Insights into HM and PHM Fellowship Programs
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A hospital medicine fellowship combines the best of hospital medicine with the opportunity for physicians to specialize early in their careers.
According to directors of successful programs at the University of California, San Francisco (UCSF), Deaconess Hospital, the Medical College of Wisconsin, and Akron Children’s Hospital, the best fellowship programs benefit the hospital as well as the fellow. These directors shared their ideas on creating and optimizing fellowships, notably in the establishment of pediatric hospital medicine (PHM) programs, which are a relatively new option.
Opportunities for enrichment
“Not every adult hospitalist should do, or needs to do, a hospital medicine fellowship,” said Margaret Fang, MD, director of the adult academic hospital medicine fellowship program at the University of California, San Francisco. “However, depending on what you want to do in your career, a fellowship can be an extremely valuable experience that can give you skills, experiences, and mentorship opportunities that might not otherwise be as easy to acquire.”
While fellowships provide many opportunities, Dr. Fang recommends evaluating the benefits, because fellow salaries are lower than faculty salaries. “Therefore, individuals need to balance the benefits of doing a fellowship program with deferring a full faculty salary,” she said.
Fellowship programs are uniquely structured and may emphasize different aspects of practice, such as medical education, clinical skills, and quality improvement. As an example, the academic hospital medicine fellowship at UCSF is tailored to hospitalists who are interested in careers as clinician-educators or clinician-administrators.
“A successful fellowship program needs to offer training and experiences that would otherwise be difficult to obtain in general clinical practice,” Dr. Fang said. “It is crucial to have strong mentors in the program and to give fellows ample access to diverse projects and opportunities.”
In her experience, successful fellowship programs also have infrastructures dedicated to helping fellows succeed. This might include access to data and statisticians or opportunities to develop specific skills. Dr. Fang encourages program leaders to “make sure that fellows who graduate from your program are well-equipped to start a faculty position.”
Fellowship programs with a single fellow have their place as well, and many of the same challenges and benefits apply. The biggest keys to a successful program are “recruiting, sub-specialist participating in electives, and a good mix of patient types,” said Mathias Kolleck, II, MD, director of the hospitalist fellowship program at Deaconess Hospital in Evansville, Ind.
He advises hospitalists who want to create a fellowship program to start slowly with one fellow. Dr. Kolleck emphasized the need for support from subspecialist preceptors before taking on a fellow. He also noted that existing fellowship programs are ideal sources of guidance for curriculum development, evaluation formats, and program structure.
One issue in managing an adult hospital medicine fellowship program is tailoring educational needs to fellows’ different ability levels. Dr. Kolleck said, “additional focused education [alleviates the issue] most of the time.”
In 2015, the American Board of Pediatrics (ABP) recommended that the American Board of Medical Specialties recognize PHM as a specialty. The ABP allows subspecialists already practicing the discipline to access the exam without having to complete a formal fellowship for a limited time. The final exam year in the practice pathway is 2024.
“Given that the ‘practice pathway’ to PHM board certification is now closed to new residency graduates, fellowship training will be required for those who wish to become board-certified pediatric hospitalists,” said Patrick J. McCarthy, MD, MME, program director of the PHM fellowship program at the Medical College of Wisconsin, Milwaukee. “With the evolving medical complexity, higher acuity, and psychosocial complexity of hospitalized children, PHM fellowships provide an opportunity to allow fellows greater focus on providing high-quality specialty care to the patients we serve.”
Dr. McCarthy said that hospitalists’ roles include participation in research, quality improvement, medical education, advocacy, and leadership, in addition to patient care. “Having time within a two-year fellowship to conduct a scholarly project under faculty mentorship also provides an opportunity to develop expertise in relevant methodologies and a chosen subject,” he said.
Tap into existing resources
If you’re considering establishing a hospitalist fellowship program, specifically a pediatric program, Dr. McCarthy recommends learning and understanding the Accreditation Council for Graduate Medical Education’s (ACGME) program requirements.
He and his colleagues have used content for in-training and certification exams from the ABP to shape their pediatric hospitalist fellowship. “The PHM core competencies also describe the current roles and expectations for pediatric hospitalists that can be used to inform the development of curricula,” Dr. McCarthy said. The PHM program directors’ council also has tools, practical advice, and support for those creating programs.
Dr. McCarthy also recommends using your local graduate medical education office, designated institutional officials, and department leaders to help in developing a successful program and ACGME application. “I personally learned a lot from our vice-chair of education and current program directors of other pediatric subspecialty fellowships,” he said.
Dr. McCarthy advised working with leaders at your institution to make sure your goals align; this will help PHM programs define a niche within the institution. He also suggested taking advantage of existing training programs, clinical divisions outside of hospital medicine, and established resources.
“We also have tried to meet the diverse need of a heterogeneous group of fellowship applicants and have tried to carve out a niche for our program as a ‘med/peds friendly’ program,” said Dr. McCarthy.
For example, PHM fellows can gain experience in the adult setting in techniques such as ultrasound, which they can apply to children. “We have a strong group of med/peds hospitalists who work at Children’s Wisconsin and Froedtert Hospital (Milwaukee), our adult hospital partner, and a unique aspect of our program is the opportunity for med/peds trained fellows to have up to one month of adult hospital medicine ward experience each year,” he said. “This allows trainees to maintain competence in adult medicine skills while focusing on applicability to the care of hospitalized children, including the importance of effective transitions to adult medical care for medically complex patients.”
For Dr. McCarthy, one of the challenges of creating a PHM fellowship program was establishing guidelines for supervision, including faculty development sessions on working with multiple levels of learners and rounding, with appropriate evaluation and feedback methods. “We worked to craft our fellows’ clinical schedules to best align with resident schedules to allow continuity of supervision and patient care while maintaining a high-autonomy environment for all,” he said. Now, two years after launching the program, “it’s exciting to see how our fellows have integrated into the ward’s teams as clinicians and educators,” he said.
The PHM fellowship program at the Medical College of Wisconsin started in July 2020—in the middle of the coronavirus pandemic. “We had to reinvent our planned community-hospital-medicine rotation and curriculum,” Dr. McCarthy said. “Figuring out how to do Zoom meetings, virtual recruitment, and modified clinical experiences was initially a challenge. The resiliency and investment in learning exhibited by our leadership, faculty, and fellows are really the keys to our success in the implementation and delivery of the first two years of our program.”
It takes a village
Fellowship programs are important vehicles to advance the body of knowledge associated with a particular field, but there’s more to a fellowship than keeping up with scientific discovery, according to Jeffrey Solomon, MD, immediate past director of the PHM fellowship at Akron Children’s Hospital, Akron, Ohio.
“Pediatric hospital medicine fellowships are organized to ensure that trainees participate in patient safety and quality improvement initiatives, gain familiarity with family-centered-care principles and transition-of-care models, and learn how to leverage health information technology,” Dr. Solomon said. “Instruction on these and other topics related to health care system delivery will make it easier to enact the changes needed to achieve high-value care for all hospitalized children.”
At Akron Children’s Hospital, successful PHM fellowship programs enjoy support from all corners of the institution, said Dr. Solomon. A successful program needs hospital administrators willing to incur the short-term costs for the long-term return on investment, leaders of other educational programs who work to ensure a comprehensive training experience, and individual division members who commit to educating the next generation of inpatient providers. “It truly does take a village to ‘raise’ a successful hospital medicine fellowship program,” Dr. Solomon said.
Dr. Solomon encourages anyone planning to start a hospitalist fellowship program to reach out to current fellowship directors. “[They’re] some of the most generous people I know when it comes to sharing their time and talent,” he said. He highlighted the value of the PHM fellowship directors’ council in providing advice and support to directors and potential directors at all stages of program development. “When starting a hospital medicine fellowship program, rest assured that there will be hurdles, but know that there is probably a program director who has already faced a similar challenge who is willing to share with you how they were able to overcome that obstacle,” Dr. Solomon said.
Dr. Solomon also credited the resiliency of his team in navigating the ongoing COVID-19 pandemic. “I think the pandemic has forced many educators to develop novel methods by which to ensure that trainees gain exposure to the clinical and educational experiences necessary to develop competency,” he said. “Whether delaying and then restructuring a surgery rotation at a time when the hospital suspended elective procedures or figuring out how to convene an interactive educational conference when no more than four people are permitted to meet in the allotted space, being a program director requires a willingness to try new things if you really want to ensure the best possible experience for your trainees.”
A fellow’s perspective
As a PHM fellow at the Medical College of Wisconsin, Leann Madion, MD, said her fellowship experience has prepared her to “hit the ground running,” when she starts her first job after training. “As the field of pediatric hospital medicine grows, the fellowships provide a unique opportunity to strengthen important knowledge and skills which will ultimately help with career advancement, likely at a faster pace,” she said.
Because the Medical College of Wisconsin has a diverse, experienced group of hospitalists with various interests, Dr. Madion said she’s been involved in research projects with different focuses including clinical, medical education, and quality improvement. “Our program provides dedicated research time for our projects, which makes it feasible to complete them in just two years,” she said. Dr. Madion also credits the program for making her a better medical educator and providing sufficient autonomy, “with the help of my attending coaching me through difficult patient and learner encounters.”
Dr. Madion advises incoming fellows to “have an idea of where you want to focus extra time for research and skill development, such as sedation, POCUS, clinical research, leadership, quality initiative work, or medical education.”
She also encourages them to assess the strengths of each program during the pre-interview and interview process. “It’s cliché, but true it’s a lot about where you think you will fit in based on your instincts and general feeling,” Dr. Madion said.
Heidi Splete is a medical journalist based in the Washington, D.C. area. Her more than 20 years of experience includes live and online news coverage of internal medicine, dermatology, rheumatology, pediatrics, gastroenterology, allergy, oncology, cardiology, obstetrics/gynecology, and primary care.