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A Watershed Moment


The announcement was made Sept. 23, 2009. The American Board of Medical Specialties (ABMS) had approved a “pilot program” for Recognition of Focused Practice (RFP) in Hospital Medicine. ABMS-sanctioned board certification for hospitalists had finally arrived.

When the announcement came, I was at the University of California at San Francisco’s CME conference with 600 other hospitalists. Robert Wachter, MD, FHM, chief of the hospital medicine 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, announced the RFP in HM to the audience—it received resounding applause. Dr. Wachter, the UCSF conference chair, then went on to recap the history behind RFP and how we got here. As he spoke, I realized that I had forgotten how long this process had taken and how much work had been done by so many people.

We will need to develop QI assessment modules, continue developing and enhancing QI education at our annual meeting, and we’ll need to consider more regional efforts at providing the education hospitalists need to do this QI work in their hospitals.

To practicing hospitalists, the creation of some sort of certification in HM seems like the proverbial no-brainer. But think about it from the American Board of Internal Medicine (ABIM) perspective: All “specialties” with board certification have training programs or fellowships that help define them. We do not have hospitalist residency programs or fellowships that are necessary for practicing as a hospitalist. Our expertise is acquired during practice.

So if the training path for hospitalists is not different—at least for now—from that of other general internists, how do we create board certification? When a group, such as hospitalists, “asks” to be recognized as a specialty with their own certification, the ABIM needs to consider the implications of creating such recognition. For hospitalists, the question was: If we do this for hospitalists, do we have to create a certificate for officists or outpatient physicians? For the broader questions around recognition of focused practice, the board needed to ask, “What if a group comes forward and asks for recognition of their focus and expertise in caring for diabetes or sepsis?”

ABIM thought very carefully about these questions. For the latter, ABIM says the field asking for recognition of focused practice must have a lot of physicians who only practice in this field while also having large numbers of physicians who never practice in the field. And they said, “Yes, if we do this for hospitalists, we will ultimately need to create a similar pathway for outpatient physicians.” Fortunately for us, they did not wait for RFP in outpatient medicine to be developed before proceeding with RFP for HM. (Figuring out how to do this on the outpatient side is even harder, and even though ABIM has been very supportive of RFP for hospitalists, the ABMS, which oversees all the specialty boards, still had to sign off on this approach. In September, they did.)

RFP Formula

So what will RFP in HM look like? The process is described on ABIM’s Web site (, but to qualify, a hospitalist must:

  • Be certified in internal medicine;
  • Have practiced for a sufficient period of time to have achieved certain volume thresholds for patients with inpatient diagnoses;
  • Participate in hospitalist-based practice improvement and self-assessment modules; and
  • Pass a secure exam, which SHM president-elect Jeff Wiese, MD, FHM, and his committee have been hard at work in creating.

All told, the bar has been set high. And from what I hear, the exam has a strong QI focus—a discipline most residency programs skimp on when designing their curriculums.

SHM recognizes that we will have to ramp up our educational efforts to prepare hospitalists for RFP. We will need to develop QI assessment modules, continue developing and enhancing QI education at our annual meeting, and we’ll need to consider more regional efforts at providing the education hospitalists need to do this QI work in their hospitals.

A Bright Future

So what does this really mean for our field? Quite a bit, actually.

We have long tracked all the elements traditionally required to call HM a specialty, and one by one we have ticked them off: large numbers of physicians in the field, a separate body of knowledge (i.e., core competencies), textbooks, a journal, national meetings, training programs. But the one element that remained unchecked was a separate certification. Cross that one off the list. Granted, training programs remain few and underdeveloped, but I expect that, too, will change and grow over time.

There are additional questions raised by this new certification. One might ask: “Will hospitals or payors require RFP in HM in order to practice or be paid for what we do?” Maybe. I expect this will not happen rapidly, as many hospitalists are likely to wait until they need to recertify before choosing to pursue RFP in HM. But if all of our colleagues start getting certified, or programs hiring hospitalists begin to require this certification (e.g., advertise the fact that all of their physicians are “certified hospitalists”), the floodgates will open.

Questions also arise about what happens now for family practice or pediatrics. Well, I am pleased to say that the American Board of Family Medicine (ABFM) has announced its intent to collaborate with ABIM to establish a similar pilot program for RFP in HM for family-practice physicians. And the pediatric societies and board-certifying agencies are watching closely to see if they might consider the same approach for pediatric hospitalists. Stay tuned.

ABMS’ recent approval of the RFP pathway is what many have been working tirelessly toward for years. It is a testament to the maturity, breadth, and importance of our field. And it validates what many of us have known for years: Hospitalists have unique skill sets that are vital to the U.S. healthcare system, and, as a result, we have been integrated into the fabric of hospital care delivery in every state.

With the coming redesign of the healthcare system, hospitalists will be counted on to lead and facilitate the work required to deliver high-quality, efficient hospital care across the country. RFP provides both a means to get hospitalists up to speed to do this important work and recognizes those who are ready to go out and lead.

This truly is a watershed moment for HM. TH

Dr. Flanders is president of SHM.

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