Special Announcement

The first Pediatric Hospital Medicine (PHM) fellowships in the United States were established in 2003;¹ and since then, the field has expanded and matured dramatically. This growth, accompanied by greater definition of the role and recommended competencies of pediatric hospitalists,² culminated in the submission of a petition to the American Board of Pediatrics (ABP) in August 2014 to consider recognition of PHM as a new pediatric subspecialty.³ After an 18-month iterative process requiring extensive input from the Joint Council of Pediatric Hospital Medicine, ABP subcommittees, the Association of Medical School Pediatric Department Chairs, the Association of Pediatric Program Directors, and other prominent pediatric professional societies, the ABP voted in December 2015 to recommend that the American Board of Medical Subspecialties (ABMS) recognize PHM as a new subspecialty.³

The ABP subsequently announced three pathways for board certification in PHM:

• Training pathway for those completing an Accreditation Council for Graduate Medical Education–accredited two-year PHM fellowship program;
• Practice pathway for those satisfying ABP criteria for clinical activity in PHM for four years prior to exam dates (in 2019, 2021, and 2023), initially described as “direct patient care of hospitalized children ≥25% full-time equivalent (FTE) defined as ≥450-500 hours per year every year for the preceding four years”;⁴
• Combined pathway for those completing less than two years of fellowship, who would be required to complete two years of practice experience that satisfy the same criteria as each year of the practice pathway.⁵

While the training pathway met near-uniform acceptance, concerns were raised through the American Academy of Pediatrics Section of Hospital Medicine (AAP SOHM) Listserv regarding the practice pathway, and by extension, the combined pathway. Specifically, language describing the necessary characteristics of acceptable PHM practice was felt to be vague and not transparent. Listserv posts also raised concerns regarding the potential exclusion of “niche” practices such as subspecialty hospitalists and newborn hospitalists. As applicants in the practice pathway began to receive denials, opinions voiced in listserv posts were increasingly critical of the ABP’s lack of transparency regarding the specific criteria adjudicating applications.

A group of hospitalists, led by Dr. David Skey, a pediatric hospitalist at Arnold Palmer Children’s Hospital in Orlando, Florida, created a petition which was submitted to the ABP on August 6, 2019, and raised the following issues:

• “A perception of unfairness/bias in the practice pathway criteria and the way these criteria have been applied.
• Denials based on gaps in employment without reasonable consideration of mitigating factors.
• Lack of transparency, accountability, and responsiveness from the ABP.”⁶

The petition, posted on the AAP SOHM listserv and signed by 1,479 individuals,⁷ raised concerns of anecdotal evidence that the practice pathway criteria disproportionately disadvantaged women, although intentional bias was not suspected by the signers of the letter. The petition’s signers submitted the following demands to the ABP:

• “Facilitate a timely analysis to determine if gender bias is present or perform this analysis internally and release the findings publicly.
• Revise the practice pathway criteria to be more inclusive of applicants with interrupted practice and varied clinical experience, to include clear-cut parameters rather than considering these applications on a closed-door ‘case-by-case basis...at the discretion of the ABP’.
• Clarify the appeals process and improve responsiveness to appeals and inquiries regarding denials.
• Provide a formal response to this petition letter through the PHM ListServ and/or the ABP website within one week of receiving the signed petition.”⁶

A formal response to the petition was released on the AAP SOHM Listserv on August 29, 2019, to address the concerns raised and is published in this issue of the Journal of Hospital Medicine.⁴ In response to the allegation of gender bias, the ABP maintained that the data did not support this, as the denial rate for females (4.0%) was not significantly different than that for males (3.7%). The response acknowledged that once clear-cut criteria were decided upon to augment the general practice pathway criteria published at the outset, these criteria should have been disseminated. The ABP maintained, however, that these criteria, once established, were used consistently in adjudicating all applications. To clarify and simplify the eligibility criteria, the percentage of the full-time equivalent and practice interruption criteria were removed, as the work-hours criteria (direct patient care of hospitalized children ≥450-500 hours per year every year for the preceding four years)⁸ were deemed sufficient to ensure adequate clinical participation.

The Society of Hospital Medicine (SHM), through pediatric hospitalists and pediatricians on its Board, committees, and the Executive Council of the Pediatric Special Interest Group, has followed with great interest the public debate surrounding the PHM certification process and the subsequent PHM petition to the ABP. The ABP responded swiftly and with full transparency to the petition, and SHM supports these efforts by the ABP to provide a timely, honest, data-driven response to the concerns raised by the PHM petition. SHM recognizes that the mission of the ABP is to provide the public with confidence that physicians with ABP board certifications meet appropriate “standards of excellence”. While the revisions implemented by the ABP in its response still may not satisfy the concerns of all members of the PHM community, SHM recognizes that the revised requirements remain true to the mission of the ABP.

SHM applauds the authors and signatories of the PHM petition for bravely raising their concerns of gender bias and lack of transparency. The response of the ABP to this petition by further improving transparency serves as an example of continuous improvement in collaborative practice to all medical specialty boards.

While SHM supports the ABP response to the PHM petition, it is clear that excellent physicians caring for hospitalized children will be unable to achieve PHM board certification for a variety of reasons. For these physicians who are not PHM board certified as pediatric hospitalists by the ABP, SHM supports providing these physicians with recognition as hospitalists. These include “niche” hospitalists, such as newborn hospitalists, subacute hospitalists, and subspecialty hospitalists. SHM will also continue to support and recognize community-based hospitalists, family medicine-trained hospitalists, and Med-Peds hospitalists whose practice may not comply with criteria laid out by the ABP. For these physicians, receiving Fellow designation through SHM, a merit-based distinction requiring demonstration of clinical excellence and commitment to hospital medicine, is another route whereby physicians can achieve designation as a hospitalist.

SHM supports future efforts by the ABP to be vigilant for bias of any sort in the certification process. Other future considerations for the PHM community include the possibility of a focused practice pathway in hospital medicine (FPHM) for pediatrics as is currently jointly offered by the American Board of Internal Medicine (ABIM) and the American Board of Family Medicine (ABFM). This maintenance of certification program is a variation of internal medicine or family medicine recertification, not a subspecialty, but allows physicians practicing primarily in inpatient settings to focus continuing education efforts on skills and attitudes needed for inpatient practice.⁹ While this possibility was discounted by the ABP in the past based on initially low numbers of physicians choosing this pathway, this pathway has grown from initially attracting 150 internal medicine applicants yearly to 265 in 2015.¹⁰ The ABMS approved the ABIM/ABFM FPHM as its first approved designation in March 2017 after more than 2,500 physicians earned this designation.¹¹ Of the >2,800 pediatric residency graduates (not including combined programs) each year, 10% report planning on becoming pediatric hospitalists,¹² and currently only 72-74 fellows graduate from PHM fellowships yearly.¹³ FPHM for pediatric hospital medicine would provide focused maintenance of certification and hospitalist designation for those who cannot match to fellowship programs.

Acknowledgments

The authors would like to acknowledge the input and support from the Executive Council of the Society of Hospital Medicine Pediatric Special Interest Group in writing this statement.

Disclosures

Dr. Chang served as an author of the Pediatric Hospital Medicine Petition to the American Board of Pediatrics for Subspecialty Certification. Drs. Hopkins, Rehm, Gage, and Shen have nothing to disclose.

The first Pediatric Hospital Medicine (PHM) fellowships in the United States were established in 2003;¹ and since then, the field has expanded and matured dramatically. This growth, accompanied by greater definition of the role and recommended competencies of pediatric hospitalists,² culminated in the submission of a petition to the American Board of Pediatrics (ABP) in August 2014 to consider recognition of PHM as a new pediatric subspecialty.³ After an 18-month iterative process requiring extensive input from the Joint Council of Pediatric Hospital Medicine, ABP subcommittees, the Association of Medical School Pediatric Department Chairs, the Association of Pediatric Program Directors, and other prominent pediatric professional societies, the ABP voted in December 2015 to recommend that the American Board of Medical Subspecialties (ABMS) recognize PHM as a new subspecialty.³

The ABP subsequently announced three pathways for board certification in PHM:

• Training pathway for those completing an Accreditation Council for Graduate Medical Education–accredited two-year PHM fellowship program;
• Practice pathway for those satisfying ABP criteria for clinical activity in PHM for four years prior to exam dates (in 2019, 2021, and 2023), initially described as “direct patient care of hospitalized children ≥25% full-time equivalent (FTE) defined as ≥450-500 hours per year every year for the preceding four years”;⁴
• Combined pathway for those completing less than two years of fellowship, who would be required to complete two years of practice experience that satisfy the same criteria as each year of the practice pathway.⁵

While the training pathway met near-uniform acceptance, concerns were raised through the American Academy of Pediatrics Section of Hospital Medicine (AAP SOHM) Listserv regarding the practice pathway, and by extension, the combined pathway. Specifically, language describing the necessary characteristics of acceptable PHM practice was felt to be vague and not transparent. Listserv posts also raised concerns regarding the potential exclusion of “niche” practices such as subspecialty hospitalists and newborn hospitalists. As applicants in the practice pathway began to receive denials, opinions voiced in listserv posts were increasingly critical of the ABP’s lack of transparency regarding the specific criteria adjudicating applications.

A group of hospitalists, led by Dr. David Skey, a pediatric hospitalist at Arnold Palmer Children’s Hospital in Orlando, Florida, created a petition which was submitted to the ABP on August 6, 2019, and raised the following issues:

• “A perception of unfairness/bias in the practice pathway criteria and the way these criteria have been applied.
• Denials based on gaps in employment without reasonable consideration of mitigating factors.
• Lack of transparency, accountability, and responsiveness from the ABP.”⁶

The petition, posted on the AAP SOHM listserv and signed by 1,479 individuals,⁷ raised concerns of anecdotal evidence that the practice pathway criteria disproportionately disadvantaged women, although intentional bias was not suspected by the signers of the letter. The petition’s signers submitted the following demands to the ABP:

• “Facilitate a timely analysis to determine if gender bias is present or perform this analysis internally and release the findings publicly.
• Revise the practice pathway criteria to be more inclusive of applicants with interrupted practice and varied clinical experience, to include clear-cut parameters rather than considering these applications on a closed-door ‘case-by-case basis...at the discretion of the ABP’.
• Clarify the appeals process and improve responsiveness to appeals and inquiries regarding denials.
• Provide a formal response to this petition letter through the PHM ListServ and/or the ABP website within one week of receiving the signed petition.”⁶

A formal response to the petition was released on the AAP SOHM Listserv on August 29, 2019, to address the concerns raised and is published in this issue of the Journal of Hospital Medicine.⁴ In response to the allegation of gender bias, the ABP maintained that the data did not support this, as the denial rate for females (4.0%) was not significantly different than that for males (3.7%). The response acknowledged that once clear-cut criteria were decided upon to augment the general practice pathway criteria published at the outset, these criteria should have been disseminated. The ABP maintained, however, that these criteria, once established, were used consistently in adjudicating all applications. To clarify and simplify the eligibility criteria, the percentage of the full-time equivalent and practice interruption criteria were removed, as the work-hours criteria (direct patient care of hospitalized children ≥450-500 hours per year every year for the preceding four years)⁸ were deemed sufficient to ensure adequate clinical participation.

The Society of Hospital Medicine (SHM), through pediatric hospitalists and pediatricians on its Board, committees, and the Executive Council of the Pediatric Special Interest Group, has followed with great interest the public debate surrounding the PHM certification process and the subsequent PHM petition to the ABP. The ABP responded swiftly and with full transparency to the petition, and SHM supports these efforts by the ABP to provide a timely, honest, data-driven response to the concerns raised by the PHM petition. SHM recognizes that the mission of the ABP is to provide the public with confidence that physicians with ABP board certifications meet appropriate “standards of excellence”. While the revisions implemented by the ABP in its response still may not satisfy the concerns of all members of the PHM community, SHM recognizes that the revised requirements remain true to the mission of the ABP.

SHM applauds the authors and signatories of the PHM petition for bravely raising their concerns of gender bias and lack of transparency. The response of the ABP to this petition by further improving transparency serves as an example of continuous improvement in collaborative practice to all medical specialty boards.

While SHM supports the ABP response to the PHM petition, it is clear that excellent physicians caring for hospitalized children will be unable to achieve PHM board certification for a variety of reasons. For these physicians who are not PHM board certified as pediatric hospitalists by the ABP, SHM supports providing these physicians with recognition as hospitalists. These include “niche” hospitalists, such as newborn hospitalists, subacute hospitalists, and subspecialty hospitalists. SHM will also continue to support and recognize community-based hospitalists, family medicine-trained hospitalists, and Med-Peds hospitalists whose practice may not comply with criteria laid out by the ABP. For these physicians, receiving Fellow designation through SHM, a merit-based distinction requiring demonstration of clinical excellence and commitment to hospital medicine, is another route whereby physicians can achieve designation as a hospitalist.

SHM supports future efforts by the ABP to be vigilant for bias of any sort in the certification process. Other future considerations for the PHM community include the possibility of a focused practice pathway in hospital medicine (FPHM) for pediatrics as is currently jointly offered by the American Board of Internal Medicine (ABIM) and the American Board of Family Medicine (ABFM). This maintenance of certification program is a variation of internal medicine or family medicine recertification, not a subspecialty, but allows physicians practicing primarily in inpatient settings to focus continuing education efforts on skills and attitudes needed for inpatient practice.⁹ While this possibility was discounted by the ABP in the past based on initially low numbers of physicians choosing this pathway, this pathway has grown from initially attracting 150 internal medicine applicants yearly to 265 in 2015.¹⁰ The ABMS approved the ABIM/ABFM FPHM as its first approved designation in March 2017 after more than 2,500 physicians earned this designation.¹¹ Of the >2,800 pediatric residency graduates (not including combined programs) each year, 10% report planning on becoming pediatric hospitalists,¹² and currently only 72-74 fellows graduate from PHM fellowships yearly.¹³ FPHM for pediatric hospital medicine would provide focused maintenance of certification and hospitalist designation for those who cannot match to fellowship programs.

Acknowledgments

The authors would like to acknowledge the input and support from the Executive Council of the Society of Hospital Medicine Pediatric Special Interest Group in writing this statement.

Disclosures

Dr. Chang served as an author of the Pediatric Hospital Medicine Petition to the American Board of Pediatrics for Subspecialty Certification. Drs. Hopkins, Rehm, Gage, and Shen have nothing to disclose.

The first Pediatric Hospital Medicine (PHM) fellowships in the United States were established in 2003;¹ and since then, the field has expanded and matured dramatically. This growth, accompanied by greater definition of the role and recommended competencies of pediatric hospitalists,² culminated in the submission of a petition to the American Board of Pediatrics (ABP) in August 2014 to consider recognition of PHM as a new pediatric subspecialty.³ After an 18-month iterative process requiring extensive input from the Joint Council of Pediatric Hospital Medicine, ABP subcommittees, the Association of Medical School Pediatric Department Chairs, the Association of Pediatric Program Directors, and other prominent pediatric professional societies, the ABP voted in December 2015 to recommend that the American Board of Medical Subspecialties (ABMS) recognize PHM as a new subspecialty.³

The ABP subsequently announced three pathways for board certification in PHM:

• Training pathway for those completing an Accreditation Council for Graduate Medical Education–accredited two-year PHM fellowship program;
• Practice pathway for those satisfying ABP criteria for clinical activity in PHM for four years prior to exam dates (in 2019, 2021, and 2023), initially described as “direct patient care of hospitalized children ≥25% full-time equivalent (FTE) defined as ≥450-500 hours per year every year for the preceding four years”;⁴
• Combined pathway for those completing less than two years of fellowship, who would be required to complete two years of practice experience that satisfy the same criteria as each year of the practice pathway.⁵

While the training pathway met near-uniform acceptance, concerns were raised through the American Academy of Pediatrics Section of Hospital Medicine (AAP SOHM) Listserv regarding the practice pathway, and by extension, the combined pathway. Specifically, language describing the necessary characteristics of acceptable PHM practice was felt to be vague and not transparent. Listserv posts also raised concerns regarding the potential exclusion of “niche” practices such as subspecialty hospitalists and newborn hospitalists. As applicants in the practice pathway began to receive denials, opinions voiced in listserv posts were increasingly critical of the ABP’s lack of transparency regarding the specific criteria adjudicating applications.

A group of hospitalists, led by Dr. David Skey, a pediatric hospitalist at Arnold Palmer Children’s Hospital in Orlando, Florida, created a petition which was submitted to the ABP on August 6, 2019, and raised the following issues:

• “A perception of unfairness/bias in the practice pathway criteria and the way these criteria have been applied.
• Denials based on gaps in employment without reasonable consideration of mitigating factors.
• Lack of transparency, accountability, and responsiveness from the ABP.”⁶

The petition, posted on the AAP SOHM listserv and signed by 1,479 individuals,⁷ raised concerns of anecdotal evidence that the practice pathway criteria disproportionately disadvantaged women, although intentional bias was not suspected by the signers of the letter. The petition’s signers submitted the following demands to the ABP:

• “Facilitate a timely analysis to determine if gender bias is present or perform this analysis internally and release the findings publicly.
• Revise the practice pathway criteria to be more inclusive of applicants with interrupted practice and varied clinical experience, to include clear-cut parameters rather than considering these applications on a closed-door ‘case-by-case basis...at the discretion of the ABP’.
• Clarify the appeals process and improve responsiveness to appeals and inquiries regarding denials.
• Provide a formal response to this petition letter through the PHM ListServ and/or the ABP website within one week of receiving the signed petition.”⁶

A formal response to the petition was released on the AAP SOHM Listserv on August 29, 2019, to address the concerns raised and is published in this issue of the Journal of Hospital Medicine.⁴ In response to the allegation of gender bias, the ABP maintained that the data did not support this, as the denial rate for females (4.0%) was not significantly different than that for males (3.7%). The response acknowledged that once clear-cut criteria were decided upon to augment the general practice pathway criteria published at the outset, these criteria should have been disseminated. The ABP maintained, however, that these criteria, once established, were used consistently in adjudicating all applications. To clarify and simplify the eligibility criteria, the percentage of the full-time equivalent and practice interruption criteria were removed, as the work-hours criteria (direct patient care of hospitalized children ≥450-500 hours per year every year for the preceding four years)⁸ were deemed sufficient to ensure adequate clinical participation.

The Society of Hospital Medicine (SHM), through pediatric hospitalists and pediatricians on its Board, committees, and the Executive Council of the Pediatric Special Interest Group, has followed with great interest the public debate surrounding the PHM certification process and the subsequent PHM petition to the ABP. The ABP responded swiftly and with full transparency to the petition, and SHM supports these efforts by the ABP to provide a timely, honest, data-driven response to the concerns raised by the PHM petition. SHM recognizes that the mission of the ABP is to provide the public with confidence that physicians with ABP board certifications meet appropriate “standards of excellence”. While the revisions implemented by the ABP in its response still may not satisfy the concerns of all members of the PHM community, SHM recognizes that the revised requirements remain true to the mission of the ABP.

SHM applauds the authors and signatories of the PHM petition for bravely raising their concerns of gender bias and lack of transparency. The response of the ABP to this petition by further improving transparency serves as an example of continuous improvement in collaborative practice to all medical specialty boards.

While SHM supports the ABP response to the PHM petition, it is clear that excellent physicians caring for hospitalized children will be unable to achieve PHM board certification for a variety of reasons. For these physicians who are not PHM board certified as pediatric hospitalists by the ABP, SHM supports providing these physicians with recognition as hospitalists. These include “niche” hospitalists, such as newborn hospitalists, subacute hospitalists, and subspecialty hospitalists. SHM will also continue to support and recognize community-based hospitalists, family medicine-trained hospitalists, and Med-Peds hospitalists whose practice may not comply with criteria laid out by the ABP. For these physicians, receiving Fellow designation through SHM, a merit-based distinction requiring demonstration of clinical excellence and commitment to hospital medicine, is another route whereby physicians can achieve designation as a hospitalist.

SHM supports future efforts by the ABP to be vigilant for bias of any sort in the certification process. Other future considerations for the PHM community include the possibility of a focused practice pathway in hospital medicine (FPHM) for pediatrics as is currently jointly offered by the American Board of Internal Medicine (ABIM) and the American Board of Family Medicine (ABFM). This maintenance of certification program is a variation of internal medicine or family medicine recertification, not a subspecialty, but allows physicians practicing primarily in inpatient settings to focus continuing education efforts on skills and attitudes needed for inpatient practice.⁹ While this possibility was discounted by the ABP in the past based on initially low numbers of physicians choosing this pathway, this pathway has grown from initially attracting 150 internal medicine applicants yearly to 265 in 2015.¹⁰ The ABMS approved the ABIM/ABFM FPHM as its first approved designation in March 2017 after more than 2,500 physicians earned this designation.¹¹ Of the >2,800 pediatric residency graduates (not including combined programs) each year, 10% report planning on becoming pediatric hospitalists,¹² and currently only 72-74 fellows graduate from PHM fellowships yearly.¹³ FPHM for pediatric hospital medicine would provide focused maintenance of certification and hospitalist designation for those who cannot match to fellowship programs.

Acknowledgments

The authors would like to acknowledge the input and support from the Executive Council of the Society of Hospital Medicine Pediatric Special Interest Group in writing this statement.

Disclosures

Dr. Chang served as an author of the Pediatric Hospital Medicine Petition to the American Board of Pediatrics for Subspecialty Certification. Drs. Hopkins, Rehm, Gage, and Shen have nothing to disclose.

In August of 2014, the Pediatric Hospital Medicine (PHM) community petitioned the American Board of Pediatrics (ABP) for a subspecialty certificate in PHM. A lengthy vetting process ensued during which the ABP consulted with a wide array of stakeholders. The ABP Board of Directors approved the request from the PHM community for a subspecialty certificate in December 2015 and published the results of the vetting process.¹

The ABP received a second petition posted on PHM listserv, which opened with the following statement:

“We submit this petition letter to register a formal complaint, demand immediate action, and request a formal response from the ABP regarding the practice pathway criteria and the application of these criteria for the Pediatric Hospital Medicine specialty exam. Recently there has been considerable discussion on the Pediatric Hospital Medicine ListServ suggesting that the ABP’s implementation of the career pathway criteria has failed to respect and fairly assess the diverse career paths of numerous experienced pediatric hospitalists, which may impede their opportunities for professional advancement. Anecdotal reports on the ListServ also suggest that the use of the current practice pathway criteria to evaluate exam applicants disadvantages women, though sufficient data is not available at this time to evaluate this assertion objectively.”

The ABP response to the PHM community’s concerns regarding the practice pathway for the first certifying exam in PHM is as follows.

ABP thanks the PHM community for the opportunity to respond to the attached petition. Our approach and response are grounded in our mission:

“Advancing child health by certifying pediatricians who meet standards of excellence and are committed to continuous learning and improvement.” 

Transparency is one of the ABP’s core values, which underpins this response. The ABP acknowledges that the petitioners did not find the guidance on the ABP website sufficiently transparent. We regret the distress this may have caused, will do our best to answer the questions forthrightly, and have revised the website language for greater clarity.

Some posts on the PHM listserv alleged gender (sex) bias against women in the ABP application process and outcomes. This allegation is not supported by the facts. A peer group of pediatric hospitalists constitutes the ABP PHM subboard which determined the eligibility criteria. The subboard thoughtfully developed these criteria and the American Board of Medical Specialties (ABMS) approved the broad eligibility criteria. The PHM subboard is composed of practicing pediatric hospitalists with a diversity of practice location, age, gender, and race. The majority of ABP PHM subboard members and medical editors are women.

Making unbiased decisions is also a core value of the ABP. Among the 1,627 applicants for the exam, the ABP has approved 1,515 (93%) as of August 15, 2019. Seventy percent of applications were from women, which mirrors the demographics of the pediatric workforce. There was no significant difference between the percentage of women (4.0%) and men (3.7%) who were denied admission to the exam (Table 1). As of August 15, 2019, the credentials committee of the PHM subboard is still reviewing 48 applications, including 35 appeals, of which 60% (N = 21) were from women and 40% (N = 14) were from men. Thirteen (N = 13) remaining applications are under review but not in the appeals process.

PHM is the 15^th pediatric subspecialty to begin the certification process with a practice pathway. In none of the prior cases was it possible to do a detailed implementation study to understand the myriad of ways in which individual pediatricians arrange their professional and personal time. This reality has led to the publication of only general, rather than specific practice pathway criteria at the start of the application process for PHM and every other pediatric subspecialty. Rather, in each case, a well-informed and diverse peer group of subspecialists (the subboard) has reviewed the applications to get a sense of the variations of practice and then decided on the criteria that a subspecialist must meet to be considered eligible to sit for the certifying exam. Clear-cut criteria were used consistently in adjudicating all applications. Although the ABP has not done this for other subspecialties, we agree that publishing the specific criteria once they had been decided upon would have improved the process. We commit to doing so in the future.

The eligibility criteria were designed to be true to the mission of the ABP and seek parity with the requirements used by other subspecialties and by the PHM training pathway. The assumption is that competent PHM practice of sufficient duration and breadth, attested to by a supervisor, would allow the ABP to represent to the public that the candidate is qualified to sit for the exam. The eligibility criteria focused on seven practice characteristics (Table 2):

The ABP recognizes that the use of %FTE, work hours, and leave exceptions led to unintended confusion among applicants. The intent had been to acknowledge the many valid reasons for interruption of practice, including parental leave. This response to the petition clarifies that the critical question from the public’s perspective is whether the candidate has accumulated enough hours of sustained practice to be considered competent in the field of PHM and specifically caring for hospitalized children (as defined above). Upon review, the ABP believes the workhours criteria (items 3 and 4) accomplish this critical goal and make the %FTE and practice interruption criteria largely redundant. Table 3 reflects the clarified and streamlined requirements. Re-examination of all the denied applications showed that using the criteria in Table 3 did not have a significant impact on the outcomes. One additional applicant’s appeal was granted, and this applicant has been so notified.

The right to appeal and the Appellate Review Procedure are included in a denial letter. The applicant is given a deadline of 14 days to notify the ABP of the intent to appeal. There is no appellate fee. Within one to three days, the ABP acknowledges receipt of the applicant’s intent to appeal and sends the applicant a date by which additional supporting information should be provided.

The appeal material is shared with the subboard credentials committee and each member individually reviews and votes on the appeal. The application is approved if a majority votes in favor of the applicant’s appeal. If there is no majority, the credentials committee discusses the case to reach a decision. The results of the appeal are final according to the ABP Appellate Review Procedure. We remain in the appeal process for several PHM applicants as of the date of this response.

Thank you for the opportunity to respond to the petition. The ABP is committed to dialogue, transparency, and continuously improving its processes.

Acknowledgment

The authors thank the ABP board of directors and the ABP PHM subboard for their review and thoughtful contributions.

Disclosures

Dr. Nichols reports other from The American Board of Pediatrics, during the conduct of the work. Dr. Woods has nothing to disclose.

In August of 2014, the Pediatric Hospital Medicine (PHM) community petitioned the American Board of Pediatrics (ABP) for a subspecialty certificate in PHM. A lengthy vetting process ensued during which the ABP consulted with a wide array of stakeholders. The ABP Board of Directors approved the request from the PHM community for a subspecialty certificate in December 2015 and published the results of the vetting process.¹

The ABP received a second petition posted on PHM listserv, which opened with the following statement:

“We submit this petition letter to register a formal complaint, demand immediate action, and request a formal response from the ABP regarding the practice pathway criteria and the application of these criteria for the Pediatric Hospital Medicine specialty exam. Recently there has been considerable discussion on the Pediatric Hospital Medicine ListServ suggesting that the ABP’s implementation of the career pathway criteria has failed to respect and fairly assess the diverse career paths of numerous experienced pediatric hospitalists, which may impede their opportunities for professional advancement. Anecdotal reports on the ListServ also suggest that the use of the current practice pathway criteria to evaluate exam applicants disadvantages women, though sufficient data is not available at this time to evaluate this assertion objectively.”

The ABP response to the PHM community’s concerns regarding the practice pathway for the first certifying exam in PHM is as follows.

ABP thanks the PHM community for the opportunity to respond to the attached petition. Our approach and response are grounded in our mission:

“Advancing child health by certifying pediatricians who meet standards of excellence and are committed to continuous learning and improvement.” 

Transparency is one of the ABP’s core values, which underpins this response. The ABP acknowledges that the petitioners did not find the guidance on the ABP website sufficiently transparent. We regret the distress this may have caused, will do our best to answer the questions forthrightly, and have revised the website language for greater clarity.

Some posts on the PHM listserv alleged gender (sex) bias against women in the ABP application process and outcomes. This allegation is not supported by the facts. A peer group of pediatric hospitalists constitutes the ABP PHM subboard which determined the eligibility criteria. The subboard thoughtfully developed these criteria and the American Board of Medical Specialties (ABMS) approved the broad eligibility criteria. The PHM subboard is composed of practicing pediatric hospitalists with a diversity of practice location, age, gender, and race. The majority of ABP PHM subboard members and medical editors are women.

Making unbiased decisions is also a core value of the ABP. Among the 1,627 applicants for the exam, the ABP has approved 1,515 (93%) as of August 15, 2019. Seventy percent of applications were from women, which mirrors the demographics of the pediatric workforce. There was no significant difference between the percentage of women (4.0%) and men (3.7%) who were denied admission to the exam (Table 1). As of August 15, 2019, the credentials committee of the PHM subboard is still reviewing 48 applications, including 35 appeals, of which 60% (N = 21) were from women and 40% (N = 14) were from men. Thirteen (N = 13) remaining applications are under review but not in the appeals process.

PHM is the 15^th pediatric subspecialty to begin the certification process with a practice pathway. In none of the prior cases was it possible to do a detailed implementation study to understand the myriad of ways in which individual pediatricians arrange their professional and personal time. This reality has led to the publication of only general, rather than specific practice pathway criteria at the start of the application process for PHM and every other pediatric subspecialty. Rather, in each case, a well-informed and diverse peer group of subspecialists (the subboard) has reviewed the applications to get a sense of the variations of practice and then decided on the criteria that a subspecialist must meet to be considered eligible to sit for the certifying exam. Clear-cut criteria were used consistently in adjudicating all applications. Although the ABP has not done this for other subspecialties, we agree that publishing the specific criteria once they had been decided upon would have improved the process. We commit to doing so in the future.

The eligibility criteria were designed to be true to the mission of the ABP and seek parity with the requirements used by other subspecialties and by the PHM training pathway. The assumption is that competent PHM practice of sufficient duration and breadth, attested to by a supervisor, would allow the ABP to represent to the public that the candidate is qualified to sit for the exam. The eligibility criteria focused on seven practice characteristics (Table 2):

The ABP recognizes that the use of %FTE, work hours, and leave exceptions led to unintended confusion among applicants. The intent had been to acknowledge the many valid reasons for interruption of practice, including parental leave. This response to the petition clarifies that the critical question from the public’s perspective is whether the candidate has accumulated enough hours of sustained practice to be considered competent in the field of PHM and specifically caring for hospitalized children (as defined above). Upon review, the ABP believes the workhours criteria (items 3 and 4) accomplish this critical goal and make the %FTE and practice interruption criteria largely redundant. Table 3 reflects the clarified and streamlined requirements. Re-examination of all the denied applications showed that using the criteria in Table 3 did not have a significant impact on the outcomes. One additional applicant’s appeal was granted, and this applicant has been so notified.

The right to appeal and the Appellate Review Procedure are included in a denial letter. The applicant is given a deadline of 14 days to notify the ABP of the intent to appeal. There is no appellate fee. Within one to three days, the ABP acknowledges receipt of the applicant’s intent to appeal and sends the applicant a date by which additional supporting information should be provided.

The appeal material is shared with the subboard credentials committee and each member individually reviews and votes on the appeal. The application is approved if a majority votes in favor of the applicant’s appeal. If there is no majority, the credentials committee discusses the case to reach a decision. The results of the appeal are final according to the ABP Appellate Review Procedure. We remain in the appeal process for several PHM applicants as of the date of this response.

Thank you for the opportunity to respond to the petition. The ABP is committed to dialogue, transparency, and continuously improving its processes.

Acknowledgment

The authors thank the ABP board of directors and the ABP PHM subboard for their review and thoughtful contributions.

Disclosures

Dr. Nichols reports other from The American Board of Pediatrics, during the conduct of the work. Dr. Woods has nothing to disclose.

In August of 2014, the Pediatric Hospital Medicine (PHM) community petitioned the American Board of Pediatrics (ABP) for a subspecialty certificate in PHM. A lengthy vetting process ensued during which the ABP consulted with a wide array of stakeholders. The ABP Board of Directors approved the request from the PHM community for a subspecialty certificate in December 2015 and published the results of the vetting process.¹

The ABP received a second petition posted on PHM listserv, which opened with the following statement:

“We submit this petition letter to register a formal complaint, demand immediate action, and request a formal response from the ABP regarding the practice pathway criteria and the application of these criteria for the Pediatric Hospital Medicine specialty exam. Recently there has been considerable discussion on the Pediatric Hospital Medicine ListServ suggesting that the ABP’s implementation of the career pathway criteria has failed to respect and fairly assess the diverse career paths of numerous experienced pediatric hospitalists, which may impede their opportunities for professional advancement. Anecdotal reports on the ListServ also suggest that the use of the current practice pathway criteria to evaluate exam applicants disadvantages women, though sufficient data is not available at this time to evaluate this assertion objectively.”

The ABP response to the PHM community’s concerns regarding the practice pathway for the first certifying exam in PHM is as follows.

ABP thanks the PHM community for the opportunity to respond to the attached petition. Our approach and response are grounded in our mission:

“Advancing child health by certifying pediatricians who meet standards of excellence and are committed to continuous learning and improvement.” 

Transparency is one of the ABP’s core values, which underpins this response. The ABP acknowledges that the petitioners did not find the guidance on the ABP website sufficiently transparent. We regret the distress this may have caused, will do our best to answer the questions forthrightly, and have revised the website language for greater clarity.

Some posts on the PHM listserv alleged gender (sex) bias against women in the ABP application process and outcomes. This allegation is not supported by the facts. A peer group of pediatric hospitalists constitutes the ABP PHM subboard which determined the eligibility criteria. The subboard thoughtfully developed these criteria and the American Board of Medical Specialties (ABMS) approved the broad eligibility criteria. The PHM subboard is composed of practicing pediatric hospitalists with a diversity of practice location, age, gender, and race. The majority of ABP PHM subboard members and medical editors are women.

Making unbiased decisions is also a core value of the ABP. Among the 1,627 applicants for the exam, the ABP has approved 1,515 (93%) as of August 15, 2019. Seventy percent of applications were from women, which mirrors the demographics of the pediatric workforce. There was no significant difference between the percentage of women (4.0%) and men (3.7%) who were denied admission to the exam (Table 1). As of August 15, 2019, the credentials committee of the PHM subboard is still reviewing 48 applications, including 35 appeals, of which 60% (N = 21) were from women and 40% (N = 14) were from men. Thirteen (N = 13) remaining applications are under review but not in the appeals process.

PHM is the 15^th pediatric subspecialty to begin the certification process with a practice pathway. In none of the prior cases was it possible to do a detailed implementation study to understand the myriad of ways in which individual pediatricians arrange their professional and personal time. This reality has led to the publication of only general, rather than specific practice pathway criteria at the start of the application process for PHM and every other pediatric subspecialty. Rather, in each case, a well-informed and diverse peer group of subspecialists (the subboard) has reviewed the applications to get a sense of the variations of practice and then decided on the criteria that a subspecialist must meet to be considered eligible to sit for the certifying exam. Clear-cut criteria were used consistently in adjudicating all applications. Although the ABP has not done this for other subspecialties, we agree that publishing the specific criteria once they had been decided upon would have improved the process. We commit to doing so in the future.

The eligibility criteria were designed to be true to the mission of the ABP and seek parity with the requirements used by other subspecialties and by the PHM training pathway. The assumption is that competent PHM practice of sufficient duration and breadth, attested to by a supervisor, would allow the ABP to represent to the public that the candidate is qualified to sit for the exam. The eligibility criteria focused on seven practice characteristics (Table 2):

The ABP recognizes that the use of %FTE, work hours, and leave exceptions led to unintended confusion among applicants. The intent had been to acknowledge the many valid reasons for interruption of practice, including parental leave. This response to the petition clarifies that the critical question from the public’s perspective is whether the candidate has accumulated enough hours of sustained practice to be considered competent in the field of PHM and specifically caring for hospitalized children (as defined above). Upon review, the ABP believes the workhours criteria (items 3 and 4) accomplish this critical goal and make the %FTE and practice interruption criteria largely redundant. Table 3 reflects the clarified and streamlined requirements. Re-examination of all the denied applications showed that using the criteria in Table 3 did not have a significant impact on the outcomes. One additional applicant’s appeal was granted, and this applicant has been so notified.

The right to appeal and the Appellate Review Procedure are included in a denial letter. The applicant is given a deadline of 14 days to notify the ABP of the intent to appeal. There is no appellate fee. Within one to three days, the ABP acknowledges receipt of the applicant’s intent to appeal and sends the applicant a date by which additional supporting information should be provided.

The appeal material is shared with the subboard credentials committee and each member individually reviews and votes on the appeal. The application is approved if a majority votes in favor of the applicant’s appeal. If there is no majority, the credentials committee discusses the case to reach a decision. The results of the appeal are final according to the ABP Appellate Review Procedure. We remain in the appeal process for several PHM applicants as of the date of this response.

Thank you for the opportunity to respond to the petition. The ABP is committed to dialogue, transparency, and continuously improving its processes.

Acknowledgment

The authors thank the ABP board of directors and the ABP PHM subboard for their review and thoughtful contributions.

Disclosures

Dr. Nichols reports other from The American Board of Pediatrics, during the conduct of the work. Dr. Woods has nothing to disclose.