Residency as rehearsal: the new pediatric hospitalist fellowship requirement scam

If you finished pediatric residency in the last decade, you probably had a very simple career plan: survive three years, pass your boards, then finally get paid like a real doctor to take care of hospitalized kids.

Instead, many new graduates are discovering a plot twist: suddenly, residency looks less like “training complete” and more like a very long, very expensive dress rehearsal for the real show a two-year pediatric hospital medicine fellowship that increasingly feels less like a choice and more like a cover charge to enter the field.

On paper, pediatric hospital medicine (PHM) fellowship is about advanced skills, quality improvement, and leadership. In practice, a growing number of residents describe it as credential creep layered on top of six-figure medical school debt, in a specialty that already pays toward the bottom of the physician salary spectrum. Add a shrinking pediatric inpatient bed base and workforce shortages, and the whole arrangement starts to look, if not like an outright con, at least like a very clever system that benefits institutions far more than the trainees it depends on.

What pediatric hospitalists actually do (and why they matter)

Pediatric hospitalists are the doctors who live in that liminal space between the ED and the subspecialty clinic. They admit the wheezing 3-year-old at 2 a.m., manage the teenager with new-onset diabetes, coordinate care for medically complex kids, talk to consultants, calm terrified parents, and keep the whole inpatient machine from wobbling off the rails.

In 2016, the American Board of Medical Specialties (ABMS) officially recognized pediatric hospital medicine as a subspecialty, with certification administered by the American Board of Pediatrics (ABP). That recognition came with a message: PHM isn’t just “what you do during residency plus a bit more call” it’s a field with its own competencies, curricula, and expectations.

The traditional training path for a pediatric hospitalist used to be straightforward: medical school → 3-year pediatrics residency → job on the ward. Now, for graduates after 2019–2020 who want to be board-eligible in PHM, the default path is medical school, residency, and then a two-year ACGME-accredited PHM fellowship.

How we got from “residency is enough” to “two more years, please”

Subspecialty status and the fine print

When PHM became a recognized subspecialty, the ABP had to define what “extra” training it would require beyond residency. The model was familiar: most pediatric subspecialties (like cardiology or endocrinology) require fellowship training and scholarly activity for board eligibility. PHM was slotted into that same framework.

At the same time, surveys of hospitalist chairs and program directors argued that residency alone didn’t reliably provide enough exposure to core PHM skills like sedation, comanagement of surgical patients, complex discharge planning, and systems-level quality improvement. If residency is the rehearsal, the argument went, fellowship is the final tech run where everything actually comes together.

The fellowship requirement for new grads

The critical shift came with timing: for physicians who completed residency before 2019, the ABP created a “practice pathway” a kind of grandfathering allowing experienced hospitalists to sit for the PHM boards based on years of practice instead of fellowship. For those finishing residency in 2020 and beyond, however, the rules changed. To be board-eligible in pediatric hospital medicine now, you must complete an approved PHM fellowship.

Recruitment materials and career guides spell this out very plainly: recent graduates who want PHM board certification can’t get there straight from residency anymore. Fellowship is the new tollbooth.

The practice pathway closes and the market shifts

As the practice pathway sunsets, the workforce is in flux. Some hospitals still hire residency-trained pediatricians as hospitalists without PHM certification. Others strongly prefer, or quietly expect, fellowship training especially large academic centers. Recent workforce analyses find that only a small minority of programs formally require PHM certification right now (under 5%), but many anticipate tightening requirements, even as two-thirds report staffing shortages.

Meanwhile, PHM fellowships are expanding and filling. Fellowships that once struggled to recruit now see high match rates, reinforcing the perception among residents that fellowship is becoming a de facto requirement if you want to work in the settings where most pediatric inpatient care happens.

The case for pediatric hospitalist fellowship (so we’re fair)

Before we declare the whole thing a scam, it’s worth acknowledging that the fellowship model isn’t pure villainy. There are legitimate reasons many leaders and trainees like PHM fellowships and some kids absolutely benefit from highly trained hospitalists.

Clinical gaps residency doesn’t always fill

Studies of PHM fellowship graduates point to specific skills that often feel under-developed at the end of residency: procedural sedation, management of children with tracheostomies or technology dependence, complex perioperative care, transport medicine, and running multidisciplinary teams.

Fellowship can offer protected time to deepen these skills instead of frantically learning them between night shifts. Fellows may also get more supervised autonomy with higher-acuity patients than residents, in a setting that encourages explicit feedback and reflection.

QI, research, and the “academic hospitalist” argument

Hospital pediatrics isn’t just about writing admission orders and signing discharge summaries. PHM leaders are often responsible for quality improvement (QI) projects, hospital throughput, clinical pathways, and safety initiatives that affect thousands of admissions per year.

Two years of fellowship can provide real training in methodology, data analysis, and implementation science things that are notoriously hard to learn while also trying not to miss your resident sign-out. For trainees who want to run programs, lead hospital initiatives, or build academic careers, fellowship can be genuinely valuable.

On this level, the story is coherent: kids are sicker, hospital systems are more complex, and hospitalists need advanced skills. So where does the “this feels like a scam” energy come from?

Why the new fellowship requirement feels scam-adjacent

Training inflation in a low-paying specialty

Let’s start with the money. The average medical school graduate in the U.S. now carries around $200,000–$250,000 in educational debt, and many owe significantly more. Pediatrics, meanwhile, is consistently among the lower-paying physician specialties.

When you ask a heavily indebted pediatric resident to sign up for two additional years of training at a fellow’s salary often with little or no guaranteed long-term pay bump compared with non-fellowship hospitalist roles it’s not surprising some call it a bad deal. For residents, it can feel like being told, “Residency was just the unpaid internship; now you get to do a second one.”

From the institutional side, however, a fellowship looks like a win: you get motivated, relatively inexpensive physicians providing substantial clinical service while also helping with QI and teaching. It’s not that anyone sat down and designed a “scam,” but the structural incentives sure rhyme with one.

Workforce shortages vs. moving the goalposts

Here’s the paradox: at the same time we are raising the training bar for pediatric hospitalists, children’s hospitals and pediatric units are struggling to staff the beds they still have and those beds are disappearing. National studies show that nearly 30% of pediatric inpatient units in the U.S. closed between 2008 and 2022, with a nearly 20% drop in pediatric beds, while adult inpatient capacity shrank far less.

Children in many regions, especially rural areas, now travel farther for inpatient care; some states report that the majority of kids live more than an hour from a facility offering pediatric emergency or specialty services. At the same time, children’s hospitals report persistent pediatric workforce shortages across multiple specialties.

In that context, telling new pediatricians they must add two more years of training to be fully credentialed for inpatient work sounds less like a quality initiative and more like moving the goalposts at exactly the wrong time.

Equity, diversity, and who gets locked out

Extended, lower-pay training disproportionately hurts trainees from lower-income backgrounds, first-generation college students, and physicians of color groups already under-represented in medicine. That’s not speculative; debt burden data show that financial barriers shape specialty choice and limit access to training for many aspiring doctors.

When the “entry ticket” to PHM includes two extra years of fellowship, you’re effectively selecting for people who can absorb additional years of reduced earnings and delay major life milestones. That’s not just a fairness problem; it’s a pipeline problem in a field that urgently needs clinicians who understand the communities they serve.

Med-peds, rural hospitals, and career dead ends

The fellowship requirement also creates awkward corners of the system. Internal medicine–pediatrics (med-peds) graduates have historically been able to practice both adult and pediatric hospital medicine. With PHM now requiring fellowship for board eligibility, some med-peds residents worry that pursuing combined adult–peds hospitalist roles will become harder or less sustainable.

Smaller community hospitals face a different challenge. They may not need, or be able to attract, fellowship-trained hospitalists for every pediatric bed, especially as pediatric volumes shrink. But if PHM certification becomes the standard expectation, these hospitals could become less appealing career destinations, accelerating the drift of hospitalists toward larger urban children’s hospitals and leaving rural kids even more under-served.

Is residency really “just rehearsal” now?

None of this means residency training is perfect. There are real gaps: residents may do fewer procedures, see fewer bread-and-butter inpatient cases, and spend more time documenting than learning. But it’s a very different thing to say, “Residency could be improved,” versus, “Residency is just the warm-up; the real training is the two years we added on top.”

If residency isn’t adequately preparing pediatricians to care for hospitalized children, the logical response is to fix residency not simply bolt on more years of training and call it a day. Residency requirements themselves already include substantial inpatient time; some analyses argue that rebalancing rotations and expectations would close many of the gaps now used to justify mandatory fellowship.

When residents see problems that could be addressed upstream in how residency is structured, staffed, and funded but instead are told to “solve it in fellowship,” the whole arrangement understandably starts to feel like a bait-and-switch.

What a more honest, less scammy system might look like

If we wanted to keep the legitimate benefits of PHM fellowship without turning residency into a glorified rehearsal, several changes could help:

• Strengthen inpatient training in residency: Ensure that core PHM skills sedation basics, comanagement, complex discharge planning, transport medicine are built into residency curricula with real responsibility and supervision, not left to “learn it later.”
• Preserve multiple paths into PHM: Maintain or reintroduce practice-based eligibility routes for hospitalists working in under-resourced or rural settings, where requiring fellowship could worsen access.
• Target fellowship to advanced roles: Reserve PHM fellowship as a true advanced pathway for those seeking academic, administrative, or highly specialized roles, not as a blanket requirement for anyone who wants to admit bronchiolitis in a community hospital.
• Align incentives with service: Offer loan repayment, salary differentials, or promotion advantages that clearly reward completion of fellowship, instead of quietly expecting extra training with minimal financial recognition.
• Monitor equity and workforce impact: Collect data on who is entering PHM fellowships, who is being shut out, and how requirements affect access to care, especially in rural and underserved communities.

In other words, if we’re going to ask people to sign up for more training, we should make the value proposition crystal clear not fuzzy, implied, or “everyone else is doing it so you probably should, too.”

Experiences from the trenches: when residency feels like practice and fellowship like the real show

The structural debates are important, but the “this feels like a scam” feeling usually comes from lived experience. The examples below are composites based on common themes in surveys, commentaries, and informal discussions among trainees and early-career hospitalists, not stories about any single individual.

Case 1: The resident who thought she was done

“Maya” finishes a solid pediatrics residency at a busy children’s hospital. She’s done hundreds of admissions, staffed countless family meetings, and led more overnight codes than she cares to remember. Her plan, formed as an MS3, has always been hospital medicine not research, not a lab, not a PhD, just really good inpatient care.

Halfway through her third year, she discovers that for jobs at the very hospital where she trained, PHM fellowship is now “strongly preferred” for long-term positions. Recruiters reassure her that she could work as a general pediatric hospitalist somewhere else, but the message is clear: if she wants to stay in her city, in an academic environment, two more years are the new default.

She’s sitting on more than $250,000 of student loans and wants to start a family. Matching into fellowship would mean delaying a meaningful salary jump and putting more life plans on hold. It doesn’t feel like a deliberate, informed choice between equal options; it feels like a gentle shove down a narrowing hallway.

Case 2: The med-peds resident boxed in by rules

“Carlos” is a med-peds resident who loves the intellectual puzzle of caring for both adults and children. He imagines a career in a smaller hospital where he can be the bridge between adult medicine and pediatrics, especially at night when there’s one hospitalist for “whoever rolls through the door.”

But as PHM fellowship becomes the expectation for pediatric hospitalists, he’s told that future jobs might require two fellowships one for adult hospital medicine, one for pediatrics or at least that he’ll be at a disadvantage without PHM board certification. The combined role he wants is increasingly hard to fit into a system that thinks in neatly separated subspecialty boxes.

To him, the new rules don’t feel like they’re protecting kids; they feel like they’re protecting a training structure that doesn’t really know what to do with physicians who want to work across traditional boundaries.

Case 3: The rural hospital that can’t compete

“Sarah” is chief of pediatrics at a mid-sized community hospital whose pediatric unit is barely hanging on. Volumes are down, but the kids who do show up tend to be sicker and more complex. Recruiting hospitalists is brutally hard.

She’d happily hire a strong, residency-trained pediatrician who wants to stay long-term, but her health system’s leadership starts asking why they can’t “hold out” for fellowship-trained hospitalists like the big city down the road. Salaries aren’t adjusted to reflect the extra training, and the hospital doesn’t offer loan repayment, so her job postings compete poorly with academic centers.

As more units like hers close or downgrade services, families travel farther for inpatient care. The requirement creep doesn’t cause the closures by itself, but it’s one more weight on a system already tipping in the wrong direction.

Case 4: The fellow who actually loves fellowship and still sees the trade-offs

“Jared” opts into PHM fellowship with eyes wide open. He genuinely wants the extra clinical depth, loves QI, and plans to stay in academic medicine. Fellowship gives him protected time for research, mentoring from senior hospitalists, and a seat at the table for hospital-wide initiatives.

He doesn’t regret his choice, but he’s uncomfortable when fellowship is framed as the responsible path for everyone who likes inpatient pediatrics. He’s watched classmates with different priorities feel cornered into applying so they won’t be locked out later. His conclusion is nuanced: the training itself is valuable, but the way the system structures access to PHM jobs around fellowship can easily cross the line from “opportunity” to “soft coercion.”

So… is the pediatric hospitalist fellowship requirement a scam?

Calling anything in medical education a “scam” is intentionally provocative. Most of the people designing PHM fellowships and certification rules are trying to do the right thing for patients, not twirl mustaches over spreadsheets. There is real value in advanced training for hospitalists caring for medically complex children.

But from the viewpoint of many residents, the current setup has all the hallmarks of a scam-adjacent ecosystem:

• The “product” (more training) is marketed as essential, even when data show multiple pathways can work.
• The costs (debt, delayed earnings, life plans on hold) fall squarely on trainees.
• The benefits (cheaper labor, easier staffing, academic productivity) accrue disproportionately to institutions.
• The policy shifts happen in the middle of people’s training timelines, long after they’ve already committed to a path.

Residency shouldn’t be a rehearsal you discover retroactively. If pediatric hospital medicine truly requires more than three years of post-MD training for everyone, that expectation should be transparent from day one of medical school, aligned with financial reality, and justified by evidence not just tradition imported from other subspecialties.

Until then, skepticism from trainees isn’t cynicism; it’s a rational response to a system that keeps asking for “just two more years” from people who have already given a decade of their lives to learning how to care for sick kids.