I have been asked to address the issue of Subspecialty Status for Hospital Medicine and I appreciate the opportunity to do so.
Before I begin, I have a few disclaimers to share. You already know that I am the President of the Academic Pediatric Association. I am also a member of the Board of Directors of the American Board of Pediatrics, and a member of the Residency Review Committee for Pediatrics. My remarks today do not represent official positions of any of these organizations; however, my thoughts have certainly been influenced by the work I do with them.
I have read summaries of the Hospital Medicine Strategic Planning documents, and I listened to the presentation of the planning chairs, Drs Maloney and Mendez, last night. I am impressed by the thoughtfulness and thoroughness of the analysis that has been done by the Strategic Planning Group. The decision before you is not an easy one, and simplistic answers are unlikely to be persuasive.
One thing you may not know about me is that along with my good friend, Jane Knapp, I was one of the first fellows in Pediatric Emergency Medicine (PEM) in the United States from 1981 until 1983. Jane trained in Kansas City, and I trained in Philadelphia. Obviously, this was nonaccredited training. One of my mentors was Stephen Ludwig, who has been helpful in supporting the development of Hospital Medicine as well. As I have watched the development of Hospital Medicine, I have been struck by the many parallels with the developmental issues that PEM faced in the 1980s, and I will say a bit more about the parallels shortly.
What I want to share with you is that I did live through the transition to subspecialty status for PEM. I strongly believed then, as I do now, that this was good for PEM. I will also tell you that within PEM, this was not controversial. At the time, the opposition to subspecialty status for PEM came largely from outside of the PEM community. Their argument was that there was nothing exceptional about practicing PEM, and that any well-trained pediatric resident has sufficient skills and knowledge to do so. Having just spent 2 years in a novel fellowship acquiring additional training, I disagreed. I and my colleagues believed that there was indeed a distinct body of knowledge and a skill set to justify subspecialty status for PEM. By the late 1980s, there were textbooks and a journal in PEM, and there were also more than 20 fellowship programs. After some complex negotiation between the American Board of Emergency Medicine, the American Board of Pediatrics, and other relevant parties, a conjoint subspecialty board was established and content areas specified; the first board examination in PEM was given in 1992. Fellowship program accreditation began in 1999.
In my view, on balance, subspecialty status has been a good thing. First, the accreditation and certification processes have resulted in standardization of training and skill and knowledge acquisition that provide assurances to the public and to our patients that board-certified PEM physicians meet and maintain high-quality standards of competence in clinical practice. Board certification in accredited training with maintenance of certification may not be the only way to provide this training and support for life-long learning, but it has been an effective way in PEM.
Subspecialty status in PEM has also elevated the pace and quality of scholarship in our field. PEM physicians have made significant contributions in discovery and integration scholarship that have impacted the health of children. Examples include elucidating the role of steroids in acute management of asthma and croup, and, most recently, the large head injury study reported by the Pediatric Emergency Care Applied Research Network, resulting in an evidence-based prediction rule for intracranial injury, aimed at reducing unnecessary computed tomography scans and radiation exposure in children. In the 1990s, I was told at a meeting of the National Institutes of Health that we would never have training grants in PEM, and yet today there are 2 t-level training grants and 5 K level grants for research training in emergency medicine, including PEM.
I believe that subspecialty status has helped us to develop and attain positions of leadership and academic advancement both within our own institutions and at regional and national levels. From the PEM subspecialty, there have been 2 presidents of the American Academy of Pediatrics, 4 presidents of the Academic Pediatric Association, 1 President of the Society for Pediatric Research and American Pediatric Society, 4 members of the Board of Directors of the American Board of Pediatrics, at least 2 members of the Institute of Medicine members of National Institutes of Health study sections special emphasis panels, and Chairmen of Departments of Pediatrics. Although subspecialty status was certainly not a prerequisite for these types of achievements, I believe it was a catalyst.
As I mentioned, I see many analogies between PEM of 25 years ago and Hospital Medicine today. We are both specialties defined to a large degree by the place in which we practice. We are both “generalist subspecialties” in that we address a wide variety of issues brought to us by our patients. We emerged from a strong service need and demand for care from our patients and hospitals.
There are some important differences too. The one that strikes me as most significant is the comparatively large number of community-based hospital physicians.
I cannot say that what was good for PEM will inevitably be good for Hospital Medicine. In my view, the most relevant domains for consideration are clinical care and scholarship. If you believe that there are distinct bodies of knowledge and skills required to practice high-quality Hospital Medicine that exceed the competencies acquired in pediatric residency, then there is a strong case for advanced subspecialty training in the clinical domain. The textbooks and journals in Hospital Medicine certainly give evidence to support this concept.
The case for scholarship is perhaps a bit more nuanced, but, in the end, I believe it is also important. Scholarship is ultimately required to improve the quality of care we provide for children not only now, but also in future generations. Not only do we work to improve the care for today’s children, but we also make the discoveries that will form the foundation for the children of the future. This work requires scholarship of discovery in basic and translational sciences, integration of this material in scholarly review and synthesis writing, dissemination of discoveries into practice, and also scholarship devoted to improving the way we teach our students, residents, colleagues, and patients. Improvement science has blossomed, and it has become a central focus of scholarship for Pediatric Hospital Medicine. Does this mean that every hospital physician needs to be a scholar? Probably not. Does it mean that Hospital Medicine might benefit from its practitioners (or perhaps someday, diplomates) spending some time learning about scholarship and engaging in scholarly activity as part of training? I think so. At the core, all physicians are lifelong learners and teachers, and, as subspecialists, we collectively need the skills to discover and transmit knowledge.
Finally, I think this is a perfect time to be considering the question of subspecialty status. I know that there is a task force at the American Board of Pediatrics looking critically at issues related to subspecialty training. Their report is not due until sometime next year, but I believe that this task force is seriously considering options for increased flexibility in subspecialty training duration based on the advanced training needs of the individual subspecialties.
Many of the things I have discussed are in the pros and cons lists developed by the Strategic Planning Group. I hope that by sharing some of my thoughts and experiences, I have been able to shed some light on this important process that Pediatric Hospital Medicine is undertaking. Thank you!!
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
- Copyright © 2012 by the American Academy of Pediatrics