Pediatric Hospital Medicine: A Proposed New Subspecialty.

Over the past 20 years, hospitalists have emerged as a distinct group of pediatric practitioners. In August of 2014, the American Board of Pediatrics (ABP) received a petition to consider recommending that pediatric hospital medicine (PHM) be recognized as a distinct new subspecialty. PHM as a formal subspecialty raises important considerations related to: (1) quality, cost, and access to pediatric health care; (2) current pediatric residency training; (3) the evolving body of knowledge in pediatrics; and (4) the impact on both primary care generalists and existing subspecialists. After a comprehensive and iterative review process, the ABP recommended that the American Board of Medical Specialties approve PHM as a new subspecialty. This article describes the broad array of challenges and certain unique opportunities that were considered by the ABP in supporting PHM as a new pediatric subspecialty.

Long-term Plans for Those Selecting Hospital Medicine as an Initial Career Choice.

BACKGROUND: The proportion of the newly graduated pediatric workforce that becomes hospitalists has been increasing slightly over the past decade. However, it is unknown what proportion of those who accept hospitalist positions as their first job intend to remain in the field longer term. This is important to workforce projections regarding the magnitude of those who will function in this role. METHODS: The American Board of Pediatrics incorporated a structured questionnaire within the online application process to the General Pediatrics certification application. Respondents identified as residents or chief residents who selected "hospitalist position" as their immediate postresidency plan were the focus this study. We compared survey responses by gender and location of the medical school attended. RESULTS: Since the initiation of the general pediatrics certification examination application survey, 6335 completed the questionnaire. 79% (n=5001) were either in residency training or were a chief resident. Of those, 8% (n=376) reported they planned to work as a pediatric hospitalist immediately after completing residency. Fewer than half (43%; n=161) reported this to be their long-term career plan. This finding varied by both medical school type and by gender. CONCLUSIONS: The majority of pediatric residents and chief residents who take hospitalist positions immediately after training do not intend for hospital practice to be the long-term focus of their careers. As the field of hospital medicine continues to develop, understanding career trajectories can help inform current and future efforts regarding the potential for different mechanisms for training and certification.

New pediatricians: first jobs and future workplace goals.

BACKGROUND AND OBJECTIVES: Concern is often expressed about the satisfaction of new physicians and the potential match of their workplace goals with available positions. We studied the interface of desired professional activities with actual initial positions. METHODS: Survey study of all general pediatricians taking the 2012 General Pediatrics Certifying Examination. RESULTS: Of the 5210 who sat for the General Pediatrics Certifying Examination, 5163 (>99%) completed the survey. Of the total respondents, 45% self- identified as general pediatricians (N = 2327). Of those who completed training <2 years ago (N = 1365), most were currently engaged in clinical care (87%; N = 1190). The most important factor, cited most frequently by both men and women, in the choice of their first job was lifestyle and spousal or family considerations. Most (83%; N = 977) reported that the allocation of time for specific duties in their current position was consistent with their goals, with no differences between men and women. Most had no desire for inpatient activity. CONCLUSIONS: Despite concerns about young general pediatricians being able to find positions that meet their career goals, most were in jobs that approximated their desired allocation of professional time and focus of clinical work.

Longitudinal assessment of the timing of career choice among pediatric residents.

OBJECTIVE: To determine the timing of and key factors in resident decision making to pursue either a career in general pediatrics or subspecialty training. DESIGN: We used a 10-item fixed-choice questionnaire that focused on exploring how and when pediatric residents make career choices. SETTING: The survey was administered to all categorical pediatric residents in the United States and Canada as part of the General Pediatrics In-Training Examination in 2007 and 2009. The 2007 level 1 residents and 2009 level 3 residents were matched by a unique person identifier to create a longitudinal data set. PARTICIPANTS: A total of 2305 individuals completed the survey as level 1 residents in 2007 and level 3 residents in 2009, representing a retention rate of 83.5%. MAIN OUTCOME MEASURES: Change in individual and aggregate pediatric resident response over time. RESULTS: A similar number of individuals planned to pursue fellowship training in 2007 and 2009 (1026 vs 1062). Among this group, 745 (72.6%) of the 2009 residents were the same individuals who had indicated that they planned to pursue fellowship training in 2007. A total of 258 (71.9%) of all residents who reported in 2007 that they intended to pursue careers in general pediatrics with little or no inpatient care were still planning to do so in 2009. CONCLUSIONS: Most pediatricians make their decisions regarding pursuit of a career in primary care or to complete a fellowship before they ever enter residency training. It is unknown whether a similar timeline of decision making is consistent across specialties.

Linking process to outcome: are we training pediatricians to meet evolving health care needs?

The Residency Review and Redesign in Pediatrics (R(3)P) Project began in 2005 and will have been completed in 2009. The purpose was to conduct a comprehensive reassessment of general pediatric residency education. The project convened 3 major colloquia supplemented by numerous meetings of an R(3)P committee and by surveys of residents, subspecialty fellows, and generalist and subspecialty practitioners. A principal conclusion was that resident learning opportunities should be more flexibly directed toward the variety of career choices available to pediatricians. Another conclusion was that reasonable expectations for residency education are most likely if learning is regarded as an integrated continuum, beginning in medical school and continuing throughout a career in practice. The R(3)P Committee declined to create a list of recommendations for immediate changes in residency education; instead, it recommends that changes be based on evidence of education outcomes that are important to improving the health of children, adolescents, and young adults.

Recently trained general pediatricians: perspectives on residency training and scope of practice.

OBJECTIVE: Because of the increase in both the prevalence and complexity of chronic diseases in children, there is heightened awareness of the need for general pediatricians to be prepared to comanage their patients with chronic disorders with subspecialists. It is not known currently how well prepared general pediatricians believe themselves to be for these roles after residency training. This study was conducted to determine the perspectives of recently trained general pediatricians in practice regarding their decisions on residency choice, career choice, and adequacy of training. METHODS: A random sample of 600 generalists whose initial application for general pediatric certification occurred between 2002 and 2003 (4-5 years out of training) and 600 generalists who applied for board certification between 2005 and 2006 and who were not currently enrolled in or had completed subspecialty training (1-2 years out of training) received a structured questionnaire by mail. The survey focused on decision-making in selection of residency programs, strength of residency training in preparation for clinical care, and scope of practice. RESULTS: The overall response rate was 76%. The majority of generalists reported that their residency training was adequate in most subspecialty areas. However, a large proportion of generalists indicated that they could have used additional training in mental health (62% [n = 424]), sports medicine (51% [n = 345]), oral health (52% [n = 356]), and developmental/behavioral pediatrics (48% [n = 326]). Most generalist respondents reported that they are comfortable comanaging cases requiring subspecialty care with a subspecialist. However, generalist respondents without local access to subspecialists were more likely to report that they are comfortable managing patients who require subspecialty care. CONCLUSIONS: The training of general pediatricians, and the needs for their adequate preparation to care for patients, should be a dynamic process. As the nature and epidemiology of pediatric care change, our educational system must change as well.

Recently trained pediatric subspecialists: perspectives on training and scope of practice.

OBJECTIVES: Little is known regarding the factors influencing the decision to pursue pediatric subspecialty fellowship training and the timing of when such a decision is made. In addition, there is no information regarding whether the general pediatrics training received in residency is perceived as valuable by subspecialists. This study was conducted to characterize the strengths and weaknesses of residency and fellowship training from the perspective of recently trained pediatric subspecialists and to assess their current and future career goals and intended scope of practice. METHODS: A random sample of 550 subspecialists whose initial application for pediatric subspecialty certification occurred between 2002 and 2003 (4-5 years out of training) and 550 subspecialists who applied for board certification between 2005 and 2006 (1-2 years out of training) received a structured questionnaire by mail. The survey focused on decision-making in selection of residency and fellowship programs, strength of residency training in preparation for clinical care provision, and scope of current practice. RESULTS: The overall response rate was 77%. More than half (54%) of the recently trained subspecialists would have shortened either their pediatric residency or fellowship training if given the opportunity, and 7% were unsure. More than one third of the respondents made the decision to pursue subspecialty training before the start of residency (36% [n = 198]), whereas approximately half of them made this decision during the first (19% [n = 106]) or second (27% [n = 150]) year of residency. CONCLUSIONS: Many subspecialists would have been interested in modifications to their pediatric residency and fellowship training programs, which may reflect changing patterns of professional activities or the preferences of a younger generation of subspecialists. Given that a substantial proportion of subspecialists decide to pursue subspecialty training before or early in residency, greater flexibility in configuring some residency experiences to meet their career goals would be feasible.

General pediatrics resident perspectives on training decisions and career choice.

OBJECTIVE: Little is known regarding at what point during the training period residents in pediatrics make decisions on their future career choices. As part of a dedicated process of reexamining the structure of residency training in pediatrics, the American Board of Pediatrics sought information to better understand the influences, process, and sequencing of both residency program selection and career decision-making among residents. METHODS: All pediatrics resident physicians in all training programs in the United States and Canada (N = 8290) received the survey as part of the general pediatrics in-training examination. The survey focused on exploring how and when pediatrics residents make career choices and assessed perceived flexibility of their individual pediatrics residency program. RESULTS: The response rate was 95%. Location was the most important factor in selecting a residency program for 42% of all residents. Almost half of the pediatrics residents planned to pursue fellowship training after residency, a proportion that changed little across the 3 training years (level 1: 47%; level 2: 49%; level 3: 47%). Those who planned to pursue a general pediatrics career (either with or without inpatient care) were more likely than those who intended to pursue fellowship training to report that lifestyle was the most important factor in their career choice (63% vs 21%). CONCLUSIONS: Not surprisingly, different priorities motivate pediatricians to pursue specific programs for training and specific career options. The finding that those with the highest priority regarding lifestyle are more likely to pursue generalist training has implications for the generalist workforce, because those persons may also be more likely to seek part-time employment. Lifestyle concerns may need to be addressed in subspecialty training and subsequent subspecialty careers to ensure a continued flow of residents into fellowship training.

Looking to the future.

Participants of the Residency Review and Redesign (R(3)P) Project have created a challenging strategic plan for pediatric residency education. In place of a list of prescriptions for immediate change, the R(3)P Committee recommends an ongoing project of goal-directed change, a quality improvement approach to resident education. It argues for changes based on evidence of important education outcomes that improve the health of children, adolescents, and young adults. Creation and maintenance of a process of ongoing, adaptive change will depend on the combined efforts of the Association of Pediatric Program Directors, the Association of Medical School Department Chairs, the American Board of Pediatrics, the Resident Section of the American Academy of Pediatrics, and the Accreditation Council for Graduate Medical Education Review Committee for Pediatrics.

Pediatric fellows: perspectives on training and future scope of practice.

OBJECTIVE: Training for pediatric residents who intend to pursue fellowship differs little from training for residents who intend to practice general pediatrics. It is unknown how well residents who intend to pursue subspecialty training believe that residency prepares them for subspecialty fellowships or future careers. To characterize the strengths and weaknesses of residency training and the factors influencing subspecialty choice from the perspective of subspecialty fellows, we conducted a survey of current fellows on these issues. METHODS: A random sample of 1000 physicians who were entering their second or third year of fellowship in the United States in 2007 received a structured questionnaire by mail. The survey focused on decision-making in selection of residency and fellowship programs, strength of residency training in preparation for fellowship, and plans for future practice. RESULTS: The overall response rate was 81%. A majority of the fellows would not have shortened their general pediatrics residency before fellowship if given the option (64% [n = 482]). However, more than half (52% [n = 390]) of the fellows would have chosen a 2-year fellowship without research or scholarly activity over the current 3-year structure. Few current fellows believed they could have used any additional training in the areas of patient safety, coordination of care for children with complex illnesses, or patient communication. CONCLUSIONS: The finding that a large proportion of fellows would opt for shortened subspecialty training should prompt discussion and debate within the profession regarding the skills necessary for a pediatric subspecialist. Patient safety, physician-parent communication, and care coordination are emphasized primarily through informal training during residency. Although most clinicians believe themselves to be adequately prepared, research has identified gaps in clinician skills and understanding of these issues of great importance to patients and their families.

The Residency Review and Redesign in Pediatrics (R3P) Project: roots and branches.

The Residency Review and Redesign in Pediatrics Project was fortunate to be able to take advantage of careful thinking by others. In addition to pediatricians, we sought advice from medical educators across the spectrum of medicine, especially in internal and family medicine. Participants in the project concluded early on that top-down "redesign" of pediatric resident education was neither realistic nor appropriate. A better and more durable alternative is a formal process by which residency education can learn and evolve over time. By committing to that model, pediatrics would finally carry out the mandate of the 1978 Task Force on Pediatric Education.

Part-time training in pediatric residency programs: principles and practices.

Despite growing interest in part-time work, few pediatricians are pursuing part-time residency training. There is currently little guidance for programs or residents who wish to design an alternative path through residency. In this article we review the need for part-time residencies and address obstacles to be overcome in their initiation. Strategies are offered for residents and program directors planning part-time training pathways, with recommendations for implementation amid a changing environment for graduate medical education. The needs of trainees, residency programs, hospitals, and credentialing organizations are considered.

The in-training examination: an analysis of its predictive value on performance on the general pediatrics certification examination.

OBJECTIVE: This study investigates the predictive validity of the In-Training Examination (ITE). Although studies have confirmed the predictive validity of ITEs in other medical specialties, no study has been done for general pediatrics. STUDY DESIGN: Each year, residents in accredited pediatric training programs take the ITE as a self-assessment instrument. The ITE is similar to the American Board of Pediatrics General Pediatrics Certifying Examination. First-time takers of the certifying examination over a 5-year period who took at least 1 ITE examination were included in the sample. Regression models analyzed the predictive value of the ITE. RESULTS: The predictive power of the ITE in the first training year is minimal. However, the predictive power of the ITE increases each year, providing the greatest power in the third year of training. CONCLUSIONS: Even though ITE scores provide information regarding the likelihood of passing the certification examination, the data should be used with caution, particularly in the first training year. Other factors also must be considered when predicting performance on the certification examination. This study continues to support the ITE as an assessment tool for program directors, as well as a means of providing residents with feedback regarding their acquisition of pediatric knowledge.

Controversy surrounding the use of home oxygen for premature infants with bronchopulmonary dysplasia.

OBJECTIVE: To determine the criteria used in the current practice of neonatology for the initiation of home oxygen therapy in premature infants with bronchopulmonary dysplasia and to compare these criteria with the available literature regarding the use of home oxygen therapy. STUDY DESIGN: Participants in the December 2000 meeting of the Vermont Oxford Network were surveyed regarding their current use of home oxygen therapy for infants with bronchopulmonary dysplasia. RESULTS: Surveys were returned by 181 out of 297 participants. Pulse oximetry saturation (SpO2) thresholds for the initiation of home oxygen therapy varied widely from <84% to <98%. The most common threshold was <90% chosen by only 43% of the respondents. Additionally, 22% of the respondents did not initiate therapy until the oxygen saturation in room air was below 88%. Once on oxygen therapy, the target SpO2 also varied widely from >84% to >98%, with only 27% of respondents aiming for an SpO2 of >94%. CONCLUSIONS: There is a clear lack of consensus among neonatologists regarding the initiation of home oxygen therapy for bronchopulmonary dysplasia. Furthermore, the criteria used for home oxygen therapy varies widely with the majority of neonatologists surveyed using oxygen saturation levels not supported by the literature. We speculate that a significant underutilization of home oxygen therapy exists for infants with bronchopulmonary dysplasia.

Variability in the use of supplemental oxygen for bronchopulmonary dysplasia.

Despite the use of "oxygen dependence at 36 weeks postmenstrual age" to define bronchopulmonary dysplasia, criteria for the use of oxygen is rarely defined. We surveyed members of the Vermont Oxford Network regarding their criteria. Pulse oximetry saturation thresholds varied widely from <84% to <96%, with only 41% of the respondents using the same criteria (<90%). This lack of uniformity in the use of oxygen casts doubt on conclusions derived from multicenter trials that use oxygen dependence at 36 weeks postmenstrual age as an outcome.