Policy & Position Statements
The 2006 Institute of Medicine Report recommended appointment of at least one physician “pediatric emergency coordinator” within all emergency medical services agencies, to assume a pediatric leadership role and ensure adequate skills and knowledge among fellow ED providers and oversee pediatric care and quality improvement initiatives within the department. Since the gold standard for expertise in pediatric emergencies is fellowship training and board certification in Pediatric Emergency Medicine (PEM) by the American Academy of Pediatrics (AAP) or the American Board of Emergency Medicine (ABEM), these physicians would be most qualified to provide pediatric leadership at community hospital emergency departments. At present less than 23% of community hospital (non-pediatric) emergency departments have any PEM-trained specialists that would be in a position to assume this role. This situation is unlikely to change in the foreseeable future for a variety of reasons, including the fact that 90% of PEM-trained physicians have previously trained in Pediatrics. Since their scope of practice is limited to seeing children, many community hospital emergency departments may not see adequate volumes of pediatric patients to justify hiring a full-time PEM-trained specialist. Recruiting PEM-trained specialists with previous Emergency Medicine training and expertise in both adult and pediatric emergencies would seem a viable solution for these emergency departments; however, such physicians make up only 10% of PEM-trained specialists, and this percentage has not changed since the inception of PEM fellowship training programs in 1994 up until the present time. Research into why Emergency Medicine graduates do not pursue fellowship training in Pediatric Emergency Medicine is lacking, but there are a number of possible reasons: For graduates of an Emergency Medicine residency, ABEM requires only two additional years of fellowship training to qualify for PEM subspecialty board certification. Many PEM fellowships will only consider applicants to their programs who are willing to complete three years of fellowship, since the additional third year of training is required by the AAP for those entering PEM fellowships from Pediatric residency. Also, some Pediatric Emergency Medicine fellowship training programs will not accept applications from graduates of Emergency Medicine residencies, and only consider candidates with training backgrounds in Pediatrics. In light of the pressing need for more leadership and expertise in pediatric emergencies at the community hospital emergency department level, Pediatric Emergency Medicine fellowship training programs should consider making efforts in the future to identify why they fail to attract Emergency Medicine graduates and take measures to recruit them into the specialty. Only then will the specialty be in a position to more directly impact the majority of emergency department visits by children in the United States, which occur exclusively in the community hospital (i.e.-non-pediatric) emergency department setting.
In view of this current situation, The PEPNETWORK endorses the concept and development of Emergency Medicine Pediatric Leadership (EMPL) Fellowships. Candidates for these fellowships would have successfully completed an ACGME-approved Emergency Medicine residency, and have an interest in assuming a pediatric leadership role as part of their future practice with both adults and children in a community hospital emergency department-based EM physician group. The EMPL fellowship would consist of only one year of additional post-residency training, and follow a specified curriculum geared to preparing these physicians for their role as pediatric leaders and educators in community hospital emergency departments. Ideally, these fellowships would take place at tertiary pediatric emergency departments where fellows could gain rigorous additional clinical training and expertise caring for very sick children, exposure to less common atypical presentations through their own shift work, and participate in QA exercises and meetings. EMPL fellows would be expected to actively participate and develop proficiency in pediatric chart review and QA, and have to demonstrate an advanced knowledge base and clinical and teaching skills for pediatric emergencies, as defined by curriculum requirements specifically designed for them. While not an ACGME-approved fellowship leading to a board certification, the enhanced pediatric knowledge and skills gained by graduates of these EMPL fellowships would add significant pediatric expertise to their group practices that wouldn’t otherwise occur. These physicians would, in a relatively short time frame, significantly strengthen the pediatric workforce in community hospital emergency departments and serve as a realistic and viable model for the future to produce an adequate supply of emergency medicine pediatric leaders at the community hospital emergency department level.