PEDIATRICS Vol. 120 No. 1 July 2007, pp. 33-39 (doi:10.1542/peds.2007-0304)
ARTICLE |
Characteristics of the Pediatric Hospitalist Workforce: Its Roles and Work Environment
a Child Health Evaluation and Research Unit
b Division of General Pediatrics, University of Michigan, Ann Arbor, Michigan
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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OBJECTIVE. Over the past 10 years, the use of hospitalists has grown in both the adult and pediatric setting as a response to pressure to deliver cost-effective, high-quality care. However, there is a paucity of information regarding the variation in the clinical roles, educational responsibilities, work patterns, and employment characteristics of pediatric hospitalists. This lack of information hampers efforts to define the nature of the field and determine whether any formalized, additional training or experience should be required for physicians in this clinical practice domain.
DESIGN. We conducted a telephone survey of a national sample of pediatric hospitalist program directors (n = 116). Questionnaire items focused on exploring the clinical roles, work patterns, employment characteristics, and training of pediatric hospitalists within each institution. Results were stratified by teaching hospitals, urban/rural location, hospital size, and membership in the National Association of Children's Hospitals and Related Institutions.
RESULTS. The response rate was 97%. The majority of hospitals surveyed (70%) reported that hospitalists do not generate enough income from professional billing to pay their salaries. Fewer than half (39%) of respondents reported that their hospital measures pediatric clinical outcomes associated with hospitalist care. A total of 42% of hospitalist program directors reported that most of their hospitalists had an average duration of employment of <3 years. In programs with residents, hospitalists serve as teaching attendings for pediatric patients in almost all cases (89%).
CONCLUSIONS. Hospital medicine is a rapidly growing enterprise. A better understanding of both its participants, as well as those affected by its practice, will enable planning for a future that meets as many needs as possible while ensuring the best possible care for children.
Key Words: pediatric workforce • hospitalists • quality of care • clinical education/teaching
Abbreviations: COTH—Council of Teaching Hospitals • NACHRI—National Association of Children's Hospitals and Related Institutions • PCP—primary care physician
The Society of Hospital Medicine defines a hospitalist as a physician whose primary focus is the general medical care of hospitalized patients and whose responsibilities also include teaching, research, and leadership related to hospital care.1 Over the past 10 years, the use of hospitalists has grown in both the adult and pediatric setting as a response to pressure to deliver cost-effective, high-quality care.2 Whether the training and experience of the physicians placed in such roles is commensurate with those expectations remains unknown.
In 2002, there were 
600 pediatric hospitalists,3 with many more believed to be active today. However, there is a paucity of information regarding the variation in the clinical roles, educational responsibilities, work patterns, and employment characteristics of pediatric hospitalists.4 This lack of information hampers efforts to define the nature of the field and to determine whether any formalized, additional training or experience should be required for physicians in this clinical practice domain.
We conducted this national study of hospitalist program directors to better understand the current nature of the field and the degree of variation present among hospitalists and the programs in which they are employed.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Study Sample
From the American Hospital Association's 2005 annual survey of hospitals, the research team identified 761 hospitals that reported having both a hospitalist service and pediatric beds. From these 761 hospitals, the research team sought a sample of 200, stratified by the following variables:
- Council of Teaching Hospitals (COTH) designation (teaching versus nonteaching);
- National Association of Children's Hospitals and Related Institutions (NACHRI) designation (children's hospital versus non–children's hospital);
- freestanding (freestanding versus part of hospital system);
- metropolitan statistical area size (urban versus rural); and
- hospital size (small [<250 total beds] versus large [
250 total beds]).
The final sample was 213. We selected an additional 13 hospitals to ensure appropriate sampling across stratification variables.
Hospitals were sampled with varying probabilities from each stratum. Weights were applied to create a representative sample of the overall hospital population. The total sampling weight (TSW) calculated for each hospital was based on the probability of selection into the study (P) and the response rate (RR). We used the formula TSW = (1/P) x (1/RR).
Survey Instrument
We constructed a 42-item structured questionnaire to be administered by telephone. The instrument was designed to be completed in 15 minutes or less. Questionnaire items explored the clinical roles, work patterns, employment characteristics, and training of pediatric hospitalists within each institution.
Questionnaire Administration
From June through September 2006, members of the research team telephoned the sampled hospitals to determine whether the hospital had pediatric hospitalists, and if so, to identify the physician responsible for each program. Most individuals were either chiefs or chairs of pediatric departments, or the head or most senior pediatric hospitalist at the institution. A study introduction letter was sent to those individuals. Research staff then contacted potential respondents, explained the purpose of the study, and obtained verbal consent to begin the survey.
Data Analysis
Initially, unweighted frequency distributions were calculated for all survey items as descriptive statistics. Next, weighted 
2 statistics were used to determine levels of association between the survey responses and the various hospital classifications listed above. For the comparisons between classifications of hospitals, only weighted percentages are provided. The study was approved by the University of Michigan Medical institutional review board.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Response Rate
Eligible respondents had to have
1 pediatric hospitalist, defined as a physician who is not running a subspecialty service and whose primary professional focus is the general medical care of hospitalized children. Ninety-seven hospitals were not eligible because they reported having no pediatric hospitalist, despite having been identified in the American Heart Association database as having both a hospitalist service and pediatric beds. These hospitals only had hospitalists that cared for adult patients. Of the remaining eligible hospitals (n = 116), 112 completed the telephone survey, representing an overall response rate of 97%. Characteristics of participating and noneligible hospitals from our original sample are found in Table 1.
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Hospital Demographics
Among the 112 hospitals with completed telephone surveys, 48% (n = 54) were designated as teaching hospitals (COTH) and 61% (n = 68) were designated as children's hospitals (NACHRI). Note there can be overlap between these 2 groupings; that is, a teaching hospital can also be a children's hospital (Table 1). Hospitals with pediatric hospitalist programs are more likely to be COTH, NACHRI-affiliated, and large.
Program Characteristics
The use of pediatric hospitalists at most hospitals is a recent trend; a majority (55%) have been using pediatric hospitalists for 
5 years. (Table 2).
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Fewer than half (44%; n = 49) of those surveyed reported that their hospital had a formal definition of a hospitalist. Of these 49 hospitals, the most common definitions given were consistent with the Society of Hospital Medicine1 (39%; n = 18), followed by a more restrictive definition of only providing inpatient care (37%; n = 17); 9% (n = 4) defined a hospitalist as a physician that spends
25% of their clinical time providing hospital-based care, whereas the remaining 15% (n = 7) did not know their hospital's definition. The majority of hospitals surveyed had small pediatric hospitalist programs; 59% (n = 66) had 1 to 5 physicians serving this role (Table 3); 49% plan to increase the number of full-time employees of pediatric hospitalists in the next year.
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The proportion of pediatric inpatients cared for by hospitalists varies widely across institutions. Only 4% (n = 5) of hospitals report that hospitalists care for 100% of their pediatric inpatient population, whereas 37% (n = 41) report hospitalists care for less than one quarter of their pediatric inpatients. There were no significant differences across hospital types.
The majority of pediatric hospitalists are employed full-time; 63% (n = 70) of programs report that at least three quarters of their pediatric hospitalists are employed full-time as hospitalists in clinical care. Only 16% of programs had no full-time hospitalists. There were no differences across hospital types.
In the majority (64%; n = 72) of programs, full-time hospitalists work >40 hours per week at the hospital on-site when on service, and in 34% (n = 38) they take call from home 1 to 2 nights per week. Nearly half (36%; n = 40) of hospitals report their hospitalists spend 26 weeks on service each year.
Clinical Roles
Nearly all respondents (96%; n = 107) reported that hospitalists provide service in the general pediatric inpatient unit during the day. Another common service covered by pediatric hospitalists was inpatient general medical consultation (88%; n = 98). Fewer hospitals reported pediatric hospitalist coverage in each of the following clinical settings: subspecialty pediatric inpatient service (38%; n = 43); normal newborn nursery (38%; n = 43); emergency department (37%; n = 41); outpatient or outreach clinics (20%; n = 22); PICU (18%; n = 20); NICU (11%; n = 12); and transports (8%; n = 9).
Regarding procedures performed or supervised by pediatric hospitalists, lumbar punctures (96%; n = 107) and sedation services (62%; n = 69) were common, whereas infusion services (26%; n = 29), percutaneous intravenous catheter line placement (26%; n = 29), and circumcision (16%; n = 18) were performed less commonly.
The number of medical and surgical beds covered was distributed fairly evenly; approximately one third of hospitals reported that hospitalists covered <15 beds (30%; n = 34), one third reported that 15 to 30 beds were covered (34%; n = 38), and 31% (n = 35), reported coverage of >30 beds. Only 48% (n = 54) of hospitals report coverage of any newborn beds by pediatric hospitalists; 21% (n = 23) report that hospitalists cover <5 newborn beds, 18% (n = 20) report coverage of 5 to 20 newborn beds, whereas just 10% (n = 11) cover >20 newborn beds.
In 80% (n = 90) of hospitals, hospitalists serve as the attending of record for all patients for whom they provide care. When asked about backup for pediatric hospitalists, respondents reported the subspecialist attending (46%; n = 52) and critical care attending (45%; n = 50) more often than either the emergency department (25%; n = 28) or the patient's private physician (15%; n = 17). Non-COTH hospitals were more likely than COTH to have the emergency department provide back up (57% vs 6%; P = .0001).
A major role served by pediatric hospitalists is to communicate with primary care or referring physicians (PCPs). Nearly all hospitals (87%; n = 97) indicated that there is a defined or expected pattern for this communication. Common communication patterns stated by hospitals include: contact of PCP on admission (61%; n = 68); updating the PCP of progress during the patient's course of stay (54%; n = 60); providing a discharge summary (71%; n = 80); and contacting the PCP on discharge (43%; n = 48).
Teaching Roles
The majority (73%; n = 82) of surveyed hospitals reported having 1 residency training program; 60% (n = 67) had pediatric residency programs (Table 4), whereas 45% (n = 50) and 41% (n = 46) reported training programs in internal medicine and family practice, respectively.
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In programs with residents (n = 82), hospitalists serve as teaching attendings for pediatric patients in almost all cases (89%). Only 18% (n = 15) of these respondents reported that their hospital had separate teaching and nonteaching hospitalist services for pediatric patients. Most hospitalist program directors (89%; n = 73) believe that hospitalists are more effective teachers than rotating subspecialist attendings.
Employment Characteristics and Arrangements
Over half of hospitals (52%; n = 58) reported no turnover in their hospitalists over the past 2 years. Pediatric hospitalist programs in existence for <2 years (n = 28) were excluded from the remainder of analyses on employment duration. When asked about the average duration of employment for a hospitalist at their institution, 46% of respondents stated that most were employed for <3 years; 29% indicated the average length of employment was 3 to 5 years, and 25% stated their hospitalists averaged >5 years on the job.
Most programs (59%; n = 66) reported that their hospitalists were employed by the hospital itself. Other employers of hospitalists included a university or medical school (25%; n = 28), general or specialty physician group (21%; n = 23), hospitalist-only group (8%; n = 9), or other (8%; n = 9).
With regard to compensation, most (72%; n = 81) reported that their hospitalists are 100% salaried. There were no significant differences across hospital types. Only 22% (n = 25) of respondents indicated that hospitalist compensation is at least partially dependent on other measures or incentives, such as patient satisfaction, quality assurance, controlling costs, or reducing length of stay.
For the 26% (n = 29) of hospitals that indicated there was a productivity component to their hospitalists' compensation, common productivity requirements or standards included billings (n = 15) and relative value unit (n = 11).
The majority of hospitals surveyed reported that hospitalists do not generate enough income from professional billing to pay their salaries. In 70% (n = 78) of cases, respondents indicated that supplemental funding was required. Sources of funding include the hospital (n = 49), medical school, or department of pediatrics (n = 13). Significant differences in funding sources were demonstrated for both teaching and children's hospitals (Table 5).
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Training
The majority of the pediatric hospitalists are pediatric-trained physicians; 73% (n = 82) report that 100% of their hospitalists providing care to children are pediatricians. Some respondents reported medicine-pediatric trained physicians (15%; n = 17), internists (2%; n = 2), critical care (7%; n = 8), and emergency physicians (2%; n = 2) serving as pediatric hospitalists, but none reported family physicians in this role.
Requirements for Hospitalists Who Care for Pediatric Patients
Most programs (82%; n = 92) state they require board certification in pediatrics, and 46% (n = 51) require pediatric advanced life support certification. In addition, most hospitals (76%; n = 85) do not require any period of mandatory supervision before a hospitalist can work independently. Of the 21 hospitals that do require a supervision period, 13 require 1 month. In most cases (n = 13), a senior hospitalist provides the supervision. Nearly all hospitals (95%; n = 106) do not require hospitalists to complete continuing medical education or training specifically related to hospital medicine.
Outcomes Associated With Hospitalists
Fewer than half (39%; n = 44) of respondents reported that their hospital measures pediatric clinical outcomes associated with hospitalist care. Of these 44 hospitals, the most common outcomes measured include length of stay (n = 39), readmission rates (n = 35), condition-specific process measures (n = 29), quality of care measures (n = 25), mortality (n = 24), timing of discharge (n = 21), and quality of transfers (n = 10). Clinical outcomes are measured significantly more often in non-COTH (compared with COTH) and non-NACHRI (compared with NACHRI) hospitals (Table 6).
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Self-Perceived Impact of Hospitalists
The vast majority (88%; n = 98) of respondents believe that use of a hospitalist service reduces hospital costs, whereas even more (92%; n = 103) believe that use of a hospitalist service increases patient satisfaction; 99% (n = 111) believe that use of a hospitalist service increases quality of care for inpatients. Finally, 94% (n = 105) do not agree with the statement that use of a hospitalist service adversely affects the primary care physician–patient relationship.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Our study provides the most comprehensive data to date on the emerging group of pediatric hospitalists. There was significant effort on both the part of hospitalist program directors and their professional associations to provide organizational structures for this group of clinicians. However, our finding that 46% of hospitalist program directors reported that most of their hospitalists had an average duration of employment of <3 years indicates there is a significant amount of turnover in this professional activity. The implications of this finding regarding the stability, and further definition of this specific group of clinicians are unclear but suggest this is a heterogeneous group of clinicians. Thus, hospitalist leaders should take note that there may be several subsets of individuals who are engaged in this line of work, including those who intend a long-term career in hospital care and those who do not.
Although there have been several studies suggesting that hospitalists may have a significant impact on clinical and financial outcomes, few hospitals actually have systems in place to measure such variables. Surprisingly, we found that only 39% measure any clinical outcomes associated with hospitalist care and only a subset of those measure length of stay or readmission rates. Until greater attention is focused on such issues, any actual benefit of hospitalists in these areas will remain theoretical and unproven.
The finding that 97 hospitals in our sampling frame had hospitalists caring for adults but not for children implies hospitals are using this model of care more frequently for their adult patients. Whether this trend will continue is unknown.
Likely because of their greater numbers, there is more research among internal medicine hospitalist programs. However, although there are several studies of hospitalist program outcomes in the internal medicine literature, almost all are single-site assessments and thus are likely subject to the nuances of local issues.2,5–10 Most such studies demonstrate a benefit from hospitalists with regard to lower costs and length of stay, but some fail to show any significant differences with previous inpatient systems. There are fewer published studies regarding the clinical impact of pediatric hospitalists, but they also are single site assessments and report mixed results.11–13
Some have questioned whether a specific set of skills are required to practice pediatric hospital medicine. It is noteworthy that the hospitals providing employment to this group currently have relatively minimal standards for certification and training of hospitalists. For example, only 55% of hospitals require pediatric hospitalists to have completed residency training in pediatrics and only 46% require them to be certified in pediatric advanced life support. In addition, only 5% require any continuing medical education or training related specifically to hospital medicine. Thus, it is not surprising that a recent study found that fewer than 30% of pediatric academic department chairs believed that hospitalists require training not currently provided in residency.14
It is unclear as to whether hospitalists are being hired by hospitals as part of a strategic decision to address quality, educational, and other issues, or whether they are employed to predominantly fill a need in clinical care. Our finding that >70% of hospitalist programs require supplemental funding to meet salary costs indicates institutions are actively investing in these programs. This could be because the cost savings attributed to hospitalist services would not translate into a greater volume of billing, but rather savings to their employing institutions in capitated or other incentive-based contracting arrangements. The payor mix of hospitalists in some institutions may also play a role in their ability to generate their salary costs. Some teaching hospitals may also be realizing a greater clinical service need after implementation of the 80-hour workweek for residents.
Our data clearly indicate that the leadership of hospitalist programs believes strongly that hospitalists bring value to both the clinical and educational arenas. Unfortunately, there is a paucity of generalizable data in the pediatric education literature regarding hospitalists, with all studies being single-site reports. In a recent review of this literature, Carlson et al15 note that "most studies on the impact of the hospitalist on pediatric medical education have been positive"; however, 1 study did report decreased ratings in resident autonomy and supervisory skills after the introduction of a hospitalist system.16 Clearly, a more comprehensive assessment of the educational impact on hospitalists nationwide is needed.
In 1999, the American Academy of Pediatrics recognized pediatric hospitalists by creating a Provisional Section on Hospital Care.17 In 2005, the American Academy of Pediatrics also issued a policy statement providing 6 guiding principles for the development of pediatric hospitalist programs.1 Our results suggest that at least some of these principles are not being implemented uniformly by current hospitalist programs including: (1) hospitalists should be board certified in pediatrics or have equivalent qualifications; (2) pediatric hospitalist programs should include appropriate outpatient follow-up; (3) pediatric hospitalist programs should provide for timely/complete communication between the hospitalist and the outpatient physician; and (4) pediatric hospitalist programs should include data collection and outcome assessment to monitor performance.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Although these findings are an important step in better understanding the current situation in pediatric hospital medicine, they provide only 1 perspective, that of hospitalist program directors. Additional perspectives specific to different stakeholders are essential for a more complete picture of this domain. For example, understanding both the motivations and the actual career plans of hospitalists will require studies of a representative sample of hospitalists themselves, not just their leadership. In the same vein, determination of the actual benefits perceived by a hospital in subsidizing a hospitalist program would be best learned from a sample of hospital chief executives or chief operating officers. Finally, an important perspective on the educational impact and utility of pediatric hospitalists will come from those entrusted with the integrity of our training programs, the residency program directors at each institution.
Hospital medicine is a rapidly growing enterprise. The better we understand its participants, as well as those affected by its practice, the better we will be able to plan for a future, meeting as many needs as possible while ensuring the best possible care for children.
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ACKNOWLEDGMENTS |
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This work was supported by the American Board of Pediatrics Foundation.
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FOOTNOTES |
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Accepted Mar 15, 2007.
Address correspondence to Gary L. Freed, MD, MPH, University of Michigan, 300 N Ingalls Building 6E08, Ann Arbor, MI 48109-0456. E-mail: gfreed{at}med.umich.edu
The authors have indicated they have no financial interests relevant to this article to disclose.
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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics
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