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Focused practice passes its first class

May 2011

Published in the May 2011 issue of Today’s Hospitalist

WHEN J. KEVIN AHERN, MD, talks about why he sat for the first focused practice exam offered in hospital medicine last fall, he describes it as a matter of professional pride.

Dr. Ahern, who is chief hospitalist for the Sound Physicians practice at Springfield Regional Medical Center in Springfield, Ohio, remembers well the conversations he had in 2003 and 2004 when hospitalists complained that they couldn’t receive any distinct board recognition. That history made him determined to be part of the inaugural group taking the focused practice exam, even though his certification wasn’t officially up until 2014. He was one of the 84% who passed the exam on their first try. (A total of 146 physicians sat for the exam.)

“This was one of the biggest honors I’ve ever had,” Dr. Ahern says. “It was a way to show that we’re progressing as a specialty.”

Experts continue to debate whether certification and recertification really measure physician competence “or physicians’ ability to study for and pass a test. But the reality is that for most hospitalists, maintaining certification is a fact of life. And if physicians have to invest the time and money to keep their certification current, it’s a major bonus to be able to take a test that focuses on their field, as opposed to a larger specialty like internal medicine.

That seems to be the consensus of a number of hospitalists who took the focused practice exam last fall. Instead of complaining about having to endure one more recertification cycle, these hospitalists were buoyed by the fact that their specialty has finally earned its own route for recertification.

Much more relevant
For Patrick Torcson, MD, MMM, director of the hospitalist program at St. Tammany Parish Hospital in Covington, La., the ability to recertify in hospital medicine, not internal medicine, is a huge step forward.

“This exam truly reflected a new knowledge base, attitude and discipline that is uniquely different from general internal medicine,” says Dr. Torcson, who sat for last fall’s exam. “I think that’s really commendable.”

Dr. Torcson has a good point for comparison, having gone through the internal medicine recertification process once before. He, like several other hospitalists who passed the focused practice exam last year, was impressed by how relevant it was to their practice.

That includes Bedri Yusuf, MD, a hospitalist with Gwinnett Medical Center in suburban Atlanta. Like Dr. Ahern, Dr. Yusuf says he felt it was important to be among the physicians taking the first exam. That was despite the fact that he recertified in general internal medicine just the year before and didn’t technically need to re-up again until 2019.

“This exam is much more relevant for general hospitalists than the internal medicine exam,” Dr. Yusuf explains. “It is extremely focused on what we do in the hospital.”

Not only was the clinical material that the exam covered much more targeted, but many of the individual exam questions zeroed in on hospitalists’ nonclinical work in areas like quality improvement and patient safety. In addition to subspecialty questions on topics including cardiology and critical care, Dr. Yusuf says questions also covered Joint Commission mandates and Medicare regulations.

“My participation on hospital committees,” he points out, “and taking an active role in day-to-day operations helped me with this exam as well.”

The exam had so many questions geared to hospitalists’ nonclinical work that Dr. Torcson suspects that physicians content to just do rounds and not get involved in committee work or quality improvement might be at a disadvantage. “People who have only a clinical focus and are leaving other things to other members of the group may not get it,” he says.

Useful feedback
According to Dr. Torcson, the relevance of the focused practice process went beyond just the exam questions. To complete one of the self-evaluation modules, for example, he chose a clinical improvement project targeting heart failure. That allowed him to submit data from a medication reconciliation project for heart failure patients he was already working on.

“That was an initiative that was already going on at the hospital level,” he says. “I was able to adapt those data and results.” Another module he chose had him sending surveys to physicians who use his hospitalist group as consultants to get their feedback on the group.

“We ended up with a checklist of things that we needed to improve their patients’ satisfaction,” says Dr. Torcson, adding that some of the suggestions included in survey responses have now become standard practice. For example, the hospitalists now make sure to mention that they are working specifically with the patients’ primary care physician “who they identify by name “when introducing themselves to new admissions. That stemmed directly from a suggestion from the survey.

A level field for IM, FP
While the physicians interviewed for this story were pleased with how well the exam addressed their skills as hospitalists, they also applauded the bigger-picture effects that recertification in hospital medicine will have on the specialty as a whole.

For one, the process of gaining recognition for focused practice isn’t for newbies: Only doctors who’ve worked for three years as a hospitalist qualify to begin the process.

And recognition in focused practice allows both internal medicine- and family practice-trained hospitalists to take the same exam and earn the same certificate. The focused practice process is a collaborative effort between the American Board of Internal Medicine (ABIM) and the American Board of Family Medicine.

That was part of the reason why Dr. Ahern, who trained in family practice, was so determined to take the first exam. According to a spokesperson from the ABIM, 15 physicians who’d originally certified in family medicine took the focused practice exam last fall.

Richard Slataper, MD, founding SHM board member and director of a 30-physician hospital medicine service at Our Lady of the Lake Regional Medical Center in Baton Rouge, La., says that allowing both family medicine and internal medicine hospitalists to achieve the same certification opens up recruiting possibilities.

“In the past, we haven’t been able to hire practicing family practice hospitalists because of all the internists we cover,” he says. “Now, with three years of hospitalist experience and this certification, we’d be able to. Internists should feel confident about any hospitalist with this credential.”

A flexible option
Dr. Torcson predicts that the new certification process for hospitalists will have other important effects on the specialty.

Focused practice recognition, says Dr. Torcson, who’s also chair of SHM’s performance standards committee, is just one more step moving the field toward “becoming our own Medicare-designated specialty.” While he sees hospital medicine remaining a generalist specialty, he eventually thinks it will evolve into a separate specialty like cardiology or nephrology.

Dr. Slataper, however, says that even if hospital medicine does develop its own certification board, he hopes that the specialty retains the focused practice exam and process. “There is more demand than there is supply,” he points out. “We need some level of validation, but we don’t want to restrict access to qualified practitioners.”

Dr. Ahern agrees, saying that he would like to see certification for hospitalists retain the flexibility of focused practice to measure doctors’ experience, not training received in a fellowship. Focused practice allows doctors who start out thinking they want to practice traditional (inpatient and outpatient) medicine to switch gears and opt for an inpatient-only route.

And while Dr. Ahern found the focused practice process and exam to be valuable, he doesn’t want to see it become a mandated certificate that hospitalists will need to practice. Making what’s now an attractive option a mandate might throw up barriers to physicians who want to enter the field.

At the same time, Dr. Ahern says, he’s worried that if hospitalists don’t embrace the option of focused practice, this hard-won milestone might go away.

“This may be just a trial balloon for a few years,” Dr. Ahern says. “If enough people don’t take the exam, they may not continue to offer it.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

When everyday practice is study review

THE HOSPITALISTS WHO TOOK the first focused practice in hospital medicine exam last fall weren’t quite sure what to study because the test had never been offered before. But looking back on how he prepared, one physician says a few study strategies served him well.

Richard Slataper, MD, medical director of the hospital medicine service at Our Lady of the Lake Regional Medical Center in Baton Rouge, La., decided to take the exam last October, even though his certification wasn’t up until this year. He did not want to wait until the last minute to sit for the very first version of the exam.

In preparing to take that exam, Dr. Slataper says he found MKSAP useful, along with “Hospital Medicine, 2nd Edition” and the Johns Hopkins Consultative Medicine for Hospitalists perioperative modules. He also found material that SHM and AHRQ have posted on patient safety, quality improvement and care transitions helpful.

But while he regularly uses UpToDate in his daily practice, Dr. Slataper notes that there is a natural lag of a year or two before new information can be incorporated in exam question. As a result, he notes, “UpToDate may not be the best option for last-minute studying.”

Dr. Slataper also offers this qualifier: “Even without additional preparation, I felt my chances of passing were much better on this recertification than on the general internal medicine exam,” he says, noting that he’s a veteran of general internal medicine recertification. “This exam reflected what we do every day as hospitalists.”