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A-Plus Achievement

From: The Hospitalist, November 2009

Recognition of Focused Practice in HM validates career hospitalists, offers specialized pathway to recertification

by Jason Carris

Timing is everything. Christopher Columbus, Abraham Lincoln, Harry Truman … each benefited from perfect timing and, in turn, helped change the course of history.

HM has had great timing, too. With numbers now estimated at more than 30,000 hospitalists nationwide, HM is systematically changing the way patients are cared for in the hospital. The maturation process is equally evident. In less than two decades, HM has organized annual meetings, developed educational programs, established a peer-reviewed journal, and published core competencies.

The next step in the evolutionary process: the Recognition of Focused Practice (RFP) in Hospital Medicine through the American Board of Internal Medicine’s (ABIM) maintenance of certification (MOC) program. Registration for the RFP in HM should be available by May 2010, with the first MOC in fall 2010.

“The timing is perfect. It’s appropriate,” says Robert Wachter, MD, FHM, chief of the hospital medicine

Board Certification, With a Healthy Dose of HM

ABIM’s new Recognition of Focused Practice (RFP) in Hospital Medicine establishes a recertification process for career hospitalists. The ABIM committee’s goal, according to Dr. Wachter, has been to create “the most rigorous, generally accepted certification for our field.”

Although it will mirror the IM recertification test in many ways, the RFP in HM test questions will focus on patients and the three core principles of HM practice: quality, patient safety, and clinical care transitions.

“That’s what the MOC means to me,” says Dr. Wiese, SHM president-elect and chair of the ABIM Hospital Medicine Maintenance of Certification Question Writing Committee. “That these individuals that have gone through the four parts of certification and can say, with confidence, that they meet the criteria that a patient would like to see in a hospitalist. They must be a competent internist knowledgeable in hospital-based care, and they must be able to demonstrate [expertise] in patient safety, quality, and transition of care.”

The RFP in HM test will have four parts:

  • Citizenship. Physicians must be licensed and in good standing and fulfill any applicable procedural requirements. This is similar to the standard ABIM test; however, RFP in HM candidates will have to demonstrate a to-be-determined minimum patient census and have passed advanced cardiac life support (ACLS) training.
  • Self-Evaluation Program (SEP). The SEP is a scoring system designed as a lifelong learning tool. The SEP is an open-book module that tests clinical and practical knowledge.
  • Secure Exam. The “rough blueprint” is a 75% inpatient, 25% outpatient split, according to Dr. Wiese. Outpatient questions will focus on the fundamentals—for example, how to set up a successful first clinic visit following discharge.
  • Performance Improvement Module (PIM). The PIM focuses on physicians improving their practice. One difference for the RFP in HM certification is that the PIMs will be required every three years, according to Dr. Wiese. “They will be more team-focused … and identify other physicians, nurses, and hospital staff. For most hospitalists, you are doing this kind of stuff anyway,” he says. “We’re driving at continual practice improvement. We must be offering it in our hospitals.”—JC

division, professor, and associate chair of the Department of Medicine at the University of California at San Francisco, a former SHM president, and author of the blog Wachter’s World. “We knew we needed to ripen and mature. It’s like watching your child growing up: their first steps, first day of school, graduating high school. This has a lot of the same feeling. This is one more statement that the field is real, here to stay, and vitally important to medicine.”

The new pathway to board recertification is as meaningful to HM’s founding fathers as it will be to the next generation of hospitalists. It represents validation to physicians who have chosen a career in HM, and it offers early-career physicians a specialized path to recertification. Moreover, hospitalists agree the RFP in HM provides accountability to the profession and patients.

“Hospitalists must be able to exhibit clinical competence in the areas of patient safety, quality, and clinical care transitions,” says Jeff Wiese, MD, FACP, FHM, associate dean of Graduate Medical Education and professor of medicine at Tulane University in New Orleans, SHM president-elect, and chair of the ABIM Hospital Medicine Maintenance of Certification Question Writing Committee. “Everything is driving at those issues. Individuals who go through the four parts of this certification will be able to say to their patients, with confidence, that one, they are a competent internist knowledgeable in hospital-based care, and two, they are an expert in patient safety, quality, and transitions of care.”

ABIM, for its part, expects to learn from this “new paradigm,” says Eric Holmbloe, MD, ABIM’s senior vice president and chief medical officer.

“The major change is the ability to implement the concept of a focused practice. It’s the first time, and it does recognize that the world has changed,” Dr. Holmbloe says, noting his group is “working feverishly” to complete the examination and build the online infrastructure needed for testing. “For those individuals whose [certificates] expire in 2010 or 2011, this is a viable pathway for recertification.”

Satisfaction Guaranteed

Ask any long-in-the-tooth hospitalist what the RFP in HM means to them, and more often than not the answer centers on professional self-regulation and career validation. Few will argue the specialty has, at times, suffered from an identity crisis. Sans fellowships, specialized training, or a particular organ to hang their hat on, HM physicians have labored to carve their niche and gain a seat at the specialist’s table.

The RFP in HM, many hospitalists envision, solves a number of those acceptance-related issues (see “Certified Special,” p. 53). Most importantly, it identifies physicians who have chosen to make HM their career.

“Hospitalists have always struggled, especially in academic settings,” says Scott Flanders, MD, FHM, SHM president, associate professor and director of the hospitalist program at the University of Michigan Health System in Ann Arbor. “I think this is a major, major moment for the field. It validates the field, and the belief that HM is a positive [for medicine].”

The new designation likely has greater meaning to older HM physicians, those who remember the early days of society formation (i.e., the National Association of Inpatient Physicians) and annual meeting attendance in the hundreds, not thousands.

“With the older docs, validation is particularly meaningful,” says Dr. Wachter, who, along with Lee Goldman, MD, first coined the term “hospitalist” in a 1996 article in the New England Journal of Medicine.1 “Paradoxically, most of the older physicians don’t have to take this test.”

That might be true, but only a small percentage of the 30,000-plus hospitalists in the U.S. are grandfathered into time-unlimited IM certificates. ABIM began time-limited certificates in 1990. The average hospitalist is 40, according to SHM’s “2007-2008 Bi-Annual Survey on the State of the Hospital Medicine Movement.”

John Nelson, MD, doesn’t have to recertify, but the co-founder of SHM is planning to be among the first to take the test. “It’s the first way hospitalists will be able to show their competence,” says Dr. Nelson, FACP, FHM, past president of SHM, and a principal in the national practice management firm Nelson Flores Hospital Medicine Consultants. A regular contributor to The Hospitalist, Dr. Nelson says the RFP in HM “will help people take our field more seriously.”

Inclusive of IM

The RFP in HM pathway is not a way to distance hospitalists from their internal medicine (IM) training and certification. Nearly 85% of hospitalists are IM-trained, according to SHM’s 2007-2008 bi-annual survey, and clinical competence as an internist will be a requisite for recertification through the new ABIM test.

“HM is borne of internal medicine … and has evolved to something unique. Therefore, your credentials should reflect that uniqueness,” says Larry Wellikson, MD, FHM, CEO of SHM. “This [process] is going to make the whole maintenance of certification process more relevant to hospitalists. This is recognition that hospitalists should be accountable for learning new things after they complete their formal training—things not emphasized in training like patient safety, quality, and care transitions.”

The language used on ABIM’s Web site to announce the new testing program furthers the message: “ABIM is developing a program to assess, set standards for, and recognize the proficiency of general internists who focus their practice in the care of hospitalized patients. The board’s decision to advance this program is consistent with its primary role of certifying internal-medicine physicians who meet the profession’s standards for focused practice in internal medicine.”

In addition to quality, patient safety, and transitions, “accountability to the patient” is a popular catchphrase used by members of the committee dedicated to writing the new certification test. Licensure and certification provide public accountability to patients, colleagues, and stakeholders, says Dr. Wiese. What differentiates career hospitalists from those making a pit stop during an alternate career path is increased accessibility to patients, expertise in patient safety and quality initiatives, and knowledge of clinical care transitions, he explains.

“Everything is driving at those issues,” he says. “From the beginning, there has been no agenda to change residency training. Any information contrary is a complete myth. Principle No. 1 is that you have to be competent internist. This new [MOC process] is much closer to an MBA.”

How hospitalists who are recertifying through the RFP in HM will refer to themselves remains up for debate. Although some physicians might say they are “board-certified in hospital medicine,” Dr. Wachter hopes hospitalists will use the phrase “board-certified in internal medicine with a recognized focused practice in hospital medicine.” “I hope to think our physicians will still say ‘IM,’ ” he says. “The goal here is not to sever ties with IM. That is a concern.”

Dr. Wiese, who, along with Dr. Wachter and other members of the test-writing committee, was required to complete the IM maintenance of certification (MOC), envisions a four-part process (see “Board Certification, With a Healthy Dose of HM,” p. 31) that challenges hospitalists in the core competencies of hospital-based practice.

“The [IM] recertification was the one test in my career that made me a better physician. I think this HM examination is going to be the same way,” Dr. Wiese says. “I want hospitalists to say, ‘When I go back to take care of my patients, they’ll be better off for it.’ ”

ABFM, ABIM Offer RFP in HM Pilot

The American Board of Family Medicine (ABFM) is joining forces with ABIM in establishing a pilot program for RFP in Hospital Medicine. This pilot was approved by the American Board of Medical Specialties (ABMS) board of directors in September.

The RFP in HM will utilize the current MOC framework and would be the first customized MOC pathway that draws heavily on practice-based learning as its foundation. The pilot would engage hospitalists in uniquely designed tools that will be developed by the ABFM and ABIM. The pilot program is scheduled to begin in the fall of 2010 and will continue for a three-year period at the outset. For more info, visit www.abim.org.

Target Audience

Dr. Flanders has about 40 hospitalists in his HM group at the University of Michigan. Although he recertified in IM in 2006, he knows many of his hospitalists are itching to take ABIM’s new HM-focused test. “They will be thrilled. They have all said to me that we can’t get this done fast enough,” he says, noting three or four of his hospitalists probably will recertify through the new test in fall 2010. “Our field is young; I suspect there are a lot of hospitalists out there who are within the 10-year window for recertification. I plan to do it at my next MOC … and that date could be moved up the way things are going.”

Dr. Wachter agrees the RFP in HM is an “attractive” option to hospitalists, especially those whose recertification is looming in the next two or three years. This MOC, he explains, “offers a pathway that is more in sync with the medicine [they are practicing] day in and day out.”

ABIM plans to have comprehensive information about the process available on its Web site (www.abim.org) this month and online registration available in May 2010 (see “FAQs,” left). While the test-writing committee finishes its tasks, Dr. Holmbloe says, ABIM’s systems department is working to build the online infrastructure. The first RFP in HM tests should go live in fall 2010.

“For those individuals [whose certificates] expire in 2010 or 2011, this is a viable pathway for recertification. If HM is their passion, this is for them,” Dr. Holmbloe says. “The major change, from ABIM’s perspective, is the ability to implement the concept of a focused practice. It’s the first time, a new paradigm. This does recognize that the world has changed.”

Crash Course

Every physician, sometime in his or her career, has crammed for a test. ABIM, however, recommends physicians start this process two or three years before their certificate expires. That timetable might work for some hospitalists, not so much for others. In any event, Dr. Flanders says hospitalists can count on SHM to help them prepare for the HM-specific examination.

“SHM has to help develop the tools and resources hospitalists will need to successfully prepare for and pass this test,” he says. He expects educational resources and self-assessment modules will be available on SHM’s Web site (www.hospitalmedicine.org) and at HM10, April 8-11 in Washington, D.C.

Dr. Wellikson says MOC preparedness “should match [SHM’s] educational projects,” and his staff “will continue to develop” tools and resources to assist hospitalists. He also recognizes the moment: the notch on HM’s evolutionary timeline where a once-fledgling group of inpatient physicians helped chart a new course for American medicine.

“Obviously, 10 years ago was too early. Now there are 30,000 hospitalists. Many of them are making HM a career. It’s evolving as a discipline,” Dr. Wellikson says. “We’ve moved beyond the idea of HM to the reality of HM.” TH

Jason Carris is editor of The Hospitalist.

Reference

  1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335(7):514-517.

Image Source: PORCOREX/ISTOCKPHOTO.COM

FAQs

The following are excerpts from www.abim.org. For the complete transcript, visit www.abim.org/news/news/hospital-medicine-qa.aspx.

Question: Why is ABIM recognizing focused practice in HM?

Answer: HM has reached a state of maturity within the discipline of IM, as demonstrated by the large and growing numbers of physicians who have concentrated their practice in the hospital setting. The board’s decision to recognize HM acknowledges the value that hospital-based internists can bring to improving patient care in this practice setting. The characteristics of focused hospital practice are described in the field’s published core curriculum (J Hosp Med. 2006;1(Suppl 1):2-95).

Q: Will diplomates be eligible for recognition of focused practice in HM at the completion of IM training?

A: No. Developing a practice focus requires a period of experience in unsupervised practice and demonstration of proficiency beyond that expected in residency before it can be recognized by ABIM. The MOC program can recognize such practice differentiation through demonstration of proficiency acquired through practice and modification of the initial IM certification to reflect the practice focus. So a typical internist seeking ABIM recognition of focused practice in HM must complete training in IM, be certified in IM, and engage in a practice that focuses primarily on HM for several years.

Q: How will ABIM implement the MOC for focused practice in HM?

A: ABIM is one of 24 member boards of the American Board of Medical Specialties (ABMS), which sets the policies and processes governing certification of medical specialists in the United States. ABIM is working with ABMS to develop the process for recognizing focused practice through MOC. ABMS must determine how ABIM’s MOC program for recognizing focused practice in HM will affect the certification and MOC programs of the other member boards. The time frame for this ABMS process is uncertain. While the deliberations are ongoing, ABIM is further refining the focused practice concept, as well as defining the competencies and developing the assessment tools needed for its application to HM.

Q: I’m a hospitalist with an IM certificate expiring in 2009. Should I wait for the HM program before beginning MOC?

A: The board recommends that you not allow your IM certification to lapse. However, as you complete the requirements to maintain your IM certification, you can choose self-assessment options that are relevant to hospital practice, such as the Hospital-Based Internal Medicine medical knowledge modules and the Hospital-Based Patient Care PIM. In this way you will have completed MOC evaluations that will count toward requirements for the HM focused practice program should you later choose to pursue this recognition.

Q: I’m a hospital-based internist and executive director for a hospitalist program, with overall responsibility for quality assurance. I serve as a hospitalist for two to three months a year. Could I qualify for the HM focused practice program?

A: Yes. The HM program is designed for internists who have focused their practice in HM. ABIM will provide a pathway within the program for part-time hospitalists who devote the majority of their professional activity to HM, including both clinical and nonclinical work. However, if you were to withdraw entirely from your clinical work to focus on leadership and systems work full time, you would not be eligible for recognition of focused practice in HM because practice is a key requirement of the program.

Q: I’m a full-time, hospital-based subspecialist and also serve as a ward attending for one month a year. Could I qualify for the focused practice program for HM?

A: No. Because HM is a subset of the broad discipline of IM, the ABIM program is designed to recognize the proficiency of general internists who have focused their practice in the hospital setting.


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