FPHM: A License to Drive Change


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 ( 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.

HM-Focused Pathway

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 ( 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.

Similar, Yet the Same

FPHM examination is “fair test” for career-minded hospitalists

By Jason Carris

Mel Anderson, MD, FACP, wasn’t required to take the boards in October; he’d passed the American Board of Internal Medicine’s (ABIM) Maintenance of Certification secure exam and fulfilled the knowledge and process improvement requirements in 2007. But having practiced as a hospitalist for years and anticipating that his program at the Denver VA Medical Center will expand in the near future, Dr. Anderson jumped at the chance to recertify with ABIM’s new Focused Practice in Hospital Medicine (FPHM) exam.

“I was happy to see that the FPHM was available,” says Dr. Anderson, assistant professor of medicine and associate director of the internal-medicine residency program at the University of Colorado Denver. “Having done both outpatient and inpatient internal medicine, I have really grown to appreciate that hospital medicine really is its own subspecialty of medicine, with its own set of clinical challenges and areas of knowledge, skills, and attitudes. Seeing that more formally recognized in the form of focused practice, that was reaffirming to me.”

Launched in early 2010, the FPHM pathway to recertification offered its first secure exam Oct. 25. Nearly 400 hospitalists signed up for the FPHM, and 140 took the test. Results will be made available to test-takers later this month.

Having taken the traditional, internal-medicine exam just three years ago and then the HM-specific exam three months ago, he says the subject matter of the FPHM test was “pretty much spot-on.” He recently talked to The Hospitalist about his experience.

For career hospitalists—those who have been involved in QI activities and are making HM a career focus—the FPHM makes sense.

Question: How did the subject matter in the FPHM test relate to your everyday practice?

Answer: The clinical content was very much what we see. It had a decent mix of some ICU topics—not too much, because I know that a substantial number of hospitalists don’t see ICU patients. The quality improvement questions … were clearly concepts that I expect most hospitalists to be familiar with. So I thought it was a pretty fair test. It was a good test in that you were plainly able to see what was being asked of you. That aspect of the test was very successful.

Q: What differences did you notice in the two tests?

A: There were a lot more similarities than differences: the general layout of questions, in terms of a lot of clinical history and an entire case being laid out for you, and then a series of four or five answers. That pattern is a familiar one, and it’s all medicine. The things that were different were, contentwise, various ambulatory issues not covered and ICU topics covered much more than they were in the traditional IM exam. And certainly the quality-improvement piece was something that was not present in the general exam and is something that is appropriate for hospitalists.

Q: Have you completed the other MOC requirements for the focused practice?

A: I believe I will need to do the more frequent self-assessment [QI] modules to both qualify for the FPHM and maintain it. I’ve built time into my academic year in the late winter/early spring.

Q: Would you recommend the FPHM for the hospitalists in your group?

A: This really isn’t for someone who is in hospital medicine as sort of something between what came before and what comes after. For career hospitalists—those who have been involved in QI activities and are making HM a career focus—the FPHM makes sense. I think the most important thing is making sure that is you.

Q: You didn’t have to take this test, so why did you choose to be among the first to go the FPHM route?

A: I wanted to put my money where my mouth is. If I call myself a hospitalist, am I up to the task of showing that based on the certified exam and the other requirements of this path of recertification, that I hold myself to that standard both personally and professionally?

The next FPHM test date is May 19. Registration for the spring exam is open until Feb. 15 through the ABIM website ( Registration for the fall exam is May 1-Aug. 1.

Q: Were you nervous?

A: No, not really. It was actually sort of a fun test.

Q: Do you expect to pass?

A: Yes, I do, and I also hope that I do.

Jason Carris is editor of The Hospitalist.