Abstract
OBJECTIVES: Pediatric hospitalists report the need for additional training in clinical and nonclinical domains. Pediatric hospital medicine (PHM) fellowships seek to provide this training and produce leaders in the field. Our objective is to describe current roles and perceived training needs of PHM fellowship graduates.
METHODS: In 2014, all PHM fellowship graduates were asked to complete a Web-based survey. Survey questions addressed demographics, past training, current roles, and training needs in clinical care, research, education, and administration. Associations between fellowship experiences and outcomes were examined.
RESULTS: Fifty-one of 61 eligible individuals completed the survey. Average duration as a pediatric hospitalist was 5 years. Ninety percent completed pediatric categorical residency, whereas 10% completed an Internal Medicine-Pediatrics Residency. Most respondents completed a 1- (38%) or 2-year (46%) fellowship program. Ninety-six percent of respondents currently work in academic environments. The perceived need for additional clinical training was low, except procedures (44%). Nearly all teach medical students and pediatric residents, reporting adequate training in variety of teaching strategies. The majority of respondents conduct research, most commonly quality improvement (QI; 67%) and education (52%). Two-thirds are first authors on at least 1 peer-reviewed article. Research training needs include QI methodology (44%), biostatistics (43%), and obtaining funding (54%). A considerable number of respondents have academic leadership positions.
CONCLUSIONS: PHM fellowship graduates are academic hospitalists with diverse responsibilities. Despite a short average career span, many have achieved leadership roles and been academically productive. Future curriculum development should focus on procedures, QI, and research training.
The first dedicated pediatric hospital medicine (PHM) fellowships were developed over 10 years ago to address training needs of pediatric hospitalists and produce leaders in the field.1 Perceived training needs of practicing hospitalists were documented in 2 national surveys conducted by Pediatric Research in the Inpatient Setting in 2003 and 2007.2,3 In 2010, Pediatric Hospital Medicine Core Competencies were published to define the knowledge, skills, attitudes, and focus on system improvements expected of all practicing pediatric hospitalists.4 Fifty-four topics in the clinical, procedural, and systems domains are included. The PHM Core Competencies provide the framework for PHM Fellowship curriculum standards.5
Previous studies reveal PHM fellowship graduates have fewer perceived training needs when compared with early-career hospitalists who did not pursue fellowship training.6,7 However, fellowship graduates identified persistent training needs. The primary objective of this study is to describe current clinical, academic, and administrative roles of PHM fellowship graduates. The secondary objectives are to explore associations between fellowship duration, training experiences, and identify perceived training needs of PHM fellowship graduates to guide future fellowship curriculum development.
Methods
PHM fellowship graduates who completed training before 2014 were invited to participate. Graduates were identified by current PHM fellowship program directors.
A Web-based electronic survey was developed, focusing on demographics, training background, current roles, and perceived training needs in domains of clinical care, research, education, and administration. Survey questions were modeled after questions used in the Pediatric Research in the Inpatient Setting Network 2007 Pediatric Hospitalist Triennial Survey and a 2009 survey of PHM fellowship graduates.3,6,8 Questions were modified to target current participants and additional questions on training background were added. The authors achieved consensus regarding survey questions through an iterative process involving discussion about each question, resulting in a final survey tool that included 45 questions of different types.
A survey link was sent via e-mail to eligible participants. Follow-up e-mails and telephone calls were made to maximize response rate. Survey data were collected from December 2013 to April 2014. SPSS software (IBM SPSS Statistics, IBM Corporation) was used for statistical analyses. χ2 tests examined associations between fellowship experiences and outcomes. Fisher’s exact tests were used when expected cell counts were less than 5. A priori significance level was α = 0.05.
Results
Fifty-one of 61 identified fellowship graduates completed the survey (response rate 84%). See Table 1 for respondent demographics and training background.
Demographics of the Responding PHM Fellowship Graduates
Most respondents completed 1- or 2-year PHM fellowship programs (38% and 46%, respectively). Eight respondents felt their fellowship length was too short. Of these, 6 had completed 1-year fellowship and 2 had completed 2-year fellowship. No respondents indicated that training was too long.
During their PHM fellowship training, a majority participated in specialized clinical rotations (74%), departmental (90%) or institutional (84%) educational sessions, national conference attendance (84%), and committee work (68%). Most completed scholarly projects (90%) and quality improvement (QI)/patient safety projects (66%). Nearly half (48%) received graduate certificates or degrees, and 30% had online training. Most (87%) fellowship graduates felt that their job search after fellowship was easier than their nonfellowship trained hospitalist colleagues.
Current Roles and Responsibilities of Fellowship Graduates
Respondents have worked an average of 5 years as a hospitalist, including time spent in fellowship training. Many (72%) work in free-standing children’s hospitals. Figure 1 displays the current clinical responsibilities of study participants.
Current clinical responsibilities of PHM fellowship graduates. PICC, peripherally inserted central catheter.
Most respondents (96%) work in academic environments (sites where trainees provide a significant portion of direct patient care). Most supervise pediatric residents and medical students (96% and 98%, respectively). Common teaching methods include bedside work rounds (98%), small group didactic sessions (83%), large group didactic sessions (60%), and bedside teaching sessions (79%).
Study participants occupy a variety of administrative and leadership positions. Most respondents (77%) serve on hospital committees, 35% have formal QI/safety roles, and 29% develop clinical practice guidelines. Many hold institutional leadership positions: 2 Division Chiefs, 6 Hospitalist Service Directors, 9 Hospitalist Program Directors, 2 Residency Program Directors, and 4 Medical Student Course Directors. Additionally, 6 respondents hold formal leadership roles in national organizations (American Academy of Pediatrics, Academic Pediatric Association, and Society of Hospital Medicine). Duration of fellowship training was positively correlated with formal QI/safety positions, with significant increase in the number of these positions in respondents who had completed 2+ years of fellowship (two 1-year fellowship graduates versus fifteen 2-year fellowships graduates, P = .011). This relationship was not statistically significant for other areas of leadership.
Most respondents conduct QI research (67%) or educational research (52%). Other research activities include health services research (33%), clinical trials (25%), and patient safety research (23%). Only 6% conduct basic science research. Twenty-six percent are the primary investigator on an externally funded study. A majority of PHM fellowship graduates (62%) are the first author on at least 1 peer-reviewed article.
Perceived Training Needs After Completion of PHM Fellowship Training
Perceived training needs of responding PHM fellowship graduates in the domains of clinical care, administration, education, and research are displayed in Table 2. In the majority of areas evaluated, less than one-third of respondents had perceived training needs. Areas of high perceived needs included procedures, hospital program management, QI methodology, and curriculum development. Duration of fellowship training did not significantly alter these areas of high perceived needs. There were several perceived training needs in the research domain, but those who completed 2+ years of fellowships were less likely to report these needs.
Perceived Training Needs of PHM Fellowship Graduates
Between 20% and 30% of respondents desired additional procedural training in intubation, moderate sedation, deep sedation, central line placement, and peripherally inserted central catheter placement. There was no statistical correlation between respondent’s perceived need for procedural training and whether the respondent actually performed that procedure as part of their current job.
Similarly, for the topics of QI, development of clinical practice guidelines and educational curricula, there was no statistical correlation between the perceived need for additional training in these areas to current roles (P = .654, .352, .894). Graduates who are active in research were significantly less likely to feel additional training was needed in manuscript writing (P = .046) and research presentations (P = .031). Other training needs did not significantly change with graduate’s current research activities. There was also no significant change in perceived training needs in comparing those who completed graduate course work and those who did not.
Discussion/Conclusions
PHM fellowship graduates in this study have diverse professional responsibilities, are academically productive, and hold local and national leadership roles. As a group, PHM fellowship graduates report relatively few persistent training needs with residual needs reflecting advanced topics in their relative academic domains.
Pediatric hospitalists are becoming leaders in QI, patient safety, education, and research.9 More pediatric residents are reporting hospital medicine as a career path,10 and there is growing realization that residency alone may not provide all the skills needed to practice PHM.7,11,12 Our study supports other findings that early career hospitalists with PHM fellowship training, when compared with those without PHM fellowship training, have greater perceived competency in a representative sample of items from the PHM Core Competencies.7 Many PHM fellowship graduates report training needs in hospital program management, practice guideline design, and development of educational curricula. Fellowship programs should expand training in these clinical and administrative areas, particularly as the field of PHM matures.13–15
In research, the need for training in more advanced research topics did not differ by duration of training. Considering graduates of ≥2-year programs may have received more comprehensive research training, this may highlight the study limitation that these are only perceived training needs. Additionally, many PHM graduates may have chosen the fellowship duration based on personal career goals. Those with interest in research-focused careers may have picked ≥2-year fellowships. PHM fellowship directors should consider these perspectives as they enhance program curricula.
Current roles of PHM fellowship graduates mirror graduates from academic general pediatrics (AGP) and other primary care fellowships with regard to remaining in academia, producing scholarship, and obtaining grants.16,17 Additionally, curriculum gaps in research and administration have been described in other early fellowship programs.18 The number of first-author manuscripts in peer-reviewed journals produced by our PHM graduates exceeds the number produced by a study of both fellowship and nonfellowship trained pediatric hospitalists.19 Practicing pediatric hospitalists indicate desire to do research, but cite lack of time, resources, and mentorship as common barriers.19 Hospitalists without mentors produce fewer presentations and publications.20 Fellowship programs offer structured ways to overcome these barriers and increase research productivity through research training, mentorship, and national networking.12,21,22
Clinician-educators are challenged with balancing trainee education with optimal patient care.23,24 Effective clinical teaching likely requires additional training beyond residency.24 Several studies have documented the positive role of hospitalists as clinician-educators,25 but a previous study of PHM fellowship curricula indicated lack of formal education training.1 Our study revealed PHM fellowship programs are meeting fellows’ needs with specific teaching skills, but enhanced training in curriculum development is needed, especially for fellows pursuing educational leadership or scholarship.
Although the number of graduates with leadership positions in our study was fewer than those held by Academic General Pediatric fellowship graduates, we suspect this is due to difference in the number of years in clinical practice at the time of the studies.16 If our graduates follow the same trajectory as AGP fellowship graduates, we would expect the number of leadership positions held by PHM fellowship graduates to increase.
Fellowship graduates report some uniformity regarding PHM fellowship curricular elements, which correlates with a recent survey of fellowship program directors.13 Interestingly, of the 20% of responding graduates who indicated training was too short, most completed 1-year programs. Given that graduates of longer programs have fewer training needs in research and greater likelihood of formal QI/roles in their current positions, ≥2-year fellowship programs may be more appropriate. In a study of fellowship training for primary care medical school faculty, 1 year of research during fellowship was associated with increased grant proposals, funding, publications, and higher academic rank.26 These are important considerations as program directors solidify fellowship goals in response to certification options.27
This study has several limitations. Although the authors attempted to identify all PHM fellowship graduates before 2014, there is potential for sampling bias. Additionally, there is potential for response bias as we measured self-assessment of training needs rather than objective measure of competency. A future investigation could compare current roles and training outcomes of PHM and non-PHM fellowship graduates.
In this study, PHM fellowship graduates are academic hospitalists with diverse leadership and professional responsibilities. Although many are early in their hospital medicine careers, they are academically productive and hold leadership roles at institutional and national levels. PHM fellowships are meeting the needs of graduates in many areas, but areas for curricular enhancement were identified, including procedural training, practice management, research, and QI. Future studies should target curricular innovation in these areas and development of standard assessment tools related to competency attainment for use across programs.
Footnotes
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
References
- Copyright © 2016 by the American Academy of Pediatrics
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