Family Matters: Pediatric Hospitalists Play a Critical Role in Family Medicine Resident Education

We pediatric hospitalists are increasingly relied upon to teach pediatrics to family medicine (FM) residents. Most FM residency programs use hospitals as their primary site for pediatric training,1 yet only a minority of FM physicians practice in these settings.2 As a result, pediatric hospitalists are often tasked with delivering comprehensive inpatient pediatric education for FM residents. Unfortunately, many face this task with limited time and without formal preparation, structured curricula, or established faculty development frameworks tailored to this interspecialty teaching.3 FM physicians are our essential partners in promoting pediatric health, historically providing 20% of pediatric visits.4 If we want to ensure all children have access to quality health care, it is critical that we give deliberate consideration to the inpatient pediatric training of FM residents.There are a variety of factors that are likely contributing to the increased reliance on pediatric hospitalists for educating FM trainees. First, FM physicians are seeing fewer pediatric patients than ever before,5 making it more difficult to obtain outpatient pediatric training for FM residents. In a 2020 survey, more than one-third of FM program directors (36.7%) reported difficulties meeting Accreditation Council for Graduate Medical Education (ACGME) requirements for outpatient pediatric encounters.1 Shortly after, in 2023, the ACGME loosened the definition of a pediatric encounter from a visit with a patient younger than 10 years to younger than 18 years.6 Although on paper, this change may help programs meet the numerical requirement, it does not actually improve the quality of outpatient pediatric training and may instead simply obscure a shift to fewer encounters with younger children in favor of adolescents. In light of these challenges in outpatient pediatric training, 46.3% of FM programs rely on hospitals as the primary source of their pediatric training, despite 37% of FM training programs having zero core faculty members who care for sick, hospitalized children,1 frequently leaving them to lean on hospitalists. Finally, there are also challenges on the inpatient pediatrics side: the number of pediatric units and beds is decreasing nationwide, especially in rural areas.7 This has led to the consolidation of inpatient pediatric care into larger cities and freestanding children’s hospitals,8 places where pediatricians make up the majority of the clinician educators.With ongoing concerns about the pediatric workforce, especially in rural and underserved areas,9 FM physicians remain a critical ally in safeguarding children’s health. Although the overall number of FM physicians caring for children has declined,5 they continue to be an important source of pediatric care, especially in areas where pediatricians are scarce. FM physicians practicing in rural areas or in regions with pediatrician shortages, or providing care in languages other than English, are more likely than their peers to care for children.10 Children in rural or underserved areas may seek care in acute care settings, such as at the nearest emergency department (ED); family physicians may make up only about 5% of the ED workforce nationwide, but in rural areas, they account for 20% to 30% of ED physicians.11 Children may also be seen at urgent care centers, where family physicians make up the majority of the physicians.12 The value of having access to FM doctors who are skilled and knowledgeable in pediatrics close to home is undeniable and starts with high-quality pediatric education for FM residents.Unfortunately, there are several challenges that are specific to this critical interspecialty teaching. A study of pediatric program directors whose hospitals host FM learners found common gaps, most notably the lack of inpatient pediatric training uniformity, FM-specific curricula, or FM faculty leadership.3 In the following sections, we explore these challenges and offer strategies for optimizing the inpatient training of FM residents, which we summarize in Table 1. Our perspectives are informed by our direct experience supervising FM residents on inpatient pediatric services, leadership roles in developing FM pediatric curricula and faculty development initiatives, scholarly contributions in pediatric and FM education, and national engagement through collaborations and committee work.First, we must acknowledge that pediatric hospitalists are experts in pediatric hospital medicine (PHM) but are unlikely to be experts in FM resident education. We recommend creating a role of Director of PHM-FM Education to lead the important task of overseeing FM inpatient pediatric education. Ideally, this person would be someone who practices inpatient pediatrics but was trained in FM, such as one of our authors; however, most programs likely do not have access to such a person. Instead, most programs have PHM faculty or pediatric residency leadership directing this effort.3 For these programs, we recommend naming a pediatric Director of PHM-FM Education and then identifying an FM education leader (eg, core faculty of a partnering FM residency program) with an interest in pediatrics with whom to partner. For PHM divisions who host multiple FM programs, consider having the Director of PHM-FM Education serve as the point person for all FM programs to foster personal relationships with the FM program leaders. If given appropriate administrative time and resources, we believe this hospitalist Director of PHM-FM Education can acquire expertise in FM education. With these strengthened relationships and knowledge, hospitalists and FM faculty can collaborate on curriculum design, evaluation, and faculty development that would best serve a division and its learners’ unique needs.Per the survey by Halley et al, few programs use a FM-specific curriculum,3 but it is unclear if this is because they lack access to or knowledge of these resources or if they feel these resources are a poor fit for them. There are published curriculum guidelines from organizations such as the Academic Pediatric Association (APA)13 and the American Academy of Family Physicians,14 but these aim to be comprehensive, outlining all pediatric topics ideally covered throughout residency training, and thus are unrealistic to cover in their entirety in an inpatient setting. The APA guidelines directly advise “While not every objective listed may be necessary for successful completion of a residency, these can serve as a basis for curriculum development and resident evaluation.”13 The Society for Teachers of Family Medicine provides a residency curriculum resource that includes lectures on 28 pediatric topics, although this database slants more toward outpatient pediatrics.15 In addition, more focused resources, such as the CRISP (Clinical Reasoning Instruction with Illness Scripts in Pediatrics) curriculum,16 have been developed to address core inpatient pediatric learning needs; this curriculum provides modular content that can be adapted to the FM context and is accessible online. Any of these resources can be a great starting point.The key to using available curricula effectively is adapting them to the priorities of both FM and PHM and to your institution’s specific attributes. One practical approach is to compare your FM partner’s list of the 10 most important learning topics with your division’s top 10 inpatient diagnoses. Topics that appear on both lists should be prioritized. Topics with discordant ratings may require a little more creativity to address. For example, the care of technology-dependent children may not be high on a FM educator’s list, but your division may care for many of these children. Teaching about constipation, calculating maintenance fluids, and reflux management (topics likely to be higher on an FM educator’s list) can enable an FM resident to better understand, contextualize, and care for a child with a gastrostomy tube presenting with feeding intolerance.Your curriculum is likely to include multimodal teaching and be subject to variables as unpredictable as swings in patient census or changes in ACGME requirements. Creating an effective curriculum is likely to be iterative process, but one that will be made easier and more effective with close collaboration with FM educators.A final challenge of teaching FM residents is the sheer variability. FM residents may vary in their prior pediatric experiences, their future plans, and their years of FM training. FM programs may vary in the duration of their inpatient pediatric rotation (or rotations), their pediatric exposure in their home institutions, and their areas of emphasis (eg, rural medicine). And finally, we as hospitalists vary in our knowledge and opinions of what FM residents should be taught and how they should be evaluated. Standardizing your division’s approach to each learner can help optimize any FM resident’s experience. Strategies can include substantial changes like creating services and/or shifts that prioritize exposure to those agreed-upon important topics or allocating time for a dedicated FM lecture series. Smaller steps can be having your Director of FM-PHM Education conduct faculty development, collecting and disseminating prepared lectures and resources, and using competency-based evaluations to ensure FM residents are not being compared directly with pediatric residents.None of these strategies are simple, and they all require time and effort, but we must prioritize forming partnerships with FM educators, using FM-specific curricula, and standardizing the FM resident experience to ensure that FM residents leave their inpatient pediatric experiences more confident and capable. As pediatric hospitalists, we are uniquely positioned to contribute to the education of our future partners in pediatric care and to make sure each child can access the comprehensive health care they need and deserve.