I was musing one morning about my day ahead. I was doing one of those subcortical activities of daily living in which the mind can wander freely. Have you ever jumped in the car with the intention of stopping at the store on the way home, only to find yourself pulling into your driveway after spending the drive contemplating those issues on your plate that day? You drive home on autopilot. It occurred to me that it can happen in much the same way in our daily practice of medicine—how easy it is to slip into autopilot when admitting patients and doing our daily rounds.
During this particular morning, I mulled over many things: the translocation between chromosomes 9 and 22 in CML, the obstructive PFTs one generally sees in cadmium exposure, debating whether to give corticosteroids or to induce delivery in a 33-week pregnant woman with HELLP syndrome. Maybe you’re wondering: Am I a physician practicing in a remote rural area that has no access to oncologists? Do I practice in an underserved industrial town next to an old battery factory? Or am I an old-fashioned GP who still delivers babies?
No, no, and no. I am a board-certified internist who was preparing for my Maintenance of Certification (MOC) examination.
A New Way of Thinking
I am 42 years old, I have a busy medical practice, I am the medical director of the 14-person HM group at Wentworth-Douglass Hospital in Dover, N.H., and I am the mother of two children, ages 9 and 11. And I found myself, on top of all these things, a student, too.
I’ve been practicing medicine for 11 years. I’ve gone from practicing primary care in a small community in Maine to working at a larger community medical center in New Hampshire, becoming a hospitalist in 2005, then taking on the job of director of my hospitalist group in 2006. With more than a decade of experience under my belt, I felt I had the depth of knowledge experience brings.
However, as I traveled through the process of preparing for the American Board of Internal Medicine’s (ABIM’s) new Focused Practice in Hospital Medicine (FPHM) secure exam, it began to dawn on me: Medicine is a complicated profession that not only requires careful attention to the details of every case, it also demands it. In order to avoid the pitfall of practicing distracted medicine, we must carefully foster our own continuing education.
Going through the studying process has enabled me to think about the medicine I practice in a much more academic way. True, I don’t necessarily need to know some of the things I’ve encountered in my study sessions for my everyday practice, but I find myself spouting off random facts to anyone who will listen—colleagues, nurses, even patients. “Did you know that only about one-fourth of crystalloid remains in the intravascular space, where the rest goes into the tissues?” “If the triglycerides in this fluid are greater than 115, this is a chylothorax!” I’m paying attention again to the theory and pathophysiology behind medical illnesses, not just to the drudgery of writing routine orders or checking off boxes on a protocol.
It has not been easy. Although I’ve known I needed to recertify in internal medicine since I took the exam the first time, I did not actively start looking into the exam and preparing until about a year and a half before my exam, when I talked to a colleague who had already started preparing. That’s when I learned that this was not only an exam, but also a process. This process is intended by the board to be an active part of maintaining certification during the 10 years before it is due again, not just to be crammed into the last year or two before certification expires. I recommend to anyone going through this process to familiarize yourself with the ABIM website (www.abim.org). Initially, it was a little unwieldy to maneuver around the site, and it wasn’t entirely clear to me what exactly was needed to recertify until I spent some time maneuvering through the site.
To add to this, at around the time I was getting ready to register for the exam, it was announced that this would be the first year ABIM would be offering the FPHM pathway, which is designed to recognize those of us who concentrate our practices on hospital medicine. This to me was an excellent opportunity to recertify in a field in which I actively practice, hopefully making the exam more applicable to what I do, but the flip side was that no one would have taken this particular exam before. Admittedly, when I first signed up, I felt like I was either a guinea pig or a pioneer.
To obtain the FPHM, one must do not one but two projects requiring turning in data on process-improvement projects. Hospitalists who intend to certify with the FPHM will be well served by participating in safety, quality, and process-improvement projects, as we often already do. These projects can be used to complete the required Practice Improvement Modules.
Furthermore, I found that doing such projects is the best way to prepare for the new content, which deals specifically with HM on the actual exam. The internal-medicine topics were covered, just as they are in the nonfocused exam, and anyone who reviews for the exam with available study aids (e.g. review books, courses, or practice questions) will have adequate exposure to these topics.
However, a colleague in my HM group chose not to take the focused practice exam, largely because there was no previously established review material to use as study aids. I anticipate that future study aids will contain references to these questions, but for now I felt that material was adequately covered just by completing the Practice Improvement Modules and by being involved in process improvement projects at my hospital. In fact, attendance at one Institute for Healthcare Improvement (www.ihi.org/IHI/Programs) conference would probably cover the topics nicely.
To all of my colleages considering the MOC in FPHM exam, I wish you luck. I feel that any practicing hospitalist is likely to be able to satisfy the requirements of the FPHM pathway without doing too much more than they would in their daily practice or their usual exam preparation. I also found the ABIM staff useful and helpful, and recommend you use the “contact ABIM” link on their website with any questions.
Focused practice is exactly what we should be driving for. TH
Dr. Ammann is medical director of the hospital medicine division at Wentworth-Douglass Hospital in Dover, N.H.