Over the past decade, pediatric hospital medicine (PHM) has matured as a distinct field, marked by the development of fellowship training, subspecialty certification, and an expanding evidence base for inpatient pediatrics. As the field of PHM has grown and evolved, important questions remain about alignment between training pathways and the realities of clinical practice. This study by Ivancie et al, “Perspectives of PHM Fellowship Graduates Working as Community Hospitalists: A Qualitative Study,” exploring fellowship graduates’ perspectives on knowledge, skills, and attitudes needed for community PHM (CPHM) practice offers a timely and necessary contribution.1 The authors conducted structured focus groups with recent PHM fellowship graduates who work at least part time in CPHM settings with a goal of evaluating the fellow’s perceived preparation for CPHM practice. By centering the voices of recent graduates working in community settings and focusing specifically on nonclinical competencies, the authors illuminate an enduring gap between how pediatric hospitalists are trained and where—and how—they ultimately practice.The study’s core finding is not simply that CPHM requires some distinct skills, but that these skills are often underemphasized or learned only after entering independent practice. The fellows described recognizing the need for more preparation to work in CPHM settings in 7 domains: (1) business and leadership, (2) practice in a resource-limited setting, (3) systems-based practice and quality care, (4) interpersonal dynamics, (5) perception of CPHM, (6) career development, and (7) high-stakes clinical competencies. The difference the setting makes was illustrated by comments on how even topics that are highly relevant in children’s hospitals, such as leadership, quality improvement, and interpersonal dynamics, are very different in community hospitals. This insight is critical given accumulating workforce data demonstrating that most pediatric hospitalists practice in community settings in some capacity.Recent national workforce data strongly reinforce the relevance of this study and show PHM jobs after training often include some form of CPHM practice. In the 2024 PHM workforce survey reported by Barrett Fromme and colleagues, only 27.9% of responding leaders worked exclusively at university sites. A total of 35.6% worked in community sites and 36.5% in hybrid settings, which means that more than 70% of PHM leaders who responded reported some portion of their clinical time to be in CPHM.2 We see a similar practice breakdown for the participants of this qualitative study, showing 70% practice in both community and university-based settings. Similarly, the national survey by Joshi and colleagues defining the hospitalist workforce in newborn care found that 68% of respondents practiced in a community hospital nursery.3 Although these studies include different sample populations within PHM, the findings nonetheless underscore how deeply embedded community practice is within the structure and leadership of the field and what a large portion of the PHM workforce it encompasses. This is also consistent with prior observations that most pediatric and newborn hospital care occurs outside tertiary academic centers.If most pediatric hospitalists practice in community and hybrid settings, then community-based training must be a core component to training for a career in PHM. The training-practice mismatch in PHM fellowship and the structural and cultural factors that contribute to it can have meaningful consequences. Fellows may graduate well prepared for tertiary care environments yet feel underprepared, isolated, or devalued when entering community practice. The noted deficiency in high-stakes clinical competencies is particularly telling in this regard. Fellows rarely attend the delivery room or manage codes within children’s hospitals, but CPHM providers are often the lone pediatric provider for critically ill newborns and children in community hospitals. Against this backdrop, the authors’ focus on exploring educational gaps in fellowship training is relevant and compelling.Importantly, the findings of this study must be interpreted with the context that fellowship programs and their leadership are overwhelmingly based in tertiary and quaternary care centers. Fellowship directors and core faculty working primarily in these settings may not fully appreciate the scope and professional demands of community practice. This structural reality infuses an inherent bias into fellowship curricula, competency frameworks, and clinical priorities and reinforces a separation between “academic” university-based PHM and CPHM. In that context, it is not all that surprising that CPHM-specific knowledge, skills, and attitudes—particularly nonclinical competencies such as business and leadership acumen, negotiation within adult systems, and practicing with constrained resources—are underrepresented or insufficiently addressed during training, as described by Ivancie et al in this study. The issue is not a lack of goodwill or intentional neglect but rather an epistemic gap: what is unfamiliar to or undervalued by those in university-based centers is less likely to be prioritized in training.This gap implicitly reinforces the antiquated notion that “academic” PHM is synonymous with university-based practice and absent in community settings. This terminology was specifically addressed in 2014 with the supposed elimination of the term “academic” as an opposite of “community,”4 and its continued use risks perpetuating a professional hierarchy that devalues much of the workforce while undermining the intellectual rigor of CPHM. The idea that “academic” PHM and CPHM are on opposite ends of a spectrum contributes to CPHM often being positioned as “less than,” as touched on in this study, implying that CPHM does not make academic contributions or offer valuable medical training in PHM. Such framing rests on the inaccurate assumption that scholarship, leadership, and medical education are inherently, or exclusively, tied to university-based settings. Community pediatric hospitalists routinely lead quality improvement initiatives, such as the important work of the Value in Inpatient Pediatrics Network5; develop care pathways; manage complex systems with limited resources; and serve as the primary pediatric advocates and leaders within predominantly adult institutions. The fact that this work occurs outside tertiary centers does not render it nonacademic; rather, it reflects a narrow and outdated definition of what academic contribution looks like in PHM.Community-based PHM represents a dominant practice environment for the field, and fellowship training must evolve to better reflect this reality. The educational gaps identified in this study reflect a broader systemic misalignment between fellowship training and the realities of PHM practice. Acknowledging the insufficiency of 4 weeks of clinical CPHM exposure to prepare PHM fellows for realistic careers in PHM and, in response, increasing longitudinal clinical exposure to CPHM settings in fellowship will be important to address the training-practice mismatch. Reframing CPHM as a normative and important practice environment, however, will take more than changes to PHM training. This calls for a fundamental shift in how the field defines expertise, scholarship, and leadership.Importantly, Ivancie et al highlight opportunities for advocacy within the field to include more community-based hospitalists in PHM fellowship and professional society leadership. The American Academy of Pediatrics Section on Hospital Medicine is purposeful about having CPHM physicians as executive committee members, but CPHM is underrepresented at the national level among other societies in which PHM is active, national Continuing Medical Education planning committees, and the American Board of Pediatrics PHM sub-board. The perspectives of those with experience in CPHM practice are critical to creating and leading effective PHM fellowship programs and should be prioritized when recruiting leadership teams. Beyond PHM fellowship, community pediatric hospitalists must be recognized as contributors to academic medicine whose work advances systems and shapes the care of hospitalized children. This may require a means of supporting the time for CPHM providers to participate in local and national efforts, because the allocation of CME funds and investment of institutions for their staff to participate in such activities can be very different in community hospitals than in academic centers.This study represents an important step in that direction by elevating the voices of fellowship graduates practicing in CPHM. Its findings challenge fellowship programs to critically examine whose perspectives shape training and if those align with the realities of postfellowship clinical practice. Aligning PHM education with where—and how—care is actually delivered will require intentional inclusion of community hospitalists in curriculum design, competency definition, and fellowship leadership. Only then can PHM training truly reflect the field it seeks to adequately prepare fellows to enter.
Harrington et al. (Mon,) studied this question.
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