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Distance-based partnerships are being increasingly used in health care and have previously been described to facilitate the training of nurses, researchers, and occupational therapists.1–6 In 2013, the Society of Hospital Medicine’s newly published guidelines for pediatric hospital medicine (PHM) programs indicated that strong leadership is critically important to a program’s success. Many smaller children’s hospitals have very few dedicated pediatric hospitalists, and these hospitalists might not have formal leadership or quality improvement (QI) training, resources, or dedicated time for QI work because of their clinical responsibilities. Similarly, pediatric residency programs at smaller institutions might lack robust inpatient QI experiences for their trainees. Leaders at Cincinnati Children’s Hospital Medical Center (Cincinnati) were approached by leaders at Niswonger Children’s Hospital (Niswonger) to complete a needs assessment of Niswonger’s inpatient program. Niswonger is a 69-bed children’s hospital colocated with Johnson City Medical Center, an adult hospital. These hospitals are located in a suburban area with a large rural catchment area. Both the adult and children’s hospitals are part of a larger health system, Mountain States Health Alliance. Niswonger is affiliated with East Tennessee State University (ETSU) Department of Pediatrics, which provided the majority of physician staffing. The needs assessment, completed in 2012, consisted of several site visits, observation of inpatient rounds, interviews with Niswonger faculty and staff, evaluation of available historical data, and collection of new data. Two main gaps in clinical care and training at Niswonger were identified. The first was the need for a dedicated hospitalist program with providers who did not have competing clinical responsibilities. The general pediatric inpatient unit was historically staffed by several ETSU faculty members, all of whom had primary responsibilities in other areas such as intensive care, outpatient primary care, and infectious disease and none of whom were dedicated pediatric hospitalists. These physicians would typically conduct inpatient teaching rounds in the morning and then resume other clinical responsibilities. The second was the need for QI training for the 19 residents in the ETSU pediatric residency program, an Accreditation Council for Graduate Medical Education requirement.

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It is commonly accepted that, prior to the rise of paediatric medicine as a formal medical specialisation in the nineteenth and twentieth centuries, medical care of children was primarily conducted by women in the context of the household. However, as this thesis argues, there was vibrant medical interest in children prior to the development of formalized paediatric medicine. Over the course of the eighteenth century, a network of medical practitioners interested in children’s health sought to establish their authority over the subject and, in doing so, devoted increased attention to children, channelling general medical interest into the basis for future medical specialisation. As this thesis argues, medical authority over children’s health was gradually constructed over the eighteenth century through printed texts, institutional experience, medical understandings of disease, and efforts to devise therapeutic practices suitable to children. Key to these developments were the efforts made by medical men to supplant women as authorities on children’s health. Also crucial was the role played by institutions in providing spaces for medical practitioners to encounter children. Institutions, such as the Dispensary for the Infant Poor and the London Foundling Hospital, increased the opportunities for medical practitioners to gain experience treating child patients. As this thesis demonstrates, it was the children of the poor who provided medical practitioners with the hands-on experience necessary to bolster their emerging claims of authority. As such, institutions and poor children both had essential roles to play in the development of medical interest in children, and the translation of that interest into claims of medical authority.

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