Adaptability is a core attribute for the successful Pediatric Hospitalist (PH). Perhaps it is because our specialty is so young that accepting and leading change seems to be woven into the PH’s DNA. Adaptability has served us well as our specialty has and continues to evolve to meet the changes in healthcare delivery models while striving to improve the care delivered to hospitalized children.

In 1996 Dr. Robert Wachter defined a hospitalist as a physician dedicated to the delivery of comprehensive medical care to hospitalized patients, while engaging in clinical care, teaching, research, or leadership in the field of General Hospital Medicine. In addition, hospitalists work to enhance the performance of hospitals and healthcare systems.¹ This definition for the hospitalist caring for adult patients also fits the pediatric hospitalist (PH), but in addition to providing expert care for infants and children, the PH must be proficient in providing family-centered patient care.²

Clinical expertise therefore, is another core attribute for PH. Pediatric Hospitalist Medicine (PHM) initially evolved to address the patient care needs of the hospitalized child. The PHM model of care diverged from the traditional model where pediatricians rounded on the ward and in the nursery at the beginning and end of the day, while spending the bulk of time caring for patients in the office setting. The traditional model worked because individual pediatricians generally had few inpatients with low acuity and relied on pediatric residents and subspecialists for hands-on management during office hours.³ Since the mid-1990’s care of the hospitalized child has become increasingly complex, both in terms of the nature of the underlying disease process, the complexity of the patient with respect to multisystem chronic illness and survival based on medical technology.⁴ Increasingly, only the sickest of patients are hospitalized.⁵ The increased acuity and complexity of inpatient pediatrics coupled with external pressures focusing on patient safety and hospital utilization made the traditional model untenable for the majority of primary care pediatricians.

What sets the PH apart from the primary care pediatrician however, is her/his focus on systems-based practice within the hospital setting. Essentially, everything that a PH does must be in the context of the impact on the healthcare system as well as that of the patient.⁶ Dr. Wachter stated during a recent American Public Media interview “…the doctor of the future has two sick patients. One is the patient they are taking care of. One is the system they are working in,”.⁷ This is especially true for PHs who are frequently the linchpin in effective patient management within the complex and expensive inpatient setting. In essence Wachter is saying that one of the keys to curing our healthcare system is preparing Hospitalists for effective careers.

In this chapter we describe current career opportunities for pediatric hospitalists in a variety of settings. These include the tertiary care academic university/children’s hospital, the community hospital academically affiliated with a university program, and the non-affiliated community hospital with a smaller pediatric unit. We also describe possible career building experiences to achieve success in the various career roles for hospitalists in both community and academic settings. Finally, we look at building careers not only from the standpoint of the trainee or new hospitalist, but from the standpoint of the division chief who wants to develop the careers of the faculty within his or her division.

TEACHING HOSPITAL

Clinical

Pediatric hospitalists fill a number of clinical roles in academic hospitals, and their careers can potentially focus on some or all of these roles. The clinical role of the PH is analogous to that of the utility infielder on a baseball team.⁸ The breadth of practice can range from caring for straightforward to medically complex patients,⁹ alone or as consultants or co-managers with surgical subspecialists.¹⁰ Advances in pediatric medicine over the last generation have resulted in a population of medically complex patients, frequently with intellectual disabilities, who are growing into adulthood as disease processes that were once fatal have become treatable. The emerging field of complex care focuses on the holistic medical care of children with complex diseases.¹¹ Many complex patients experience frequent hospitalizations as a result of exacerbations of chronic illness or technology malfunction.¹² Their care requires general pediatric skills, expertise in coordination of care, and expertise in communication with patients’ families and other medical and nonmedical providers.¹³ PH are pivotal to providing the coordinated care needed care for these costly patients within accountable care organizations.¹⁴

PH are evolving models where they consult during pre-surgical outpatient visits to develop a plan of care that they later implement in the postoperative period.¹⁵ They are also critical to the smooth transition of the patient from the acute inpatient setting to home. Hospitalists increasingly staff follow-up clinics or transitional/rehabilitation facilities that serve to continue to provide care and coordinate the transition of responsibility back to the family and primary care provider and medical home.¹⁶

At the polar opposite of medically complex patients, PHs provide care for sick children increasingly classified as “observation patients”; previously healthy with an acute single-organ system disease process, such as asthma, necessitating brief hospital stays and rapid handoffs from the Emergency Department back to the Primary Medical Doctor (PMD).¹⁷ The PH must work with insurance payers and hospital utilization management departments to develop and continually refine evidence-based best processes to efficiently manage these patients at low cost in an inherently complex hospital environment.

For both acute and complex patients, PHs often assume the role of proceduralists,¹⁸ performing conscious sedation, placing percutaneous catheters, etc.¹⁹ Some PHs also function as subspecialty PHs, extending the capability of subspecialists as an embedded member of the subspecialty inpatient team.²⁰ Most subspecialty PHs obtain on-the-job training from subspecialists to be able to manage common problems that occur in that patient population. The PH remains present on inpatient units supervising residents or ancillary staff and troubleshooting patient problems, while the subspecialist may be working in the outpatient clinic or doing procedures.

Education

In a typical Academic Children’s Hospital, the PH serves as the supervisor and team leader for pediatric residents medical students, and in some cases PH fellows. In this role they are responsible not only for day-to-day patient care decisions, but also for the education of trainees at a variety of levels.²¹ Numerous educational career opportunities exist for PHs.

The role of the PH in medical education has increased dramatically over the past two decades. In a 1998 survey of academic pediatric department chairs in Canada and the United States, Srivastava et al. determined that 77% of respondents either had or were planning to institute pediatric hospitalists within their institutions.²² In those institutions with hospitals, two-thirds of hospitals were involved in teaching. By early 2008 approximately 75% of pediatric residents, program directors, and clerkship directors reported using PHs as teaching attendings.¹⁹

In a survey of a national sample of PHs, 94% of respondents reported teaching medical students and pediatric and housestaff, while 45% of respondents reported holding a leadership position in education.²³ PH respondents to the 2007 PRIS (Pediatric Research in Inpatient Settings) network survey also reported intense involvement in medical education. Although most respondents reported teaching pediatric residents and medical students, up to 40% indicated that they were teaching other trainees, faculty members and community pediatricians.²⁴

Hospitalists have been recognized by trainees as making exemplary teachers because of their enthusiasm, evidence-based practice, and ability to role-model core competencies such as interpersonal skills and professionalism through their daily interactions with parents/patients during family-centered rounds and interdisciplinary teams.²⁵ These daily activities provide opportunities to also assess these skills in trainees, which is essential to collect data for the Milestones project.²⁶

To be maximally effective in teaching activities, hospitalists must seek opportunities to further refine their teaching skills. Many residency programs now have RATS programs (Residents as Teachers)²⁷ so that graduates pursuing hospitalist careers have an understanding of how to apply adult learning principles in their teaching strategies, and are effective at orienting and providing feedback to learners. Hospitalists can learn teaching skills by attending workshops at regional and national conferences, such as the Pediatric Hospitalist Medicine Conference, the Society for Hospital Medicine annual conference, the Pediatric Academic Society Annual Meeting and the Pediatric Educational Excellence Across the Continuum (PEEAC) Conference.²⁸ For more advanced study, there are several structured programs available through national organizations, such as the Academic Pediatric Association’s Educational Scholar Program (ESP),²⁹ through institutions such as the Harvard Macy Foundation³⁰ and formal university-based Masters in Education certificate or degree programs (see Table 15-1).

To continually refine their teaching skills, hospitalists should reflect on feedback from their learners. They should encourage learners to provide qualitative feedback in addition to the standard numeric ratings.³¹ A safe learning climate is essential for this. In addition, peer feedback is invaluable to improving teaching techniques. Peer coaching serves several purposes in addition to providing feedback to the hospitalist being observed.³² By observing the practices of others, division members develop more uniformity in teaching and expectations for learners. Peer assessment makes teaching a more scholarly activity and raises its importance within the division and institution.

Hospitalists are evolving the educational model in the inpatient setting. Traditional inpatient teaching has been carried out in teacher-led small groups using case-based didactics, where the attending described the epidemiology, clinical presentation, diagnostic testing, and management of a specific disease or syndrome. As PHs with advanced educational training assume leadership roles, they are incorporating best practices in adult learning theory to meet challenges posed by duty hour changes and make the most of opportunities afforded by technology. For example, PHs have developed and implemented a nighttime curriculum to enhance resident learning during the night shift.³³ PHs lead simulation activities designed to provide deliberate practice in procedural skills and teamwork.³⁴ Computer-based learning management systems provide PHs with a repository for e-learning modules—multimedia files and readings that can be delivered in a programmed sequence to learners so that they access and learn background information at their own pace and schedule.³⁵ This “flipped classroom” approach allows small group teaching sessions to be learner-centered interactive discussions on how to apply background information to patients on the clinical service.³⁶

Family-centered bedside rounds are an ideal setting for teaching and assessing communication, physical exam, diagnostic reasoning, and team leadership skills.³⁷ Hospitalists are uniquely positioned to teach clinical reasoning skills, to emphasize the importance of good physical exam skills and judicious use of diagnostic testing. This is critical for reducing unnecessary healthcare costs and to avoid diagnostic errors.³⁸

PHs are in a unique position to advocate for optimal resident case experience and graduated autonomy, based upon entrustment decisions they can make through close working relationships with residents.³⁹ PH educators can best position themselves to succeed in local leadership opportunities as the clerkship, residency, fellowship, or continuing medical education (CME) director by attending academic leadership conferences such as those sponsored by the Academic Pediatric Association or Society for Hospital Medicine. To advance academically as clinician-educators, PHs must produce scholarship that will advance the field. Scholarship in pediatric hospital medicine (PHM) need not be limited to published articles; it can include educational resources such as curricula and assessment tools that have been evaluated and posted on peer-reviewed repositories, such as Med Ed Portal.⁴⁰

Research

PH research has been rapidly advancing as the field as a whole has matured, and an increasing number of pediatric hospitalists are engaging in research as either the primary focus or as part of their professional careers. Initial hospitalist research focused on defining and characterizing the field. Much of the work was done through surveys of key stakeholders.⁴¹ The effectiveness and efficiency of hospitalist systems was also studied in initial hospitalist research.^42,43