A few years ago, I was interviewing candidates for a position in our community hospital group. I was telling a resident who was graduating from a highly specialized university program about our range of activities and proudly describing our relationships with community practitioners when she abruptly ended the interview, explaining that she did not want to be what we were; she wanted to be a hospitalist. I was confused. If we were not hospitalists, what were we? “Hospital-based generalists,” she said. Until that exchange, I had no appreciation for a difference between being a pediatric hospitalist and being a hospital-based pediatric generalist. But as I considered her frame of reference, I understood: she was seeking what she knew, a general inpatient niche position within a full department of pediatrics, whereas we aspired to address the care of children everywhere in the hospital as an integral part of a pediatric community providing care for children. The distinction might largely be between the role generally performed by pediatric hospitalists in university/children’s hospitals and what pediatric hospitalists do in community hospitals, activities that may include any or all of the following in addition to inpatient care: newborn nursery care, delivery room resuscitations/stabilization, emergency department consultations, outpatient consultations; procedural sedations, advocacy for the needs of children within an adult-oriented system, and transport medicine. Hospitalists in university/children’s hospitals may perform some of these activities as well, of course, but the expanded scope of activities may well define the unique role of pediatric generalists in community hospitals. The role, or opportunity, as I see it, is generally out of sight of learners making career choices, and the literature about pediatrics in community hospitals is scant.1–5 So for those who aspire to be “hospital-based pediatric generalists” with an expanded role, this commentary seeks to make the case for being a pediatric hospitalist in a community hospital.
The scope of practice of pediatric hospitalists in community hospitals is more likely defined by their capabilities and the needs of children in their institution than by “turf” boundaries established by subspecialists. For the hospitalists (and patients) to benefit from this opportunity, however, the hospitalists require a breadth of clinical knowledge and skills extending into areas generally addressed by subspecialists in university/children’s hospitals. Moreover, to fully meet the needs of children wherever they are in the hospital (including locations such as radiology suites) and ensure that the services they require are provided appropriately (including pharmacy, radiology, laboratory, respiratory therapy, physical therapy, occupational therapy, etc) requires specific knowledge about these areas in community hospitals where care is oriented toward adults. For example, although it may be reasonable to presume that provisions will be made to keep babies warm when undergoing radiographic procedures in university/children’s hospitals, such special consideration might require the specific oversight of pediatric hospitalists in a community hospital. And when young infants require intubation in the operating room or emergency department of a community hospital, the services of a pediatric hospitalist may be required. Effecting change requires not only being aware of what needs to be done but also understanding how hospitals work and having administrative and leadership skills in advocacy and negotiation. The ability to apply principles of quality improvement that characterizes hospitalists in whatever type of facility they practice is, of course, also of considerable importance.
Pediatric hospitalists in community hospitals need to be able not only to identify the level of illness a child has at the moment but also what the likely trajectory of worsening or improvement will be. Some children can return to primary care soon but others may require transport to a tertiary care regional center. The ability to effect a safe, timely transport requires critical assessment skills, the ability to stabilize vital processes, and knowledge of resources, both local and at the regional center. Transferring a child by ambulance or helicopter is quite a different process from wheeling a child down the hall to an ICU.
The link pediatric hospitalists in community hospitals provide between primary care and tertiary care, between primary care providers and subspecialists, between community offices and regional referral centers has been termed “secondary care.”2 The hospitalists not only provide direct inpatient care but may also provide consultative care to assist community physicians; such consultations may be inpatient, outpatient, or by telephone. Because the hospitalists serve as a link to referral centers, they may be consulted about the appropriate use of available resources, both local and regional. The link between primary care and tertiary care is important for the seamless care of children but is also of considerable importance for our profession, keeping the house of pediatrics together.
Hospitalists in community hospitals are in a position to identify needs of children that are better addressed in the community than in the hospital and to advocate for the considerable clout of the hospital to be leveraged to create and enhance services out in the community that benefit children. Examples include establishing new services, such as subspecialty practices, and developing or enhancing pediatric capability in existing services, such as ambulance transport and emergency medical services.
Community hospitals offer interested pediatric hospitalists the opportunity to teach about the needs of children, the care of children, the support of families, and the diseases that affect children. Learners include families, of course, but also nurses, hospital staff, administrators, the lay public, and community primary care providers. Newsletters to community pediatricians, with instructive case discussions and identification of new resources, provide valuable continuing education, as do grand rounds presentations. Medical students and residents (in pediatrics and family medicine) can get the benefit of a more real-world experience in community hospitals compared with referral centers, particularly if the hospitalists involve the community practitioners and their offices. Community hospitals are also a laboratory for hospitalists to conduct studies or participate in collaborative research into best practices for the care of children with relatively common disorders. Opportunities for scholarly activities abound for those with academic interests.6
How available are such positions? Consider that, according to the American Hospital Association, there are ∼2000 hospitals in the United States with designated pediatric inpatient units,7 many more than are accounted for by children’s and university hospitals. Residency graduates continue to choose pediatric hospital medicine (PHM) at a rate of ∼8% to 10% per year (L. Althouse, American Board of Pediatrics, personal communication, September 2014).8 Some will choose community hospitals,4 and although most may remain in tertiary centers, it seems inevitable that there will be spillover into community hospitals, as has occurred in neonatology and critical care. Fellowships in PHM continue to increase in number, and this is an excellent time for the PHM community to embrace the full range of opportunities for hospitalists, including those in community hospitals, by addressing the knowledge and skills needed for success. A community hospitalist subcommittee now exists within the American Academy of Pediatrics Section on Hospital Medicine with its own listserv; there are seats on both the subcommittee’s executive committee and the Joint Council of Pediatric Hospital Medicine designated for hospitalists in community hospitals, and a community hospital track has been in place at the annual PHM meeting since 2013.5 Learners aspiring to be hospital-based pediatric generalists with expanded roles would do well to look into opportunities in community hospitals.
The author gratefully acknowledges the review, suggestions, and support of Jeff Brown, MD, Jack Percelay, MD, Rachel Marek, MD, and Michael Burke, MD.
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICTS OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
- Pediatric Hospital Medicine
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- 7.↵American Hospital Association. AHA Hospital Statistics. Chicago, IL: Health Forum LLC; 2014.
- Copyright © 2015 by the American Academy of Pediatrics