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Focused Practice in Hospital Medicine


Some in her HM group think Cathleen Ammann, MD, is the guinea pig. Dr. Ammann, the medical director of the hospital medicine division at Wentworth-Douglass Hospital in Dover, N.H., will be one of the first to complete her American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) through the new Focused Practice in Hospital Medicine (FPHM) pathway. Dr. Ammann—and the hospital administration—sees things a little differently.

“Am I the guinea pig or a pioneer?” a hospitalist in Dr. Ammann’s group asked her recently. “I definitely see it as being a pioneer. When you look back in another 10 years, hospital medicine might be a specialty with its own certification. I know it’s a little corny, but I look forward to getting in on that at the ground floor.”

Dr. Ammann is one of about 175 hospitalists who have signed up to recertify through FPHM. Her internal-medicine (IM) certification expires at the end of the year, so she will be taking the recertification exam Oct. 25.

“I hope the test focuses more on what I’m doing … stroke, quality measures,” she says. “Hospitalists know that stuff like the back of our hand. … I think it will work out well for me, but I also think it will be great for our program to have a director who has a Focused Practice in Hospital Medicine. It shows my commitment, and we can hold that up to the rest of the organization and say we really have someone who is concentrated in this field.”

Why Should I Pay Extra?

The Focused Practice in Hospital MOC will cost diplomates an extra $380, and Dr. Holmboe of ABIM says it’s fair to question the additional fee. Most of the added costs are operational—extra administration, extra attestation, and auditing.

“We’re actually carving out a new exam,” Dr. Holmboe explains. “The two biggest drivers were the committee for the new test to create the exam and the infrastructure changes to the website.”

Dr. Holmboe also points out that although the test will cost more than a general IM MOC ($1,570), it remains less than a subspecialty MOC.—JC

Dr. Ammann sums up the thinking of many HM leaders who’ve been working with ABIM and the American Board of Medical Specialties to launch the MOC pathway for hospitalists: Not only does a focused practice certification allow the more than 30,000 hospitalists in the U.S. to define themselves as different, it also provides hospitalists an MOC process and secured examination more acutely tailored to their skill sets and daily practice. The new pathway also requires ACLS certification and stresses continued “maintenance of competency,” according to SHM leaders, through a triennial self-evaluation requirement (60 self-evaluation points, with at least 20 points from medical knowledge modules and 40 points from completion of practice performance modules). The traditional IM MOC requires a practice-improvement module (PIM) every 10 years.

“The process will ask diplomates to participate in practice improvement every three years, which will focus on the ongoing need for performance improvement,” says Jeff Wiese, MD, FACP, SFHM, SHM president and chair of the ABIM Hospital Medicine MOC Question Writing Committee. “It will separate out the authentic hospitalist who is representing the goals and virtues that we are espousing as a society, particularly with regards to quality healthcare and safe healthcare. But I also think there are unique benefits for the patient that will be receiving the healthcare, because through this process, I believe, every diplomate will be a better hospitalist as a product of having done it.”

Here’s a brief look at what hospitalists interested in the FPHM MOC can expect:

Hospital Medicine Exam Blueprint Versus Internal Medicine Exam Blueprint click for large version

click for large version

The Process and Timeline

ABIM and SHM began working toward an HM-focused pathway about five years ago, and the two groups announced the FPHM program in September 2009. ABIM is in the process of retooling its website for the new MOC pathway. The entry system—to sign up and begin the MOC’s attestation process—was made public in March. The registration interface for the secure exam opened to the hospitalist community May 1, says Eric Holmboe, MD, ABIM’s chief medical officer.

“Diplomates can signify their interest and start the attestation process, which will allow them to get formal entry into the pathway,” Dr. Holmboe says. “Once they receive the attestation confirmation back, they can start doing the requirements around the medical knowledge and performance and practice requirements. Those are all available on the website. … We’re excited. The first phase of the project is live. This is a brand-new pathway for MOC, and we’re really hopeful people will find it valuable and useful.”

Board recertification is no easy task, and prospective diplomates should organize a plan of attack based upon individual workloads and regular involvement in performance-improvement programs. Some hospitalists will only need six to nine months to complete all the requirements and take the exam; others might take a conservative approach and need one to two years.

“Eighteen months is very reasonable,” Dr. Holmboe says. “Because of the 40-point requirement for the evaluation of performance and practice, that means you have to do the hospital-based PIM or self-directed PIM, or some combination thereof, twice. So if you haven’t been active in QI projects in your hospital, you really need to get going.”

Some hospitalists and HM groups work on quality-improvement (QI) projects regularly. Dr. Ammann plans to use a recent QI project looking at her group’s compliance with antibiotic selection for pneumonia to satisfy one of her required PIMs.

Focused Practice

“[The three-year] requirement should be easy for directors because we’re always doing that kind of work anyway,” she says. “We just finished a project where we had to improve our compliance with antibiotic selection. We looked at our processes and found that our pathway wasn’t clear, and it could be interpreted a couple different ways. So our chief of medicine and I just changed the pathway, put it out there, and since then, our compliance has consistently been 100%.

We have two quarters of data, and I’m going to use that for my PIM, which is nice, because it’s done.”

For hospitalists whose certification runs out in 2011 or beyond, Dr. Holmboe suggests the following timeline:

Now through end of 2010

  • Register for the Focused Practice in Hospital Medicine MOC pathway on ABIM’ website ( aspx);
  • Complete the attestation process;
  • Get involved in an appropriate (hospital-based) performance-improvement activity; and
  • Complete Update in Hospital Medicine using ABIM or ACP medical education modules.
I hope the test focuses more on what I’m doing … stroke, quality measures. Hospitalists know that stuff like the back of our hand.

—Cathleen Ammann, MD, medical director, hospital medicine division, Wentworth-Douglass Hospital, Dover, N.H.

First six months of 2011

  • Complete the next yearly Update in HM module;
  • Develop a strategy to prepare for the exam, which is given in the fall; and
  • Plan and complete your second performance improvement activity.

Second half of 2011

  • Prepare for the exam; and
  • Pass the exam.

Start Process Now, Start Earning Points

ABIM is encouraging prospective FPHM diplomates to begin working on medical-knowledge modules. Most are designed to “stretch folks and to get them to look things up.”

Family Physicians Join FOCUSED Pilot Program

The American Board of Family Physicians will participate in the new focused-practice MOC as a pilot program, Dr. Holmboe explains. Family-medicine physicians who practice as hospitalists will be allowed to use the focused-practice pathway.

“We obviously will be sharing a fair number of resources across the two disciplines,” Dr. Holmboe says. “They, too, are interested in learning about this concept of focus within family medicine. Diplomates will have to meet the same requirements as general internists.”—JC

“ACP, to their credit, also has hospital-based modules,” Dr. Holmboe says. “So if somebody is a dual member, they can certainly use the ACP’s MKSAP (Medical Knowledge Self-Assessment Program) hospital-based modules as well. We’re also working with SHM, looking for areas they might fill in around knowledge and updates—things that could be brought into the program over time.”

In regard to the evaluation and performance modules, ABIM offers three main pathways, including the Hospital-Based PIM, which targets core measure sets like community-acquired pneumonia and congestive heart failure and DVT prophylaxis. “Hospitalists can use those PIMs to start a quality-improvement program, or they can use it to report on one they are working on,” Dr. Holmboe says, adding the Hospital Based PIM’s online module will be redesigned this summer to improve the user experience.

Two other approaches are the Self-Directed PIM and the Accepted Quality Improvement programs. “That would be for hospitalists who may not be working on the core measure sets in the hospital-based PIM, but are still important,” he says. “They can use that module to report on those activities and get the points they need.”

Dr. Holmboe also points out that diplomates do not have to complete all the other requirements before they take the exam. “Some people get confused; you don’t have to cram in the 100 points before the exam,” Dr. Holmboe explains. He notes that the exam can, for example, be taken this year and the remainder of the requirements completed at a later date.

Online Exclusive

Read about a Chicago doctor who recertified in 2008 and is planning to take the FPHM MOC—again—next year.

“If it was up to me, you should do a [PIM] every year,” says Larry Wellikson, MD, SFHM, CEO of SHM and one of the architects of the new FPHM pathway. “If you are a real hospitalist, completing a PIM every three years shouldn’t be a big deal. You should be able to say, ‘I’ve looked at 10 things: how I’m doing in pneumonia, how I’m doing in DVT, how I’m doing in glycemic control. This isn’t work for me; it’s part of my workflow.’ It’s like asking a salesman how many sales calls have you made, how many miles have you driven, and how many sales have you closed.”

The Examination

Dr. Wiese, associate dean of Graduate Medical Education and professor of medicine at Tulane University in New Orleans, completed his 10-year MOC in 2008, and he says the process made him “a better physician.” As president of SHM and chair of the FPHM test-writing committee, he envisions that the new MOC pathway will help “ramp up the quality of care for the hospitalized patient.”

“The FPHM MOC process is much more than just a different exam,” he says. “It is true the secure examination will have a lot more hospital-medicine-patient content focus, but not to the exclusion of ambulatory content.”

The FPHM MOC process is much more than just a different exam. It is true the secure examination will have a lot more hospital-medicine-patient content focus, but not to the exclusion of ambulatory content. If there is one component of the exam that will [be HM-focused], it’s the questions of the exam that are focusing on the core principles of quality and patient safety.

—Jeff Wiese, SHM president, ABIM Focused Practice in Hospital Medicine Test Writing Committee chair

The content-area blueprint (see “Traditional IM Test vs. Focused Practice in HM Test” below) for the FPHM exam includes 15% of questions in the areas of quality and patient safety, along with another 15% in consultative and comanagement topics. Transitions of care and ambulatory questions make up another 15% of the exam.

“If there is one component of the exam that will [be HM-focused], it’s the questions of the exam that are focusing on the core principles of quality and patient safety,” Dr. Wiese says.

That’s music to the ears of many hospitalists—including Dr. Ammann—who know questions about managing cholesterol aren’t relevant to hospitalists. Dr. Ammann was an office-based physician before becoming a hospitalist in 2005. One year later, she was promoted to director of her group, which includes 14 physicians and two nonphysician providers.

“I was really hoping I would be able to [MOC] through the focused practice in HM,” she says. “I did practice office medicine, so I probably have a little advantage. But I was not looking forward to spending time learning and brushing up on things that I am not doing anymore—not only because I’m not doing it anymore, but it would be a waste of time because I’m not going to be doing it, either.”

One of her hospitalist colleagues is taking the traditional IM pathway to MOC, Dr. Ammann says, because “she doesn’t want to limit her scope.” But that’s not how Dr. Ammann sees the FPHM. She is committed to HM and doesn’t have “any problems kissing office medicine goodbye.”

“I think it will work out well for me, but I also think it will be great for our program to have a director who has a Focused Practice in Hospital Medicine,” she says. “It shows my commitment, and we can hold that up to the rest of the organization and say we really have someone who is concentrated in this field.”


Dr. Wiese explains the methodology behind the FPHM, READ MORE

Educational Efforts

Vikas Parekh, MD, FHM, is in his second year as the chair of SHM’s Education Committee, and says the first task at hand is to educate hospitalists about the new FPHM pathway to MOC. The University of Michigan hospitalist says his committee, working with ABIM and SHM staff, is focused on two major educational efforts: developing the SHM strategy to assist hospitalists with the new FPHM MOC pathway, and “fulfilling the needs of hospitalists, in terms of the resources they have for the MOC process.”

“We’ve already started down this route, in terms of developing resources,” Dr. Parekh says. “We’ve done a few things that have been easy. One is the ABIM learning session pre-course at the annual meeting. … It earns you points toward the medical-knowledge component.”

ABIM and ACP are the traditional avenues for medical-knowledge and practice-improvement requirements for the MOC process. SHM and ABIM currently are working to develop medical-knowledge modules in the domains of patient safety and quality improvement, areas most relevant to HM. Dr. Parekh expects those components to be available in early 2011.

“Practice improvement is likely to be our second main effort,” Dr. Parekh says. “SHM has a lot of resources within our resource rooms that have the shell of what you would really need to meet ABIM requirements for a PIM but aren’t quite complete or thorough enough, or have all the bells and whistles that ABIM wants them to have. … We think we can do a much better job focusing the PIMs to hospitalists.”

At a more granular level, Dr. Wellikson envisions a “suite of products” to assist members in the MOC process. “What we are trying to do is develop resources that help people practice better medicine,” he says, “and while we are helping you practice better medicine, you can also use that to prove to [ABIM] that you have done it.

“So if you log onto the website today and downloaded and completed any of those SHM resource rooms, somewhere in the next several months you will be able to click on a form, enter the results, send it to ABIM, and you’ll have satisfied a PIM,” Dr. Wellikson says. “You can do the work today.”

SHM’s Project BOOST (Better Outcomes for Older Adults through Safer Transitions) and Glycemic Control Mentored Implementation programs are prime candidates for Web-based PIMs, according to Dr. Holmboe.

“I think it is still very early, but we are very excited about this,” Dr. Parekh says. “I think a lot of people still have questions about what exactly this mean to me, and why should I recertify through this focused practice as opposed to the traditional general pathway? We hope to change that by making the resources focused to their practice.” TH

Jason Carris is editor of The Hospitalist.

Hospitalists as Test Subjects

Hospitalists as Test Subjects

Seeing as how the focused-practice pathway for hospitalists is a first of its kind for physician credentialing boards, the ABIM is planning a “fairly significant” research effort tracking participants’ experience, Dr. Holmboe says.

“We’re also going to spend time talking with credentialists and other stakeholders about what value they potentially see having someone participate in this focused-practice pathway,” he says. “The more folks that can do this in the first one or two years, the better, because it will give us an opportunity to learn if the approach makes sense and is providing value to the diplomates, as well as the other stakeholders, such as the hospitals and credentialing agencies.”

Dr. Holmboe also expects ABIM to explore ways to assess teamwork skills in the hospital setting. ABIM is shooting for a mid- to late-summer launch of beta testing, and hospitalists who participate in the pilot program will receive MOC credit.

“It’s an area that, when we were developing the program, came out repeatedly from the leadership of the community—how important teamwork is for this discipline,” he says.

In all, ABIM and hospitalists are blazing new trails in certification testing and fulfillment.

“It’s fair to say the HM community is pioneer in this concept of continuous maintenance of certification, or, if you want to say, maintenance of competence,” Dr. Holmboe says. “That was an initial part of the conversation five years ago. They have really set the table. What we learn from this group will help inform the MOC program.”—JC

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