Preparation for PHM: Considerations for Pediatric Residency Programs

In response to the evolution and sub-specialization of pediatric medicine, the Accreditation Council for Graduate Medical Education (ACGME) has recently revised the pediatric residency requirements to include more individualized, career-focused components. The new requirements deemphasize inpatient rotations overall but include at least 16 weeks of inpatient general pediatrics and 40 weeks of individualized curriculum to include subspecialty experiences and electives.1 In response to these changes, we advocate for establishing dedicated pediatric hospital medicine (PHM) tracks within residency programs.The recognition of PHM by the American Board of Pediatrics as a distinct subspecialty occurred in 2019. Fellowship accreditation by the ACGME followed in 2020. Parallel to these changes, pediatric residency training has become increasingly concentrated within large university-affiliated hospitals. Only a small portion of programs require rotations in community hospital settings, yet many future pediatric hospitalists will practice in settings with limited access to subspecialty consultation.2 It has been estimated that the supply of fellowship-trained pediatric hospitalists will not be sufficient to meet demand for the next 2 decades.3 In the meantime, graduates of pediatric and combined internal medicine–pediatric (MedPeds) residencies will continue to obtain positions immediately after graduation, often outside of large tertiary centers. Therefore, pediatric residencies must adapt to provide appropriate individualized training for all those who will practice PHM.3We believe that integrating PHM entrustable professional activities4 and the ACGME Pediatric Residency Milestones 2.05 framework into a dedicated PHM track may be part of the solution to secure the future of the PHM workforce. Successful models, such as pediatric primary care tracks6 and the University of Colorado's Internal Medicine Hospitalist Training Track,7 have demonstrated both learner satisfaction and graduate career alignment with training track focus. PHM divisions can partner with pediatric residency programs to promote a competency-based approach to producing pediatricians equipped to practice within the complexities of hospital-based medicine.In recent years, graduating residents have reported decreasing preparedness for independent practice as pediatric hospitalists.8 We strive to bolster resident preparation with our PHM elective rotation. This elective provides senior residents with exposure to various skills required for PHM practice, including responding to rapid response scenarios, triaging transfer requests, determining patient disposition from the emergency department, completing inpatient and physician call line general pediatrics consultations, and precepting new patient admissions. During this rotation, residents work with attending physicians on our direct care services and receive increased autonomy in patient care decisions. They also gain experience alongside essential nonphysician providers, including nurses from our vascular access and wound/ostomy teams, as well as lactation and therapy specialists. As recommended by Patel and colleagues,9 we aim to provide mentorship and education on various nonclinical aspects of PHM, including billing and coding, bedside teaching, giving and receiving feedback, high-value care, patient safety, and quality improvement.Participation in the elective has grown over the 3 years since its inception, with a corresponding increase in the number of residents pursuing a community hospitalist role or PHM fellowship after graduation (Fig 1). Although it is unclear whether participation inspired or simply reinforced residents' career decisions, this illustrates a sustained interest in our specialty. In rotation evaluations, residents appreciated experiencing the various roles we fulfill as PHM faculty. They also found benefit in the opportunity to network with hospitalists and gain insights into the variety of clinical and academic opportunities within the field.As we look to the future, we anticipate expanding our senior resident elective into a formal residency track. Although our institution offers experiences not necessarily available at every program, all pediatric residencies can capitalize on preexisting resources and experiences to scaffold a PHM-specific curriculum.To our knowledge, there are no existing publications regarding the effectiveness of hospital medicine training tracks in pediatrics. Limes et al implemented a hospitalist track for internal medicine residents with a 20-week inpatient clinical curriculum, focused didactics, and interest-aligned mentorship. They demonstrated that participating residents chose hospital-based careers at a high rate and valued the experience for skill development and clinical training.6The ACGME outline for curriculum organization and resident experiences provides the basic structure for all pediatric resident training and the framework for individualized experiences based on trainee interests and career goals.1 In Fig 2, we outline a proposed pathway for opting into a PHM track and overarching track goals. We suggest residents enter training under the standard curriculum and elect to the pathway once they have had time for career exploration. The goal of the track is to support residents with career aspirations in PHM while allowing the flexibility to change paths during training without penalty. Residents must have regular coaching to reflect on personal goals and evaluate progress within the track.Figure 3 describes recommended track components, aligning with the new ACGME requirements. Because available rotations will vary by institution, we offer suggestions for experiences and opportunities that can be tailored as needed to provide an overview of PHM in several different forms. Broad exposure to both clinical and nonclinical aspects of PHM combined with mentoring will allow residents to affirm their choice of PHM as a specialty and discern whether to pursue fellowship training.For a PHM track resident, the 40 weeks of inpatient training should include the management of patients with medical complexity, as well as exposure to inpatient subspecialty care. Experience with patient flow coordination and level of care determination should also be built into this setting.Portions of the 40 weeks of ambulatory pediatrics can also be offered with an inpatient lens. Specifically, adolescent medicine, mental health, and developmental–behavioral pediatrics allow for inpatient components, although they should have a primarily outpatient focus. The 4-week mental health experience might include behavioral de-escalation techniques and safety planning for patients with suicidal ideation. Adolescent medicine experiences may include medical management of protein-calorie malnutrition and acute gynecologic concerns. These opportunities allow residents to consider the associated hospital-based components of each field providing additional elements of preparation for PHM.Within the individualized curriculum, subspecialty experiences for PHM-interested residents should include exposure to a variety of pathologies in hospitalized children. The extent of subspecialty inpatient experiences will be dictated by availability at individual institutions, but learning the subspecialist's approach to diagnosis and treatment is a valuable experience. Residents should aim to experience both inpatient and consultative subspecialty medicine, if available because each model provides a unique perspective. Newborn nursery experience remains critical to preparedness for PHM practice in many settings. Consideration should be given to additional delivery experiences and care of the newborn beyond the required 4 weeks. If possible, dedicated time with pediatric respiratory therapists, pediatric nurses, and lactation specialists helps to prepare residents for settings in which those professionals are not readily available. In large tertiary centers, the opportunity to rotate at a community site provides additional perspective and context to the variety of environments in which hospitalists practice. With fewer immediately available subspecialists and support staff, residents rotating at a community site can partake in portions of patient care they may not typically encounter. Such rotations prepare future community hospitalists to enter the workforce and provide those preparing for PHM fellowship with valuable perspectives for future discussions around triage and transfers from outlying hospitals.A survey of current and recently graduated PHM fellows indicates that respondents felt more prepared for clinical tasks than research or teaching tasks at the beginning of the fellowship.10 The individualized curriculum for a future hospitalist should include training in nonclinical skills such as quality improvement, leadership, and medical education. Because non-fellowship-trained hospitalists will continue to make up a significant part of the PHM workforce for years to come, acquiring these necessary skills should not be deferred until fellowship.The creation of a PHM track stands to benefit all trainees who intend to practice hospital medicine, including those in combined training programs. In the 2015 AAP workforce study, 90.3% of MedPeds respondents felt their training prepared them well to practice as combined hospitalists.11 Although the ACGME requirements for MedPeds will not change in 2025, restructuring within pediatric residencies will inevitably affect MedPeds trainees. A PHM track will benefit MedPeds trainees, who have fewer pediatric rotations to begin with, by identifying high-yield experiences within the institutional offerings. Although the prospect of PHM fellowship was not popular with MedPeds residents in a recent survey, it is possible that by exposing this group to the nonclinical facets of PHM, a higher proportion may see value in fellowship training.12 Like their categorical counterparts, those choosing to enter the workforce directly will also benefit from this exposure.Considering the ACGME's revised program requirements, the clear next step is for residency programs to create opportunities and systems that support residents who plan to practice inpatient pediatrics. Engaging in both clinical and nonclinical experiences through the PHM lens will set residents up for success in PHM, whether they are fellowship-bound or entering directly into practice. A thoughtful, personalized, inpatient-focused residency track may be just the solution that PHM needs.We wish to acknowledge Susi Miller, MLIS, for her assistance with the literature review.