Certification on Our Minds
I was wondering whether and when hospital medicine might become a board certification and distinct subspecialty?
Susan Pereira, MD
Dr. Hospitalist responds: This is a question on many minds nowadays. With fewer primary care doctors providing inpatient care, new hospitalist programs are popping up all over.
Approximately 85% of this country’s more than 20,000 hospitalists are general internists. For that reason, we are seeing a divergence in the career pathways of these physicians. Some consider themselves outpatient providers; others want to offer only inpatient care. Should we call general internists who just provide inpatient care “inpatient care specialists”? The answer depends on whom you ask.
Robert M. Wachter, MD, professor and associate chairman of the Department of Medicine at the University of California, San Francisco (UCSF), holder of the Lynne and Marc Benioff Endowed Chair in Hospital Medicine, chief of the Division of Hospital Medicine, and chief of the Medical Service at UCSF Medical Center, past president of SHM, member of the American Board of Internal Medicine (ABIM) board of directors, and author of “Wachter’s World” (www.wachtersworld. com) coined the term “hospitalist.” Early in the movement, he and other leaders worried that identifying individuals who worked as hospitalists would hinder the growth of hospital medicine because it would allow payers to exclude primary care providers from practicing in the hospital. Clearly that has not occurred, and the field continues to grow.
Four years ago, the SHM Board of Directors began to look at this issue of hospitalist certification. Mary Jo Gorman, MD, past president of SHM, said certifying hospitalists would allow patients, payers, and hospitals to recognize the quality of work these physicians provide. Later in 2004, the SHM Board of Directors approved a resolution outlining the need to recognize hospitalists as unique providers, and began developing a process for formally certifying hospital medicine.
In 2006, ABIM, a governing board that sets the standards and certifies the knowledge, skills, and aptitudes of U.S. physicians who practice internal medicine and its subspecialties, announced it would create a Recognition of Focused Practice (RFP) for Hospital Medicine, as part of its Maintenance of Certification (MOC) process.
The exact criteria aren’t yet finalized, but ABIM President and Chief Executive Officer Christine K. Cassel, MD, said they likely will include “a combination of significant practice focus in hospital medicine, a high knowledge level of modern, evidence-based hospital care, and a demonstrated commitment to continuously improving the quality of hospital care.”
“ABIM looks forward to working with experts in hospital medicine to develop a process and standards for recognition of this important discipline,” she says.
In my opinion, the SHM/ABIM pairing is wise for several reasons. Partnership with an established organization brings credibility to the process and speeds eventual acceptance of certification. Also, ABIM is the logical choice to start because so many hospitalists are internists. This does not, however, preclude working with the American Board of Pediatrics, the American Board of Family Medicine, or any other certifying organization. In fact, a successful SHM/ABIM partnership could establish a framework for others to follow.
One thing to keep in mind: Dr. Wachter has stressed the fact that ABIM is recognizing an area of focused practice—not expertise. Certification is not the same as fellowship. Nobody is suggesting hospitalists need fellowship training to do their jobs.
What about general internists who practice outpatient medicine? In 2007, ABIM proposed a Comprehensive Care Internal Medicine (CCIM) credential for office-based general internists. This would differentiate internists in the office setting who provide ongoing, coordinated care for a panel of patients from internists who work in urgent care or academic, administrative, or research settings.
The American College of Physicians (ACP) expressed concern about the CCIM credential, saying it would burden physicians and hurt primary care outreach efforts. “CCIM may pose another burdensome hoop that adds time, expense, and limited value, leading to fewer students choosing careers in, and fewer physicians practicing, office-based internal medicine,” wrote ACP in a review of the proposal. More work will be necessary before the larger medical community will accept the CCIM credential.
Meanwhile, the ABIM continues to move forward with the RFP in hospital medicine. For example, Jeff Wiese, MD, professor of medicine at Tulane University in New Orleans and member of SHM’s Board of Directors, became chair of the hospital medicine MOC examination committee, which aims to add hospital medicine-specific elements to the MOC process. If this rapid pace continues, it is realistic to expect examinees to sit for the first tests in 2010.
In the past, Dr. Wachter has raised important questions about this RFP. Will anybody choose to get certified in hospital medicine? What effect will it have on primary care? How will the market value this certification? Will certified hospitalists get paid more? What will happen to those who aren’t certified? Is this the start of a separate specialty with separate training?
I believe when the time comes, hospitalists will choose to get certified. They will view this as a way to distinguish themselves from physicians who work as hospitalists for one to two years between residency and fellowship. Right now, job opportunities for hospitalists abound, but at some point the market will become saturated. The more saturated the market, the greater the value of hospitalist certification. Employers will use this RFP to separate qualified candidates. I also believe it will prevent the remaining primary care physicians from providing care in the hospital. Without additional external funding, however, I doubt this will lead to separate hospitalist training. TH