspecialty inpatient service (38% versus 16%; P < 0.0001), transports (14% versus 6%; P = 0.0227), inpatient consultation (61% versus 45%; P = 0.0086), and the emergency response team (29% versus 19%; P = 0.0021).
Professional Roles and Parameters
Respondents from COTH hospitals were more likely to have no involvement in utilization review, compared to their peers at non‐COTH hospitals (49% versus 37%; P = 0.0220).
DISCUSSION
This study provides the most comprehensive information available regarding the clinical and nonclinical roles, training, work expectations, and career plans of pediatric hospitalists. Among the most important of our findings is the distribution of the length of time that pediatric hospitalists had served in their roles. While over one‐third (37%) reported having been practicing as hospitalists for over 5 years, 45% of our respondents had been in practice for fewer than 3 years. This is consistent with both the perceptions of rapid growth of the field and with significant turnover of hospitalists.1, 8 It is important to note that our findings may actually overestimate the proportion of hospitalists with longer durations of employment as our sampling strategy would have been less likely to include those who left the field within the first 12 to 18 months of practice. Nevertheless, over half (61%) of our respondents expected to remain a hospitalist for the duration of their career and few reported choosing to become a hospitalist as a short‐term employment option. This finding has important implications for the future stability of the hospitalist workforce and the potential development of specific expertise among this cadre of clinicians.6
The demographic profile of pediatric hospitalists was also consistent with these findings. The mean age of 39 years for our respondents is indicative of a significant proportion of this group of physicians recently having completed their residency training. Further, the gender distribution approximates that of current pediatric residency graduates, thus indicating that that this is not a clinical choice for which there would be a skewed distribution as is the case in some pediatric subspecialties.9
Our findings were similar to the 2004 Ottolini et al.10 findings on the roles of pediatric hospitalists. Respondents in our study reported spending less time providing inpatient care (61% versus 75%), providing clinical teaching or supervising residents (16% versus 26%), performing administrative duties (8% versus 19%), and conducting research (3% versus 9%) compared with the respondents in the Ottolini et al.10 survey.
At this point in time, fewer than half of our respondents reported any hospitalist‐specific training, including workshops at professional meetings or CME coursework. As there are a paucity of fellowships offering postresidency training in pediatric hospital medicine, and most of the existing programs are newly established, few in practice have completed such programs.11 In addition, most respondents reported that current CME offerings do not meet their needs, and that they could have used additional QI training to prepare them for their role as pediatric hospitalists. However, almost three‐quarters of respondents (73%) do not believe any additional training beyond residency should be required. As such, it is unclear if a defined, unique body of knowledge specific to hospitalists is either needed or desired by those currently in the field.
Although there are a broad range of potential clinical roles within hospital medicine, and this clinical variety influenced most respondents' decisions to become hospitalists, the current scope of an individual hospitalist tends to become somewhat focused.12, 13 While we found almost all provided service on the pediatric inpatient unit, many fewer provided inpatient consultation and normal newborn care, or were involved in interhospital transport or as part of an emergency response team. There is also wide variation in the types of procedures performed or supervised by hospitalists at different institutions. More than half never perform or supervise infusion services, PICC or central line placement, or circumcision. The variation seen among hospitalists practicing in different hospital settings likely is a result, at least in part, of different needs in teaching hospitals for both service and for clinical experience of trainees. For example, our results demonstrate that pediatric hospitalists in nonteaching and non‐children's hospitals are more likely to have a broader scope of clinical care provision. Another potential issue is that some hospitalists may be employed by institutions which have no pediatric ICU, neonatal ICU, or other specialty unit. As such, these hospitalists would not have the opportunity to work in such settings.
Further, those without academic appointments are also more likely to have expanded clinical roles compared with their academic counterparts. This may be due to the fact that there is likely a greater number of subspecialty‐trained pediatric providers in academic centers and thus the need for hospitalists to cover specific services or perform specific procedures is lessened. There may also be a desire to prevent competition among care providers within the same institution. In contrast, hospitalists with academic appointments are more likely (though still uncommonly) to have taken leadership roles in hospital administration and QI initiatives. Thus, the nature of their efforts appears to expand into nonclinical delivery areas.
Clearly, hospitalists report they have assumed a significant role in the clinical teaching of trainees at all levels, with 94% of our respondents maintaining at least some involvement in education. On average, they spend 16% of their time in educational efforts. However, there are few data on the impact of their work in this area.5, 13 Studies in pediatrics to date have been limited to a few institutions,3, 5 and have not addressed the issue from the perspective of residency program directors or those who are in charge of inpatient curricula.
This study, like the majority of studies related to pediatric hospitalists, is hampered by the difficulty of identifying pediatric hospitalists. Rather than utilizing a hospital medicine membership list, which would be potentially biased by self‐selection, we attempted to obtain a more representative sample through utilization of the AHA database.
CONCLUSIONS
Findings from this study provide an additional perspective regarding pediatric hospitalists to add to our previous study of hospitalist program directors.1 However, the field is currently a moving target. Our data demonstrate that there is significant flux in the hospitalist workforce, uncertainty regarding turnover, and variation in the roles of these professionals in their clinical and nonclinical work environment. Moreover, additional studies of the educational impact of hospitalists on residency and medical student education are needed. Questions regarding the nature and degree of resident autonomy and experience conducting procedures in the hospitalist environment have been raised. These must be assessed through studies of residency program directors, their expectations of residents, and the curricula they have developed.
As with any new phenomenon, it will take time to understand the impact of hospitalists in a variety of domains. Additional research will be helpful in following the development of this field and the manner in which it will interface with existing medical practice and educational programs.
- ,,,; The Research Advisory Committee of the American Board of Pediatrics.Characteristics of the pediatric hospitalist workforce: its roles and work environment.Pediatrics.2007;120:33–39.
- .The evolution of the hospitalist model in the United States.Med Clin North Am.2002;86:687–706.
- ,.Hospitalists in children's hospitals: what we know now and what we need to know.J Pediatr.2006;148:296–299.
- ,.Hospitalists: the new model of inpatient medical care in the United States.Eur J Intern Med.2003;14:65–70.
- ,,,,,.Effect of a pediatric hospitalist system on housestaff education and experience.Arch Pediatr Adolesc Med.2002;156:877–883.
- ,,,.Hospitalists' perceptions of their residency training needs: results of a national survey.Am J Med.2001;111:247–254.
- ,,,,,.Pediatric hospitalists in Canada and the United States: a survey of pediatric academic department chairs.Ambul Pediatr.2001;1:338–339.
- .Hospitalists in the United States: mission accomplished or work in progress?N Engl J Med.2004;350:1935–1936.
- ,.Pediatric workforce: a look at general pediatrics data from the American Board of Pediatrics.J Pediatr.2006;148:166–169.
- ,,,,PRIS survey: pediatric hospitalist roles and training needs [Abstr].Pediatr Res.2004;55:360A.
- ,,,.Hospital medicine fellowships: works in progress.Am J Med.2006;119:1.e1–1.e7.
- ,,.How hospitalists spend their time: insights on efficiency and safety.J Hosp Med.2006;1:88–93.
- ,,.Pediatric hospitalists fill varied roles in the care of newborns.Pediatr Ann.2003;32:802–810.
- ,,,; The Research Advisory Committee of the American Board of Pediatrics.Characteristics of the pediatric hospitalist workforce: its roles and work environment.Pediatrics.2007;120:33–39.
- .The evolution of the hospitalist model in the United States.Med Clin North Am.2002;86:687–706.
- ,.Hospitalists in children's hospitals: what we know now and what we need to know.J Pediatr.2006;148:296–299.
- ,.Hospitalists: the new model of inpatient medical care in the United States.Eur J Intern Med.2003;14:65–70.
- ,,,,,.Effect of a pediatric hospitalist system on housestaff education and experience.Arch Pediatr Adolesc Med.2002;156:877–883.
- ,,,.Hospitalists' perceptions of their residency training needs: results of a national survey.Am J Med.2001;111:247–254.
- ,,,,,.Pediatric hospitalists in Canada and the United States: a survey of pediatric academic department chairs.Ambul Pediatr.2001;1:338–339.
- .Hospitalists in the United States: mission accomplished or work in progress?N Engl J Med.2004;350:1935–1936.
- ,.Pediatric workforce: a look at general pediatrics data from the American Board of Pediatrics.J Pediatr.2006;148:166–169.
- ,,,,PRIS survey: pediatric hospitalist roles and training needs [Abstr].Pediatr Res.2004;55:360A.
- ,,,.Hospital medicine fellowships: works in progress.Am J Med.2006;119:1.e1–1.e7.
- ,,.How hospitalists spend their time: insights on efficiency and safety.J Hosp Med.2006;1:88–93.
- ,,.Pediatric hospitalists fill varied roles in the care of newborns.Pediatr Ann.2003;32:802–810.
Copyright © 2009 Society of Hospital Medicine
Pediatric Hospital Medicine Fellowships
The field of pediatric hospital medicine is undergoing rapid growth. In 2002, there were approximately 600 pediatric hospitalists1 and in 2006 this number was estimated to be approximately 1000.2 A recent study found that approximately 25% of pediatric hospitalist practices are less than 2 years old.3 As such, there are many new physicians entering the field and most do so without specific training in hospital medicine prior to beginning their employment.4 There is also significant variability in the roles, work patterns, and scope of practice across institutions,3 and hospitalists are engaged in a wide variety of clinical, educational, and administrative functions.
A survey of pediatric department chairs in 2001 found that very few believed that any additional training beyond a pediatric residency was required to perform hospitalist medicine.5 However, since then the field has undergone significant growth. A more recent survey of practicing hospitalists found that 92% believed there was a need for additional training in a variety of domains.6 Specifically, respondents were most interested in achieving greater skill in performing critical care procedures and academic training. These hospitalists regarded pediatric hospitalist fellowships as the best way to gain the additional skills in teaching, research, and administration needed for their positions.
Nonetheless, for a variety of reasons, not the least of which is perhaps the paucity of hospitalist fellowship training programs, few hospitalists in practice today have completed a fellowship in hospital medicine. Over the past several years, a number of pediatric‐specific hospitalist fellowship programs have been initiated, yet little is known of their requirements or curricula. We conducted a study to explore the structure, components, and training goals of the pediatric hospitalist fellowship programs in North America.
MATERIALS AND METHODS
Sample
To examine the characteristics of pediatric hospitalist training in North America, we examined all 8 fellowships or training programs that were in existence in early 2007. The total sample included the following sites: Children's Hospital Boston, Children's Specialists of San Diego, Children's National Medical Center, Children's Healthcare of Atlanta, Texas Children's Hospital, All Children's Hospital, University of North Carolina, and The Hospital for Sick Children.
Survey Instrument
We constructed a 17‐item structured questionnaire to be administered by phone. The instrument was designed to be completed in approximately 10 minutes. Questionnaire items focused on documenting the goals, training, requirements, and clinical duties that characterize current pediatric hospitalist training programs. The questionnaire was comprised of a mixture of fixed‐choice and open‐ended questions. A draft of the instrument was shared with representatives of the Society of Hospital Medicine Pediatrics Committee for comment and suggestions.
Questionnaire Administration
The research team sent a prenotification letter to directors of the 8 pediatric hospitalist training programs to inform them of the research study. From February through June 2007, research staff contacted the directors of the programs, explained the purpose of the study, and obtained verbal consent.
Data Analysis
Responses were reviewed to compare and contrast the characteristics of the various programs. The study was approved by the University of Michigan Medical Institutional Review Board.
RESULTS
Response Rate
Of the 8 training programs, all completed the survey, representing a response rate of 100%. One institution offers 2 separate fellowship paths: academic and clinical.
Pediatric Hospitalist Fellowship and Training Program Overview
The first pediatric hospital medicine fellowship was initiated 15 years ago. However, the majority of pediatric hospitalist training programs in North America were established more recently, between 2003 and 2007.
Most pediatric hospitalist training programs offer 1 position per year. The duration of the training programs range from 1 to 3 years. Minimum clinical duties required by the programs vary from 4 to 8 months and the maximum amount of clinical time permitted ranges from 4 to 20 months. Most programs indicated that there is some flexibility in the clinical duties required or available to the fellows.
Six of the 8 programs offer an academic degree. Table 1 provides an overview of the programs, types of degrees offered, and funding sources for academic work. Subsequent tables provide blinded results to protect respondent confidentiality.
| Program | Year Established | Division | Number of Positions, 2007 | Duration of Program | Minimum Clinical Time | Maximum Clinical Time | Degree Possible? | Who Pays for Degree? |
|---|---|---|---|---|---|---|---|---|
| ||||||||
| Toronto‐Academic | 1992 | Pediatric medicine | 3 | 2 years | 4 months | 4 months | Yes: fellow's choice | Fellow |
| Children's Boston | 1998 | Emergency medicine | 1 | 2 years | 8 months | 12 months | Yes: MPH, MEd, MPP | Depart. funds; Externalfunds (creative) |
| Children's National | 2003 | Hospital medicine | 1‐2 | 2‐3 years | 6 months | 20 months | Yes: MPH | Faculty benefits |
| Children's Spec. San Diego | 2003 | Hospital medicine | 1 | 1‐2 years | 7 months | NA | Yes: MAS | Division |
| Toronto‐Clinical | 2004 | Pediatric medicine | 1 | 1 year | 8 months | 8 months | No | NA |
| Texas | 2005 | Emergency medicine | 1 | 2 years | 8 months | 8 months | Yes: MPH, MME | Varies |
| University of North Carolina | 2006 | General pediatrics and adolescent medicine | 1 | 1 year | 5 months | 6 months | No | NA |
| All Children's | 2007 | General pediatrics | 1 | 2 years | 8 months | 9 months | Yes: MPH, MS | External funding pending (federal grants) |
| Children's Atlanta | 2007 | Pediatric hospitalist section | 1 | 1 year | 6 months | 6 months | No | NA |
The number of fellowship or training program positions available each year has remained fairly consistent. However, to date, enrollment has not kept up with position availability (Table 2).
| Program | 2006‐2007 Positions Available | 2006‐2007 Fellows Enrolled | 2007‐2008 Positions Available |
|---|---|---|---|
| A | NA | NA | 1 |
| B | 2 | 1 | 2 |
| C | 1 | 1 | 1 |
| D | NA | NA | 1 |
| E | 1 | 0 | 2 |
| F | 1 | 0 | 1 |
| G | 2 | 0 | 3 |
| H | 1 | 2 | 1 |
| I | 1 | 1 | 0 |
Program Goals
Seven out of 8 programs reported the provision of advanced training in the clinical care of hospitalized patients, quality improvement (QI), and hospital administration to be central goals of their training program. Six respondents reported the provision of training in the education of medical students and residents to be a primary goal of their program, while 5 indicated training in health services research to be a primary goal.
Participation in General Hospital Activities
Trainees in all programs participate in clinical care, resident education, student education, research activities, and hospital committees. Seven out of 8 programs reported that fellows or trainees participate in patient safety activities and guideline development.
Formal Training
Half of the programs reported that they provide formal coursework in areas of education and hospital administration including quality improvement, resident teaching, and student teaching. Three of the 8 programs provide formal coursework in hospital economics.
Three of the 8 programs provide seminars in resident teaching, student teaching, hospital economics, and leading a healthcare team (Table 3).
| Programs | Resident Teaching | Student Teaching | Hospital Economics | Quality Improvement | Leading a Healthcare Team | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| Coursework | Seminars | Coursework | Seminars | Coursework | Seminars | Coursework | Seminars | Coursework | Seminars | |
| ||||||||||
| A | Yes | Yes | Yes | Yes | ||||||
| B | Yes | Yes | Yes | Yes | Yes | |||||
| C | Yes | Yes | Yes | Yes | Yes | |||||
| D | Yes | Yes | Yes | Yes | Yes | |||||
| E | Yes | Yes | Yes | Yes | ||||||
| F | Yes | |||||||||
| G | Yes | Yes | Yes | Yes | Yes | Yes | ||||
| H | Yes | Yes | Yes | Yes | Yes | Yes | ||||
| I | Yes | Yes | ||||||||
Seven of 8 pediatric hospitalist training programs provide formal coursework in epidemiology and research methodology. Six programs reported that they provide formal coursework in biostatistics and 5 in publications or grant writing. Four offer seminars in health economics, research methodology, and QI methodology (Table 4).
| Epidemiology | Biostatistics | Health Economics | Research Methodology | QI Methodology | Publications/Grant Writing | Translation Research | Educational Research | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Course | Seminar | Course | Seminar | Course | Seminar | Course | Seminar | Course | Seminar | Course | Seminar | Course | Seminar | Course | Seminar | |
| ||||||||||||||||
| A | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | ||||||||
| B | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | |||||||
| C | Yes | Yes | Yes | Yes | Yes | Yes | Yes | |||||||||
| D | Yes | Yes | Yes | Yes | Yes | Yes | Yes | |||||||||
| E | Yes | Yes | Yes | Yes | Yes | Yes | Yes | |||||||||
| F | Yes | Yes | Yes | Yes | Yes | Yes | ||||||||||
| G | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| H | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| I | ||||||||||||||||
Program Requirements
Seven pediatric hospitalist training programs require fellows to complete a research project. Six programs reported that they require fellows or trainees to complete a quality improvement project or participate on a hospital committee. Six of the programs require pediatric hospitalist fellows to attempt to present at a national meeting, and 4 programs require that fellows attempt to publish their research in a peer‐reviewed publication. Graduate degrees are required at 3 of the 8 pediatric hospitalist training programs (Table 5).
| QI Project | Research Project | Abstract/Presentation at National Meeting* | Peer‐Reviewed Publication* | Committee Participation at Hospital | Attending on General Ward Leading Resident Team | Specific Advanced Clinical Training | Graduate Degree Program | Other | |
|---|---|---|---|---|---|---|---|---|---|
| |||||||||
| A | Yes | Yes | Yes | Yes | Yes | Yes | Yes | ||
| B | Yes | Yes | |||||||
| C | Yes | Yes | Yes | Yes | Yes | Yes | Yes | ||
| D | Yes | Yes | Yes | Yes | Yes | Yes | |||
| E | Yes | Yes | Yes | Yes | Yes | Yes | Yes | ||
| F | Yes | Yes | Yes | Yes | Yes | Yes | Yes | ||
| G | Yes | Yes | Yes | Yes | |||||
| H | |||||||||
| I | Yes | Yes | Yes | Journal club | |||||
Clinical Service Requirements
All programs indicated that they require the fellow or trainee to serve as an attending on the general pediatric ward. Five programs require the fellow or trainee to provide service at the fellow or PL‐3 level in the pediatric intensive care unit (PICU), anesthesia service, and transport team. Four programs reported that they require service in the emergency department, and 3 programs require service in the neonatal intensive care unit (NICU), newborn nursery, and general pediatric ward at the fellow or PL‐3 level. Only 2 programs require service in the pediatric subspecialty ward, and 1 program requires service in outpatient urgent care. No program requires primary care service (Table 6).
| PICU | NICU | Anesthesia | Primary Care (Outpatient) | Emergency Department | Urgent Care | Transport | General Pediatric Ward | Pediatric Subspecialty Ward | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Attd | Fellow | Attd | Fellow | Attd | Fellow | Attd | Fellow | Attd | Fellow | Attd | Fellow | Attd | Fellow | Attd | Fellow | Attd | Fellow | Other Units | |
| |||||||||||||||||||
| A | Yes | Yes | Yes | Yes | Yes | Newborn nursery | |||||||||||||
| B | Yes | ||||||||||||||||||
| C | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Stepdown ICU | |||||||||||
| D | Yes | Yes | Yes | Yes | Yes | Yes | |||||||||||||
| E | Yes | Yes | Yes | Yes | Yes | Child abuse, newborn nursery, subacute care rehabilitation facility | |||||||||||||
| F | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Variety of hospitals (county‐based) | |||||||||||
| G | Yes | Child abuse, consultation clinic, community‐based practice | |||||||||||||||||
| H | Yes | Child abuse, consultation clinic, community‐based practice | |||||||||||||||||
| I | Yes | Yes | Yes | Yes | Newborn nursery | ||||||||||||||
Pediatric Hospitalist Fellowship and Training Program Funding Sources
Five of the programs use department funds to finance the fellowship program. Four of the programs utilize the fellow or trainee's clinical work as a funding source. Two of the programs reported that the program is paid for through hospital funds.
Pediatric Hospitalist Fellow or Trainee Independence
Respondents indicated that fellows or trainees become increasingly independent over the course of the program. Fellows are supervised or mentored by hospitalists on staff. Half of the programs surveyed allow fellows or trainees to bill independently under certain circumstances (Table 7).
| Bill Independently? | Supervision? | |
|---|---|---|
| A | No: bill under a supervising attending | Supervised by hospitalist and given autonomy with supervision from hospitalist attending. |
| B | Yes | First couple of months during fellow's clinical period, more interaction with supervisors. Senior folks always available for consultation. |
| C | Yes: after 3 months | Clinical mentor (1 of 4 senior hospitalists) with whom they discuss patients on a more informal basis when on service. |
| D | Yes: on general wards, when functioning as attending | Fellows meet weekly with fellowship director. Hospitalist on call available for consult. |
| E | Fellows: no; faculty fellows: yes | Traditional fellowship role. Fellows complete several clinical electives with various levels of supervision. |
| F | Yes: after first 6 months | Fellows are supervised in their first year by hospitalist faculty. |
| G | No | Day to day in patient care, senior staff review as needed. Each fellow has 1 primary supervisor. When on service overnight, fellows call staff attending. |
| H | No | Day to day in patient care, senior staff review as needed. Each fellow has 1 primary supervisor. When on service overnight, fellows call staff attending. |
| I | Yes | Trainees are supervised by the director of the hospitalist program, the inpatient attending, and other hospitalists. |
DISCUSSION
There appear to be 2 distinct tracks for pediatric hospitalist training programs: clinical or academic specialization. However, this is not surprising, as most programs are relatively new and there are no standards or requirements for fellowship training from an external accrediting body. As such, the curriculum for these programs is likely driven by a combination of service requirements and local speculation on the needs of a future generation of pediatric hospitalists. Most programs also reported that they provide significant flexibility for each fellow based on their self‐perceived training needs and background.
Although there has been considerable emphasis on the potential educational role of hospitalists, formal coursework in teaching and education is not a part of the curriculum for half of the existing fellowship programs. Recent reports have demonstrated that hospitalists have received better teaching evaluations than traditional subspecialty attendings.7 However, this is in the absence of additional training in education and may reflect greater time that hospitalists might devote to their clinical trainees. The opportunity to further improve the educational training of hospitalists could be an important part of the fellowship experience.
Hospitalists have also been hypothesized to be in a prime position to either lead or have meaningful participation in quality improvement and cost‐saving efforts in the hospital setting. However, only half of programs provide formal coursework in QI and even fewer in areas of hospital economics.
Interestingly, most programs provide coursework in research methods, epidemiology, and grant writing. Requirements regarding clinical duties ranged from a minimum of 17% to a maximum of 67% of program time. It is unclear what the long‐term expectations in career achievement with regard to research will be for those physicians who spend the majority of their training time providing clinical care rather than in research. Previous authors have described the fallacy of expecting brief periods of coursework to prepare individuals for independent research careers.8 However, such coursework can certainly assist graduates of such programs to meaningfully participate in research projects and to put to valuable use their knowledge in both the educational and clinical aspects of their work. Though trainees enrolled in 1‐year programs will spend a larger proportion of their time providing clinical care based on program requirements, trainees in multiyear programs can choose to spend additional time performing clinical duties. Thus, 1 of the possible advantages of a 2‐year or 3‐year program may simply be the flexibility that the fellow has to tailor the program to his or her individual career goals.
Although previous studies have demonstrated that pediatric hospitalists may provide clinical service in a variety of hospital settings,2, 3, 911 most of the current fellowship programs do not provide extensive clinical experiences beyond the general pediatric ward. If hospitalists are to play a more comprehensive role in the care of the pediatric hospitalized patient, programs should consider expanding the scope of clinical training and exposure they provide.
The financial viability of hospitalist fellowship programs is also an important issue. If the additional training provided by these programs is felt to be of value to individual hospitals, it is likely that there will be an increase in the proportion of hospitals who wish to fund such training. A likely incentive for hospitals would be to position themselves to attract and retain hospitalists who possess a unique skill set for which they ascribe value for their patients and/or their bottom line.
Currently, in contrast to traditional, subspecialty‐based fellowships, half of the existing hospitalist fellowship programs allow hospitalist fellows to bill independently. This will have important implications both from an economic perspective, as well as relative to the perceptions of the degree of supervision provided by the respective training programs. This finding may also raise questions as to whether the need for additional clinical training after residency is really necessary to practice hospital medicine.
Whether the training and experience provided by these programs will be seen as a necessary precursor for careers in hospital medicine remains unknown. However, currently there appears to be a mismatch between what some hospitalists have identified as potential clinical educational needs6 with more than 50% desiring additional training in intensive care unit settings, and what is provided through the existing programs. In 2001, a survey of pediatric department chairs found that most did not believe additional formal training beyond residency was necessary to take on the role of a pediatric hospitalist.5 The value of pediatric hospitalist training programs may lie in their provision of or exposure to academic skill sets and the provision of administrative opportunities, in addition to targeted clinical training.
Potential Future Areas of Focus
The potential of a mismatch between education and practice or a training practice gap has been identified in internal medicine hospitalist training programs.12 To provide guidance to address this gap, Glasheen et al.13 assessed the spectrum and volume of specific diagnoses encountered in hospitals and the level of involvement of hospitalists in the care of these patients. They posit that training prioritized to the case mix expected to be encountered by hospitalists would be an appropriate concentration on which both tracked residency and fellowships could focus.
Of significant importance to many community physicians is the pattern of communication between hospitalists and the primary care physician of their patients. Recent reports have suggested this is a problem for many hospitalist programs.14 As such, it seems relevant that any hospitalist training program both develop a defined communication protocol and include instruction in physician‐to‐physician communication as a distinct part of their curriculum. Specifically, the importance of initial contact and timely discharge summaries should be addressed.
We did not explicitly ask respondents to discuss the scope of mentorship in their fellowship programs. However, based on respondents' descriptions of fellow or trainee supervision, we believe that the structure of mentorship programs likely varies across fellowships. Further study will be needed to determine the scope of mentorship in pediatric hospitalist training programs, and the impact of mentorship on training efficacy.
CONCLUSIONS
Pediatric hospitalist fellowship training programs are in the very early stages of their development. In time, greater structure across institutions will need to be put in place if they are to succeed in becoming a necessary prerequisite to the practice of hospital medicine. As the roles of hospitalists become more defined, the nature and extent of their advanced training needs will do so as well.
- ,.The emerging role of pediatric hospitalists.Clin Pediatr (Phila).2003;42(4):295–297.
- ,,, et al.Pediatric hospitalists: report of a leadership conference.Pediatrics.2006;117(4):1122–1130.
- ,,,, The Research Advisory Committee of the American Board of Pediatrics.Characteristics of the pediatric hospitalist workforce: its roles and work environment.Pediatrics.2007;120:33–39.
- ,,,.Hospital medicine fellowships: works in progress.Am J Med.2006;119:1.e1–1.e7.
- ,,,,,.Pediatric hospitalists in Canada and the United States: a survey of pediatric academic department chairs.Ambul Pediatr.2001;1:338–339.
- ,,,.PRIS Survey: pediatric hospitalist roles and training needs [Abstract].Pediatr Res.2004;55:360A.
- ,.Third‐year medical students' evaluation of hospitalist and nonhospitalist faculty during the inpatient portion of their pediatrics clerkships.J Hosp Med.2007;2(1):17–22.
- .Challenges in the development of pediatric health services research.J Pediatr.2002;140:1–2.
- ,,.Improved survival with hospitalists in a pediatric intensive care unit.Crit Care Med.2003;31(3):847–852.
- New study highlights ingredients for reengineering success.Health Care Cost Reengineering Rep.1999;4(5):72–74,65.
- ,,.Pediatric hospitalists fill varied roles in the care of newborns.Pediatr Ann.2003;32(12):802–810.
- ,,,,.Closing the gap between internal medicine training and practice: recommendations from recent graduates.Am J Med.2005;118(6):680–685; discussion 685–687.
- ,,,,.The spectrum of community‐based hospitalist practice: a call to tailor internal medicine residency training.Arch Intern Med.2007;167(7):727–728.
- ,,,,,.Deficits in communication and information transfer between hospital‐based and primary care physicians: implications for patient safety and continuity of care.JAMA.2007;297(8):831–841.
The field of pediatric hospital medicine is undergoing rapid growth. In 2002, there were approximately 600 pediatric hospitalists1 and in 2006 this number was estimated to be approximately 1000.2 A recent study found that approximately 25% of pediatric hospitalist practices are less than 2 years old.3 As such, there are many new physicians entering the field and most do so without specific training in hospital medicine prior to beginning their employment.4 There is also significant variability in the roles, work patterns, and scope of practice across institutions,3 and hospitalists are engaged in a wide variety of clinical, educational, and administrative functions.
A survey of pediatric department chairs in 2001 found that very few believed that any additional training beyond a pediatric residency was required to perform hospitalist medicine.5 However, since then the field has undergone significant growth. A more recent survey of practicing hospitalists found that 92% believed there was a need for additional training in a variety of domains.6 Specifically, respondents were most interested in achieving greater skill in performing critical care procedures and academic training. These hospitalists regarded pediatric hospitalist fellowships as the best way to gain the additional skills in teaching, research, and administration needed for their positions.
Nonetheless, for a variety of reasons, not the least of which is perhaps the paucity of hospitalist fellowship training programs, few hospitalists in practice today have completed a fellowship in hospital medicine. Over the past several years, a number of pediatric‐specific hospitalist fellowship programs have been initiated, yet little is known of their requirements or curricula. We conducted a study to explore the structure, components, and training goals of the pediatric hospitalist fellowship programs in North America.
MATERIALS AND METHODS
Sample
To examine the characteristics of pediatric hospitalist training in North America, we examined all 8 fellowships or training programs that were in existence in early 2007. The total sample included the following sites: Children's Hospital Boston, Children's Specialists of San Diego, Children's National Medical Center, Children's Healthcare of Atlanta, Texas Children's Hospital, All Children's Hospital, University of North Carolina, and The Hospital for Sick Children.
Survey Instrument
We constructed a 17‐item structured questionnaire to be administered by phone. The instrument was designed to be completed in approximately 10 minutes. Questionnaire items focused on documenting the goals, training, requirements, and clinical duties that characterize current pediatric hospitalist training programs. The questionnaire was comprised of a mixture of fixed‐choice and open‐ended questions. A draft of the instrument was shared with representatives of the Society of Hospital Medicine Pediatrics Committee for comment and suggestions.
Questionnaire Administration
The research team sent a prenotification letter to directors of the 8 pediatric hospitalist training programs to inform them of the research study. From February through June 2007, research staff contacted the directors of the programs, explained the purpose of the study, and obtained verbal consent.
Data Analysis
Responses were reviewed to compare and contrast the characteristics of the various programs. The study was approved by the University of Michigan Medical Institutional Review Board.
RESULTS
Response Rate
Of the 8 training programs, all completed the survey, representing a response rate of 100%. One institution offers 2 separate fellowship paths: academic and clinical.
Pediatric Hospitalist Fellowship and Training Program Overview
The first pediatric hospital medicine fellowship was initiated 15 years ago. However, the majority of pediatric hospitalist training programs in North America were established more recently, between 2003 and 2007.
Most pediatric hospitalist training programs offer 1 position per year. The duration of the training programs range from 1 to 3 years. Minimum clinical duties required by the programs vary from 4 to 8 months and the maximum amount of clinical time permitted ranges from 4 to 20 months. Most programs indicated that there is some flexibility in the clinical duties required or available to the fellows.
Six of the 8 programs offer an academic degree. Table 1 provides an overview of the programs, types of degrees offered, and funding sources for academic work. Subsequent tables provide blinded results to protect respondent confidentiality.
| Program | Year Established | Division | Number of Positions, 2007 | Duration of Program | Minimum Clinical Time | Maximum Clinical Time | Degree Possible? | Who Pays for Degree? |
|---|---|---|---|---|---|---|---|---|
| ||||||||
| Toronto‐Academic | 1992 | Pediatric medicine | 3 | 2 years | 4 months | 4 months | Yes: fellow's choice | Fellow |
| Children's Boston | 1998 | Emergency medicine | 1 | 2 years | 8 months | 12 months | Yes: MPH, MEd, MPP | Depart. funds; Externalfunds (creative) |
| Children's National | 2003 | Hospital medicine | 1‐2 | 2‐3 years | 6 months | 20 months | Yes: MPH | Faculty benefits |
| Children's Spec. San Diego | 2003 | Hospital medicine | 1 | 1‐2 years | 7 months | NA | Yes: MAS | Division |
| Toronto‐Clinical | 2004 | Pediatric medicine | 1 | 1 year | 8 months | 8 months | No | NA |
| Texas | 2005 | Emergency medicine | 1 | 2 years | 8 months | 8 months | Yes: MPH, MME | Varies |
| University of North Carolina | 2006 | General pediatrics and adolescent medicine | 1 | 1 year | 5 months | 6 months | No | NA |
| All Children's | 2007 | General pediatrics | 1 | 2 years | 8 months | 9 months | Yes: MPH, MS | External funding pending (federal grants) |
| Children's Atlanta | 2007 | Pediatric hospitalist section | 1 | 1 year | 6 months | 6 months | No | NA |
The number of fellowship or training program positions available each year has remained fairly consistent. However, to date, enrollment has not kept up with position availability (Table 2).
| Program | 2006‐2007 Positions Available | 2006‐2007 Fellows Enrolled | 2007‐2008 Positions Available |
|---|---|---|---|
| A | NA | NA | 1 |
| B | 2 | 1 | 2 |
| C | 1 | 1 | 1 |
| D | NA | NA | 1 |
| E | 1 | 0 | 2 |
| F | 1 | 0 | 1 |
| G | 2 | 0 | 3 |
| H | 1 | 2 | 1 |
| I | 1 | 1 | 0 |
Program Goals
Seven out of 8 programs reported the provision of advanced training in the clinical care of hospitalized patients, quality improvement (QI), and hospital administration to be central goals of their training program. Six respondents reported the provision of training in the education of medical students and residents to be a primary goal of their program, while 5 indicated training in health services research to be a primary goal.
Participation in General Hospital Activities
Trainees in all programs participate in clinical care, resident education, student education, research activities, and hospital committees. Seven out of 8 programs reported that fellows or trainees participate in patient safety activities and guideline development.
Formal Training
Half of the programs reported that they provide formal coursework in areas of education and hospital administration including quality improvement, resident teaching, and student teaching. Three of the 8 programs provide formal coursework in hospital economics.
Three of the 8 programs provide seminars in resident teaching, student teaching, hospital economics, and leading a healthcare team (Table 3).
| Programs | Resident Teaching | Student Teaching | Hospital Economics | Quality Improvement | Leading a Healthcare Team | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| Coursework | Seminars | Coursework | Seminars | Coursework | Seminars | Coursework | Seminars | Coursework | Seminars | |
| ||||||||||
| A | Yes | Yes | Yes | Yes | ||||||
| B | Yes | Yes | Yes | Yes | Yes | |||||
| C | Yes | Yes | Yes | Yes | Yes | |||||
| D | Yes | Yes | Yes | Yes | Yes | |||||
| E | Yes | Yes | Yes | Yes | ||||||
| F | Yes | |||||||||
| G | Yes | Yes | Yes | Yes | Yes | Yes | ||||
| H | Yes | Yes | Yes | Yes | Yes | Yes | ||||
| I | Yes | Yes | ||||||||
Seven of 8 pediatric hospitalist training programs provide formal coursework in epidemiology and research methodology. Six programs reported that they provide formal coursework in biostatistics and 5 in publications or grant writing. Four offer seminars in health economics, research methodology, and QI methodology (Table 4).
| Epidemiology | Biostatistics | Health Economics | Research Methodology | QI Methodology | Publications/Grant Writing | Translation Research | Educational Research | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Course | Seminar | Course | Seminar | Course | Seminar | Course | Seminar | Course | Seminar | Course | Seminar | Course | Seminar | Course | Seminar | |
| ||||||||||||||||
| A | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | ||||||||
| B | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | |||||||
| C | Yes | Yes | Yes | Yes | Yes | Yes | Yes | |||||||||
| D | Yes | Yes | Yes | Yes | Yes | Yes | Yes | |||||||||
| E | Yes | Yes | Yes | Yes | Yes | Yes | Yes | |||||||||
| F | Yes | Yes | Yes | Yes | Yes | Yes | ||||||||||
| G | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| H | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| I | ||||||||||||||||
Program Requirements
Seven pediatric hospitalist training programs require fellows to complete a research project. Six programs reported that they require fellows or trainees to complete a quality improvement project or participate on a hospital committee. Six of the programs require pediatric hospitalist fellows to attempt to present at a national meeting, and 4 programs require that fellows attempt to publish their research in a peer‐reviewed publication. Graduate degrees are required at 3 of the 8 pediatric hospitalist training programs (Table 5).
| QI Project | Research Project | Abstract/Presentation at National Meeting* | Peer‐Reviewed Publication* | Committee Participation at Hospital | Attending on General Ward Leading Resident Team | Specific Advanced Clinical Training | Graduate Degree Program | Other | |
|---|---|---|---|---|---|---|---|---|---|
| |||||||||
| A | Yes | Yes | Yes | Yes | Yes | Yes | Yes | ||
| B | Yes | Yes | |||||||
| C | Yes | Yes | Yes | Yes | Yes | Yes | Yes | ||
| D | Yes | Yes | Yes | Yes | Yes | Yes | |||
| E | Yes | Yes | Yes | Yes | Yes | Yes | Yes | ||
| F | Yes | Yes | Yes | Yes | Yes | Yes | Yes | ||
| G | Yes | Yes | Yes | Yes | |||||
| H | |||||||||
| I | Yes | Yes | Yes | Journal club | |||||
Clinical Service Requirements
All programs indicated that they require the fellow or trainee to serve as an attending on the general pediatric ward. Five programs require the fellow or trainee to provide service at the fellow or PL‐3 level in the pediatric intensive care unit (PICU), anesthesia service, and transport team. Four programs reported that they require service in the emergency department, and 3 programs require service in the neonatal intensive care unit (NICU), newborn nursery, and general pediatric ward at the fellow or PL‐3 level. Only 2 programs require service in the pediatric subspecialty ward, and 1 program requires service in outpatient urgent care. No program requires primary care service (Table 6).
| PICU | NICU | Anesthesia | Primary Care (Outpatient) | Emergency Department | Urgent Care | Transport | General Pediatric Ward | Pediatric Subspecialty Ward | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Attd | Fellow | Attd | Fellow | Attd | Fellow | Attd | Fellow | Attd | Fellow | Attd | Fellow | Attd | Fellow | Attd | Fellow | Attd | Fellow | Other Units | |
| |||||||||||||||||||
| A | Yes | Yes | Yes | Yes | Yes | Newborn nursery | |||||||||||||
| B | Yes | ||||||||||||||||||
| C | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Stepdown ICU | |||||||||||
| D | Yes | Yes | Yes | Yes | Yes | Yes | |||||||||||||
| E | Yes | Yes | Yes | Yes | Yes | Child abuse, newborn nursery, subacute care rehabilitation facility | |||||||||||||
| F | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Variety of hospitals (county‐based) | |||||||||||
| G | Yes | Child abuse, consultation clinic, community‐based practice | |||||||||||||||||
| H | Yes | Child abuse, consultation clinic, community‐based practice | |||||||||||||||||
| I | Yes | Yes | Yes | Yes | Newborn nursery | ||||||||||||||
Pediatric Hospitalist Fellowship and Training Program Funding Sources
Five of the programs use department funds to finance the fellowship program. Four of the programs utilize the fellow or trainee's clinical work as a funding source. Two of the programs reported that the program is paid for through hospital funds.
Pediatric Hospitalist Fellow or Trainee Independence
Respondents indicated that fellows or trainees become increasingly independent over the course of the program. Fellows are supervised or mentored by hospitalists on staff. Half of the programs surveyed allow fellows or trainees to bill independently under certain circumstances (Table 7).
| Bill Independently? | Supervision? | |
|---|---|---|
| A | No: bill under a supervising attending | Supervised by hospitalist and given autonomy with supervision from hospitalist attending. |
| B | Yes | First couple of months during fellow's clinical period, more interaction with supervisors. Senior folks always available for consultation. |
| C | Yes: after 3 months | Clinical mentor (1 of 4 senior hospitalists) with whom they discuss patients on a more informal basis when on service. |
| D | Yes: on general wards, when functioning as attending | Fellows meet weekly with fellowship director. Hospitalist on call available for consult. |
| E | Fellows: no; faculty fellows: yes | Traditional fellowship role. Fellows complete several clinical electives with various levels of supervision. |
| F | Yes: after first 6 months | Fellows are supervised in their first year by hospitalist faculty. |
| G | No | Day to day in patient care, senior staff review as needed. Each fellow has 1 primary supervisor. When on service overnight, fellows call staff attending. |
| H | No | Day to day in patient care, senior staff review as needed. Each fellow has 1 primary supervisor. When on service overnight, fellows call staff attending. |
| I | Yes | Trainees are supervised by the director of the hospitalist program, the inpatient attending, and other hospitalists. |
DISCUSSION
There appear to be 2 distinct tracks for pediatric hospitalist training programs: clinical or academic specialization. However, this is not surprising, as most programs are relatively new and there are no standards or requirements for fellowship training from an external accrediting body. As such, the curriculum for these programs is likely driven by a combination of service requirements and local speculation on the needs of a future generation of pediatric hospitalists. Most programs also reported that they provide significant flexibility for each fellow based on their self‐perceived training needs and background.
Although there has been considerable emphasis on the potential educational role of hospitalists, formal coursework in teaching and education is not a part of the curriculum for half of the existing fellowship programs. Recent reports have demonstrated that hospitalists have received better teaching evaluations than traditional subspecialty attendings.7 However, this is in the absence of additional training in education and may reflect greater time that hospitalists might devote to their clinical trainees. The opportunity to further improve the educational training of hospitalists could be an important part of the fellowship experience.
Hospitalists have also been hypothesized to be in a prime position to either lead or have meaningful participation in quality improvement and cost‐saving efforts in the hospital setting. However, only half of programs provide formal coursework in QI and even fewer in areas of hospital economics.
Interestingly, most programs provide coursework in research methods, epidemiology, and grant writing. Requirements regarding clinical duties ranged from a minimum of 17% to a maximum of 67% of program time. It is unclear what the long‐term expectations in career achievement with regard to research will be for those physicians who spend the majority of their training time providing clinical care rather than in research. Previous authors have described the fallacy of expecting brief periods of coursework to prepare individuals for independent research careers.8 However, such coursework can certainly assist graduates of such programs to meaningfully participate in research projects and to put to valuable use their knowledge in both the educational and clinical aspects of their work. Though trainees enrolled in 1‐year programs will spend a larger proportion of their time providing clinical care based on program requirements, trainees in multiyear programs can choose to spend additional time performing clinical duties. Thus, 1 of the possible advantages of a 2‐year or 3‐year program may simply be the flexibility that the fellow has to tailor the program to his or her individual career goals.
Although previous studies have demonstrated that pediatric hospitalists may provide clinical service in a variety of hospital settings,2, 3, 911 most of the current fellowship programs do not provide extensive clinical experiences beyond the general pediatric ward. If hospitalists are to play a more comprehensive role in the care of the pediatric hospitalized patient, programs should consider expanding the scope of clinical training and exposure they provide.
The financial viability of hospitalist fellowship programs is also an important issue. If the additional training provided by these programs is felt to be of value to individual hospitals, it is likely that there will be an increase in the proportion of hospitals who wish to fund such training. A likely incentive for hospitals would be to position themselves to attract and retain hospitalists who possess a unique skill set for which they ascribe value for their patients and/or their bottom line.
Currently, in contrast to traditional, subspecialty‐based fellowships, half of the existing hospitalist fellowship programs allow hospitalist fellows to bill independently. This will have important implications both from an economic perspective, as well as relative to the perceptions of the degree of supervision provided by the respective training programs. This finding may also raise questions as to whether the need for additional clinical training after residency is really necessary to practice hospital medicine.
Whether the training and experience provided by these programs will be seen as a necessary precursor for careers in hospital medicine remains unknown. However, currently there appears to be a mismatch between what some hospitalists have identified as potential clinical educational needs6 with more than 50% desiring additional training in intensive care unit settings, and what is provided through the existing programs. In 2001, a survey of pediatric department chairs found that most did not believe additional formal training beyond residency was necessary to take on the role of a pediatric hospitalist.5 The value of pediatric hospitalist training programs may lie in their provision of or exposure to academic skill sets and the provision of administrative opportunities, in addition to targeted clinical training.
Potential Future Areas of Focus
The potential of a mismatch between education and practice or a training practice gap has been identified in internal medicine hospitalist training programs.12 To provide guidance to address this gap, Glasheen et al.13 assessed the spectrum and volume of specific diagnoses encountered in hospitals and the level of involvement of hospitalists in the care of these patients. They posit that training prioritized to the case mix expected to be encountered by hospitalists would be an appropriate concentration on which both tracked residency and fellowships could focus.
Of significant importance to many community physicians is the pattern of communication between hospitalists and the primary care physician of their patients. Recent reports have suggested this is a problem for many hospitalist programs.14 As such, it seems relevant that any hospitalist training program both develop a defined communication protocol and include instruction in physician‐to‐physician communication as a distinct part of their curriculum. Specifically, the importance of initial contact and timely discharge summaries should be addressed.
We did not explicitly ask respondents to discuss the scope of mentorship in their fellowship programs. However, based on respondents' descriptions of fellow or trainee supervision, we believe that the structure of mentorship programs likely varies across fellowships. Further study will be needed to determine the scope of mentorship in pediatric hospitalist training programs, and the impact of mentorship on training efficacy.
CONCLUSIONS
Pediatric hospitalist fellowship training programs are in the very early stages of their development. In time, greater structure across institutions will need to be put in place if they are to succeed in becoming a necessary prerequisite to the practice of hospital medicine. As the roles of hospitalists become more defined, the nature and extent of their advanced training needs will do so as well.
The field of pediatric hospital medicine is undergoing rapid growth. In 2002, there were approximately 600 pediatric hospitalists1 and in 2006 this number was estimated to be approximately 1000.2 A recent study found that approximately 25% of pediatric hospitalist practices are less than 2 years old.3 As such, there are many new physicians entering the field and most do so without specific training in hospital medicine prior to beginning their employment.4 There is also significant variability in the roles, work patterns, and scope of practice across institutions,3 and hospitalists are engaged in a wide variety of clinical, educational, and administrative functions.
A survey of pediatric department chairs in 2001 found that very few believed that any additional training beyond a pediatric residency was required to perform hospitalist medicine.5 However, since then the field has undergone significant growth. A more recent survey of practicing hospitalists found that 92% believed there was a need for additional training in a variety of domains.6 Specifically, respondents were most interested in achieving greater skill in performing critical care procedures and academic training. These hospitalists regarded pediatric hospitalist fellowships as the best way to gain the additional skills in teaching, research, and administration needed for their positions.
Nonetheless, for a variety of reasons, not the least of which is perhaps the paucity of hospitalist fellowship training programs, few hospitalists in practice today have completed a fellowship in hospital medicine. Over the past several years, a number of pediatric‐specific hospitalist fellowship programs have been initiated, yet little is known of their requirements or curricula. We conducted a study to explore the structure, components, and training goals of the pediatric hospitalist fellowship programs in North America.
MATERIALS AND METHODS
Sample
To examine the characteristics of pediatric hospitalist training in North America, we examined all 8 fellowships or training programs that were in existence in early 2007. The total sample included the following sites: Children's Hospital Boston, Children's Specialists of San Diego, Children's National Medical Center, Children's Healthcare of Atlanta, Texas Children's Hospital, All Children's Hospital, University of North Carolina, and The Hospital for Sick Children.
Survey Instrument
We constructed a 17‐item structured questionnaire to be administered by phone. The instrument was designed to be completed in approximately 10 minutes. Questionnaire items focused on documenting the goals, training, requirements, and clinical duties that characterize current pediatric hospitalist training programs. The questionnaire was comprised of a mixture of fixed‐choice and open‐ended questions. A draft of the instrument was shared with representatives of the Society of Hospital Medicine Pediatrics Committee for comment and suggestions.
Questionnaire Administration
The research team sent a prenotification letter to directors of the 8 pediatric hospitalist training programs to inform them of the research study. From February through June 2007, research staff contacted the directors of the programs, explained the purpose of the study, and obtained verbal consent.
Data Analysis
Responses were reviewed to compare and contrast the characteristics of the various programs. The study was approved by the University of Michigan Medical Institutional Review Board.
RESULTS
Response Rate
Of the 8 training programs, all completed the survey, representing a response rate of 100%. One institution offers 2 separate fellowship paths: academic and clinical.
Pediatric Hospitalist Fellowship and Training Program Overview
The first pediatric hospital medicine fellowship was initiated 15 years ago. However, the majority of pediatric hospitalist training programs in North America were established more recently, between 2003 and 2007.
Most pediatric hospitalist training programs offer 1 position per year. The duration of the training programs range from 1 to 3 years. Minimum clinical duties required by the programs vary from 4 to 8 months and the maximum amount of clinical time permitted ranges from 4 to 20 months. Most programs indicated that there is some flexibility in the clinical duties required or available to the fellows.
Six of the 8 programs offer an academic degree. Table 1 provides an overview of the programs, types of degrees offered, and funding sources for academic work. Subsequent tables provide blinded results to protect respondent confidentiality.
| Program | Year Established | Division | Number of Positions, 2007 | Duration of Program | Minimum Clinical Time | Maximum Clinical Time | Degree Possible? | Who Pays for Degree? |
|---|---|---|---|---|---|---|---|---|
| ||||||||
| Toronto‐Academic | 1992 | Pediatric medicine | 3 | 2 years | 4 months | 4 months | Yes: fellow's choice | Fellow |
| Children's Boston | 1998 | Emergency medicine | 1 | 2 years | 8 months | 12 months | Yes: MPH, MEd, MPP | Depart. funds; Externalfunds (creative) |
| Children's National | 2003 | Hospital medicine | 1‐2 | 2‐3 years | 6 months | 20 months | Yes: MPH | Faculty benefits |
| Children's Spec. San Diego | 2003 | Hospital medicine | 1 | 1‐2 years | 7 months | NA | Yes: MAS | Division |
| Toronto‐Clinical | 2004 | Pediatric medicine | 1 | 1 year | 8 months | 8 months | No | NA |
| Texas | 2005 | Emergency medicine | 1 | 2 years | 8 months | 8 months | Yes: MPH, MME | Varies |
| University of North Carolina | 2006 | General pediatrics and adolescent medicine | 1 | 1 year | 5 months | 6 months | No | NA |
| All Children's | 2007 | General pediatrics | 1 | 2 years | 8 months | 9 months | Yes: MPH, MS | External funding pending (federal grants) |
| Children's Atlanta | 2007 | Pediatric hospitalist section | 1 | 1 year | 6 months | 6 months | No | NA |
The number of fellowship or training program positions available each year has remained fairly consistent. However, to date, enrollment has not kept up with position availability (Table 2).
| Program | 2006‐2007 Positions Available | 2006‐2007 Fellows Enrolled | 2007‐2008 Positions Available |
|---|---|---|---|
| A | NA | NA | 1 |
| B | 2 | 1 | 2 |
| C | 1 | 1 | 1 |
| D | NA | NA | 1 |
| E | 1 | 0 | 2 |
| F | 1 | 0 | 1 |
| G | 2 | 0 | 3 |
| H | 1 | 2 | 1 |
| I | 1 | 1 | 0 |
Program Goals
Seven out of 8 programs reported the provision of advanced training in the clinical care of hospitalized patients, quality improvement (QI), and hospital administration to be central goals of their training program. Six respondents reported the provision of training in the education of medical students and residents to be a primary goal of their program, while 5 indicated training in health services research to be a primary goal.
Participation in General Hospital Activities
Trainees in all programs participate in clinical care, resident education, student education, research activities, and hospital committees. Seven out of 8 programs reported that fellows or trainees participate in patient safety activities and guideline development.
Formal Training
Half of the programs reported that they provide formal coursework in areas of education and hospital administration including quality improvement, resident teaching, and student teaching. Three of the 8 programs provide formal coursework in hospital economics.
Three of the 8 programs provide seminars in resident teaching, student teaching, hospital economics, and leading a healthcare team (Table 3).
| Programs | Resident Teaching | Student Teaching | Hospital Economics | Quality Improvement | Leading a Healthcare Team | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| Coursework | Seminars | Coursework | Seminars | Coursework | Seminars | Coursework | Seminars | Coursework | Seminars | |
| ||||||||||
| A | Yes | Yes | Yes | Yes | ||||||
| B | Yes | Yes | Yes | Yes | Yes | |||||
| C | Yes | Yes | Yes | Yes | Yes | |||||
| D | Yes | Yes | Yes | Yes | Yes | |||||
| E | Yes | Yes | Yes | Yes | ||||||
| F | Yes | |||||||||
| G | Yes | Yes | Yes | Yes | Yes | Yes | ||||
| H | Yes | Yes | Yes | Yes | Yes | Yes | ||||
| I | Yes | Yes | ||||||||
Seven of 8 pediatric hospitalist training programs provide formal coursework in epidemiology and research methodology. Six programs reported that they provide formal coursework in biostatistics and 5 in publications or grant writing. Four offer seminars in health economics, research methodology, and QI methodology (Table 4).
| Epidemiology | Biostatistics | Health Economics | Research Methodology | QI Methodology | Publications/Grant Writing | Translation Research | Educational Research | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Course | Seminar | Course | Seminar | Course | Seminar | Course | Seminar | Course | Seminar | Course | Seminar | Course | Seminar | Course | Seminar | |
| ||||||||||||||||
| A | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | ||||||||
| B | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | |||||||
| C | Yes | Yes | Yes | Yes | Yes | Yes | Yes | |||||||||
| D | Yes | Yes | Yes | Yes | Yes | Yes | Yes | |||||||||
| E | Yes | Yes | Yes | Yes | Yes | Yes | Yes | |||||||||
| F | Yes | Yes | Yes | Yes | Yes | Yes | ||||||||||
| G | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| H | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| I | ||||||||||||||||
Program Requirements
Seven pediatric hospitalist training programs require fellows to complete a research project. Six programs reported that they require fellows or trainees to complete a quality improvement project or participate on a hospital committee. Six of the programs require pediatric hospitalist fellows to attempt to present at a national meeting, and 4 programs require that fellows attempt to publish their research in a peer‐reviewed publication. Graduate degrees are required at 3 of the 8 pediatric hospitalist training programs (Table 5).
| QI Project | Research Project | Abstract/Presentation at National Meeting* | Peer‐Reviewed Publication* | Committee Participation at Hospital | Attending on General Ward Leading Resident Team | Specific Advanced Clinical Training | Graduate Degree Program | Other | |
|---|---|---|---|---|---|---|---|---|---|
| |||||||||
| A | Yes | Yes | Yes | Yes | Yes | Yes | Yes | ||
| B | Yes | Yes | |||||||
| C | Yes | Yes | Yes | Yes | Yes | Yes | Yes | ||
| D | Yes | Yes | Yes | Yes | Yes | Yes | |||
| E | Yes | Yes | Yes | Yes | Yes | Yes | Yes | ||
| F | Yes | Yes | Yes | Yes | Yes | Yes | Yes | ||
| G | Yes | Yes | Yes | Yes | |||||
| H | |||||||||
| I | Yes | Yes | Yes | Journal club | |||||
Clinical Service Requirements
All programs indicated that they require the fellow or trainee to serve as an attending on the general pediatric ward. Five programs require the fellow or trainee to provide service at the fellow or PL‐3 level in the pediatric intensive care unit (PICU), anesthesia service, and transport team. Four programs reported that they require service in the emergency department, and 3 programs require service in the neonatal intensive care unit (NICU), newborn nursery, and general pediatric ward at the fellow or PL‐3 level. Only 2 programs require service in the pediatric subspecialty ward, and 1 program requires service in outpatient urgent care. No program requires primary care service (Table 6).
| PICU | NICU | Anesthesia | Primary Care (Outpatient) | Emergency Department | Urgent Care | Transport | General Pediatric Ward | Pediatric Subspecialty Ward | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Attd | Fellow | Attd | Fellow | Attd | Fellow | Attd | Fellow | Attd | Fellow | Attd | Fellow | Attd | Fellow | Attd | Fellow | Attd | Fellow | Other Units | |
| |||||||||||||||||||
| A | Yes | Yes | Yes | Yes | Yes | Newborn nursery | |||||||||||||
| B | Yes | ||||||||||||||||||
| C | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Stepdown ICU | |||||||||||
| D | Yes | Yes | Yes | Yes | Yes | Yes | |||||||||||||
| E | Yes | Yes | Yes | Yes | Yes | Child abuse, newborn nursery, subacute care rehabilitation facility | |||||||||||||
| F | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Variety of hospitals (county‐based) | |||||||||||
| G | Yes | Child abuse, consultation clinic, community‐based practice | |||||||||||||||||
| H | Yes | Child abuse, consultation clinic, community‐based practice | |||||||||||||||||
| I | Yes | Yes | Yes | Yes | Newborn nursery | ||||||||||||||
Pediatric Hospitalist Fellowship and Training Program Funding Sources
Five of the programs use department funds to finance the fellowship program. Four of the programs utilize the fellow or trainee's clinical work as a funding source. Two of the programs reported that the program is paid for through hospital funds.
Pediatric Hospitalist Fellow or Trainee Independence
Respondents indicated that fellows or trainees become increasingly independent over the course of the program. Fellows are supervised or mentored by hospitalists on staff. Half of the programs surveyed allow fellows or trainees to bill independently under certain circumstances (Table 7).
| Bill Independently? | Supervision? | |
|---|---|---|
| A | No: bill under a supervising attending | Supervised by hospitalist and given autonomy with supervision from hospitalist attending. |
| B | Yes | First couple of months during fellow's clinical period, more interaction with supervisors. Senior folks always available for consultation. |
| C | Yes: after 3 months | Clinical mentor (1 of 4 senior hospitalists) with whom they discuss patients on a more informal basis when on service. |
| D | Yes: on general wards, when functioning as attending | Fellows meet weekly with fellowship director. Hospitalist on call available for consult. |
| E | Fellows: no; faculty fellows: yes | Traditional fellowship role. Fellows complete several clinical electives with various levels of supervision. |
| F | Yes: after first 6 months | Fellows are supervised in their first year by hospitalist faculty. |
| G | No | Day to day in patient care, senior staff review as needed. Each fellow has 1 primary supervisor. When on service overnight, fellows call staff attending. |
| H | No | Day to day in patient care, senior staff review as needed. Each fellow has 1 primary supervisor. When on service overnight, fellows call staff attending. |
| I | Yes | Trainees are supervised by the director of the hospitalist program, the inpatient attending, and other hospitalists. |
DISCUSSION
There appear to be 2 distinct tracks for pediatric hospitalist training programs: clinical or academic specialization. However, this is not surprising, as most programs are relatively new and there are no standards or requirements for fellowship training from an external accrediting body. As such, the curriculum for these programs is likely driven by a combination of service requirements and local speculation on the needs of a future generation of pediatric hospitalists. Most programs also reported that they provide significant flexibility for each fellow based on their self‐perceived training needs and background.
Although there has been considerable emphasis on the potential educational role of hospitalists, formal coursework in teaching and education is not a part of the curriculum for half of the existing fellowship programs. Recent reports have demonstrated that hospitalists have received better teaching evaluations than traditional subspecialty attendings.7 However, this is in the absence of additional training in education and may reflect greater time that hospitalists might devote to their clinical trainees. The opportunity to further improve the educational training of hospitalists could be an important part of the fellowship experience.
Hospitalists have also been hypothesized to be in a prime position to either lead or have meaningful participation in quality improvement and cost‐saving efforts in the hospital setting. However, only half of programs provide formal coursework in QI and even fewer in areas of hospital economics.
Interestingly, most programs provide coursework in research methods, epidemiology, and grant writing. Requirements regarding clinical duties ranged from a minimum of 17% to a maximum of 67% of program time. It is unclear what the long‐term expectations in career achievement with regard to research will be for those physicians who spend the majority of their training time providing clinical care rather than in research. Previous authors have described the fallacy of expecting brief periods of coursework to prepare individuals for independent research careers.8 However, such coursework can certainly assist graduates of such programs to meaningfully participate in research projects and to put to valuable use their knowledge in both the educational and clinical aspects of their work. Though trainees enrolled in 1‐year programs will spend a larger proportion of their time providing clinical care based on program requirements, trainees in multiyear programs can choose to spend additional time performing clinical duties. Thus, 1 of the possible advantages of a 2‐year or 3‐year program may simply be the flexibility that the fellow has to tailor the program to his or her individual career goals.
Although previous studies have demonstrated that pediatric hospitalists may provide clinical service in a variety of hospital settings,2, 3, 911 most of the current fellowship programs do not provide extensive clinical experiences beyond the general pediatric ward. If hospitalists are to play a more comprehensive role in the care of the pediatric hospitalized patient, programs should consider expanding the scope of clinical training and exposure they provide.
The financial viability of hospitalist fellowship programs is also an important issue. If the additional training provided by these programs is felt to be of value to individual hospitals, it is likely that there will be an increase in the proportion of hospitals who wish to fund such training. A likely incentive for hospitals would be to position themselves to attract and retain hospitalists who possess a unique skill set for which they ascribe value for their patients and/or their bottom line.
Currently, in contrast to traditional, subspecialty‐based fellowships, half of the existing hospitalist fellowship programs allow hospitalist fellows to bill independently. This will have important implications both from an economic perspective, as well as relative to the perceptions of the degree of supervision provided by the respective training programs. This finding may also raise questions as to whether the need for additional clinical training after residency is really necessary to practice hospital medicine.
Whether the training and experience provided by these programs will be seen as a necessary precursor for careers in hospital medicine remains unknown. However, currently there appears to be a mismatch between what some hospitalists have identified as potential clinical educational needs6 with more than 50% desiring additional training in intensive care unit settings, and what is provided through the existing programs. In 2001, a survey of pediatric department chairs found that most did not believe additional formal training beyond residency was necessary to take on the role of a pediatric hospitalist.5 The value of pediatric hospitalist training programs may lie in their provision of or exposure to academic skill sets and the provision of administrative opportunities, in addition to targeted clinical training.
Potential Future Areas of Focus
The potential of a mismatch between education and practice or a training practice gap has been identified in internal medicine hospitalist training programs.12 To provide guidance to address this gap, Glasheen et al.13 assessed the spectrum and volume of specific diagnoses encountered in hospitals and the level of involvement of hospitalists in the care of these patients. They posit that training prioritized to the case mix expected to be encountered by hospitalists would be an appropriate concentration on which both tracked residency and fellowships could focus.
Of significant importance to many community physicians is the pattern of communication between hospitalists and the primary care physician of their patients. Recent reports have suggested this is a problem for many hospitalist programs.14 As such, it seems relevant that any hospitalist training program both develop a defined communication protocol and include instruction in physician‐to‐physician communication as a distinct part of their curriculum. Specifically, the importance of initial contact and timely discharge summaries should be addressed.
We did not explicitly ask respondents to discuss the scope of mentorship in their fellowship programs. However, based on respondents' descriptions of fellow or trainee supervision, we believe that the structure of mentorship programs likely varies across fellowships. Further study will be needed to determine the scope of mentorship in pediatric hospitalist training programs, and the impact of mentorship on training efficacy.
CONCLUSIONS
Pediatric hospitalist fellowship training programs are in the very early stages of their development. In time, greater structure across institutions will need to be put in place if they are to succeed in becoming a necessary prerequisite to the practice of hospital medicine. As the roles of hospitalists become more defined, the nature and extent of their advanced training needs will do so as well.
- ,.The emerging role of pediatric hospitalists.Clin Pediatr (Phila).2003;42(4):295–297.
- ,,, et al.Pediatric hospitalists: report of a leadership conference.Pediatrics.2006;117(4):1122–1130.
- ,,,, The Research Advisory Committee of the American Board of Pediatrics.Characteristics of the pediatric hospitalist workforce: its roles and work environment.Pediatrics.2007;120:33–39.
- ,,,.Hospital medicine fellowships: works in progress.Am J Med.2006;119:1.e1–1.e7.
- ,,,,,.Pediatric hospitalists in Canada and the United States: a survey of pediatric academic department chairs.Ambul Pediatr.2001;1:338–339.
- ,,,.PRIS Survey: pediatric hospitalist roles and training needs [Abstract].Pediatr Res.2004;55:360A.
- ,.Third‐year medical students' evaluation of hospitalist and nonhospitalist faculty during the inpatient portion of their pediatrics clerkships.J Hosp Med.2007;2(1):17–22.
- .Challenges in the development of pediatric health services research.J Pediatr.2002;140:1–2.
- ,,.Improved survival with hospitalists in a pediatric intensive care unit.Crit Care Med.2003;31(3):847–852.
- New study highlights ingredients for reengineering success.Health Care Cost Reengineering Rep.1999;4(5):72–74,65.
- ,,.Pediatric hospitalists fill varied roles in the care of newborns.Pediatr Ann.2003;32(12):802–810.
- ,,,,.Closing the gap between internal medicine training and practice: recommendations from recent graduates.Am J Med.2005;118(6):680–685; discussion 685–687.
- ,,,,.The spectrum of community‐based hospitalist practice: a call to tailor internal medicine residency training.Arch Intern Med.2007;167(7):727–728.
- ,,,,,.Deficits in communication and information transfer between hospital‐based and primary care physicians: implications for patient safety and continuity of care.JAMA.2007;297(8):831–841.
- ,.The emerging role of pediatric hospitalists.Clin Pediatr (Phila).2003;42(4):295–297.
- ,,, et al.Pediatric hospitalists: report of a leadership conference.Pediatrics.2006;117(4):1122–1130.
- ,,,, The Research Advisory Committee of the American Board of Pediatrics.Characteristics of the pediatric hospitalist workforce: its roles and work environment.Pediatrics.2007;120:33–39.
- ,,,.Hospital medicine fellowships: works in progress.Am J Med.2006;119:1.e1–1.e7.
- ,,,,,.Pediatric hospitalists in Canada and the United States: a survey of pediatric academic department chairs.Ambul Pediatr.2001;1:338–339.
- ,,,.PRIS Survey: pediatric hospitalist roles and training needs [Abstract].Pediatr Res.2004;55:360A.
- ,.Third‐year medical students' evaluation of hospitalist and nonhospitalist faculty during the inpatient portion of their pediatrics clerkships.J Hosp Med.2007;2(1):17–22.
- .Challenges in the development of pediatric health services research.J Pediatr.2002;140:1–2.
- ,,.Improved survival with hospitalists in a pediatric intensive care unit.Crit Care Med.2003;31(3):847–852.
- New study highlights ingredients for reengineering success.Health Care Cost Reengineering Rep.1999;4(5):72–74,65.
- ,,.Pediatric hospitalists fill varied roles in the care of newborns.Pediatr Ann.2003;32(12):802–810.
- ,,,,.Closing the gap between internal medicine training and practice: recommendations from recent graduates.Am J Med.2005;118(6):680–685; discussion 685–687.
- ,,,,.The spectrum of community‐based hospitalist practice: a call to tailor internal medicine residency training.Arch Intern Med.2007;167(7):727–728.
- ,,,,,.Deficits in communication and information transfer between hospital‐based and primary care physicians: implications for patient safety and continuity of care.JAMA.2007;297(8):831–841.
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