Published in the January 2007 issue of Today’s Hospitalist.
Ten years ago, the leaders of the fledgling hospitalist movement didn’t even talk about a separate certification process for physicians who called themselves hospitalists. Any such suggestion, they knew, would raise a storm of protest from other physicians worried about being shut out of inpatient care.
What a difference a decade makes. Late last year, the American Board of Internal Medicine (ABIM) announced that it was moving forward to develop a specific recertification pathway for hospital medicine. According to an announcement posted online by the Society of Hospital Medicine, the ABIM’s decision marks the first time the board has designated a new credential-known as "focused recognition"-for a subset of internal medicine. It is also the first time that the ABIM is developing a certification credential not directly tied to a specific type of training requirement.
Exactly what focused recognition for hospitalists will look like won’t be known until later this year. But according to Robert M. Wachter, MD, who was named chair of the ABIM’s ad hoc committee that will make recommendations about the new pathway to the board, the move marks a milestone in hospital medicine’s coming of age.
"The field has grown and thrived organically without any specific formal recognition," says Dr. Wachter, a member of ABIM’s board of directors and the director of the hospitalist service at University of California, San Francisco. "It now has grown to the point where we feel it’s the right time to recognize those physicians who have focused their practice on hospital medicine."
Dr. Wachter spoke with Today’s Hospitalist about the new pathway.
The ad hoc committee will make recommendations to the ABIM. What is the timeline?
The committee will meet for the first time this month. We’ll then take a fairly fast track to finish our report in time to go to the board for consideration this summer.
Whatever decision the board makes will have to be blessed by the American Board of Medical Specialties, the larger umbrella organization. Even if focused recognition moves along fairly quickly, it won’t be a reality for a couple of years.
Was there some urgency to make sure hospital medicine got some designated certification process?
I wouldn’t say "very urgent," because that implies a willingness to take short-cuts. My sense is that over the last few years, both the board and the field of hospital medicine have come to feel that this was the right thing to do.
At the same time, everyone involved realized how tricky this is to get right, on many levels. Hospital medicine is a brand-new field. It’s still evolving and any kind of formal certification has to be seen in the context of what’s happening more broadly to general internal medicine. We have to consider, for example, the impact this might have on the attractiveness of primary care. We also have to think about whether there should be a parallel certification pathway for someone who focuses on ambulatory-based internal medicine.
At the same time, the ABIM has to consider the case of hospital medicine in light of more general changes to the certification process that are likely over the next 10 or 20 years. So no one wanted this to go fast at the expense of getting it right.
The new credential will fall short of designating hospital medicine as a subspecialty. What are advantages to that? Personally, I don’t pay a lot of attention to whether or not hospital medicine will be considered its own "specialty" or "subspecialty." The point is that there are now many practitioners who have focused their practice in a certain area, and we need a way for them-as well as for employers and the public-to recognize that.
That said, we want to keep certain considerations in mind. One, we don’t envision this as being a recognition that would require additional formal training, such as a fellowship.
And we don’t want something so rigid that people will lose the ability to move back and forth between different care settings. Some people now start in primary care, become a hospitalist and stay a hospitalist forever. Others work as a hospitalist for five years and then transition to a completely different job. As we think through the implications of certification, we want to respect that fluidity in both directions.
What options are being considered for focused recognition?
First, we’re not talking about changing the process of initial board certification in internal medicine.
However, we want to figure out some mechanism whereby physicians who practice as a hospitalist for several years-that number still needs to be determined-would be able to participate in a recertification process that would lead to focused recognition in hospital medicine.
Part of this would be sitting for an exam that would likely be different than today’s recertification exam in internal medicine.
One challenge is this: Should we take today’s internal medicine exam in maintenance of certification and simply add questions about hospital medicine? Or should it be a different test that focuses on hospital medicine, with fewer questions on preventing osteoporosis, for example, and more questions on managing sepsis or acute stroke. This will need to be sorted out.
So the recertification exam may be different. How about the self-evaluation portion of the process?
It’s quite likely that the self-evaluation and practice improvement modules you could choose from would be focused to some degree on hospital medicine. We’ll have to see whether that would be the exclusive focus.
I personally think hospitalists have to keep up with inpatient cardiology and inpatient neurology, for example. So some modules may have an overarching hospital medicine "branding," but there may be the opportunity to participate in other relevant areas that aren’t branded as such.
Whatever the final process, it has to be both user-friendly for participants and sufficiently rigorous to be credible to all stakeholders.
What would the advantages of focused recognition be for individual physicians?
One way to think about that is to look at the advantages of maintenance of certification in general. I think those advantages are real in terms of professional advancement, personal satisfaction, and, increasingly, the way you’re perceived by insurers, institutions and patients. We’ve come to a time in American medicine when patients want a level of assurance that their physician is maintaining competence and expertise.
Focused recognition would make the recertification process more relevant to hospitalists because they’d be studying and reflecting on what they actually do for a living. It would also help separate out hospitalists who have really focused on hospital medicine for a career from the physician working in hospital medicine for a year before starting a fellowship or something else.
As for what tangible advantages certification might bring, that depends on the market.
Do you think hospitalists may eventually need this credential to be hired?
I think over time, we’ll see certain institutions that will want to hire physicians who either have this certification or are engaged in the focused recognition pathway as one marker of their career focus and perhaps of the quality of their practice.
Will hospitals ultimately say, "Physicians must have this credential to be able to serve as a hospitalist in our organization"? I doubt that will happen, and if it does, it’s many, many years away.
Look at how long it’s taken hospitals to put in hiring criteria for intensivists in the ICU. Very few ICUs-virtually all in big academic institutions-exclude physicians from seeing patients because they’re not board-certified intensivists. Nevertheless, the credential demonstrates focus and expertise, and has real value.
Phyllis Maguire is Executive Editor of Today’s Hospitalist.