Focused Practice Recognition Sets the Bar in Hospital Medicine

The steady growth of hospital medicine has led to a push for specified certification in this field. But who should provide that certification, and is the move in this direction good or bad for hospitalists and hospital medicine?

Back in the early days of the hospitalist movement, Robert Wachter, MD, professor, University of California, San Francisco and physician blogger, expressed the belief that any formal identification of physicians who worked specifically as hospitalists would hinder the growth of hospital medicine. Since then, the hospitalist movement has grown rapidly, from 2,000 practicing hospitalists in 1998 to nearly 30,000 today—exceeding even Wachter’s expectations. As such, the focus has turned from concern over restricting hospital medicine’s growth to recognizing it.

“I think there’s a natural tendency for a group of people who are doing specialized work to, over time, begin to say ‘we are different,’” says Wachter, who first coined the term “hospitalist” in 1996. “There are certain competencies that we have accrued through our work, our experience, and our training that are different, and we would like the world around us to know that.”

Growth driving change

In a March 13 blog post, Wachter noted that a recent NEJM study “proves what we all know—the hospitalist field is the only thing growing faster than the national debt.” The study analyzed data from Medicare claims and found a substantial increase in the care of hospitalized patients by hospitalists. Wachter also pointed out that the study reveals that one of the key factors driving the growth of hospital medicine has been an increase in co-management of other patient populations. For example, the study found that in the US, the chances that a patient with an orthopedic or neurologic DRG will be managed by a hospitalist are the same as for a patient with a pulmonary or gastrointestinal DRG.

“Hospitalists are doing as much work helping surgeons manage their complex patients as they are with more traditional internal medicine patients,” Wachter says. “And we think there is virtue in having that codified by some sort of designation that tells everyone that you’ve achieved a certain level of competence associated with practicing in this field.”

That designation is taking shape in the form of focused practice recognition through the American Board of Internal Medicine (ABIM) Maintenance of Certification (MOC) program in internal medicine. According to the board’s website, the MOC permits recognition of areas within the broad domain of internal medicine in which diplomates achieve focused proficiency through practice. Hospital medicine is the first area to be considered for focused practice recognition.

Christine Cassel, MD, MACP, president and CEO of ABIM, says the board’s policy on recognizing new areas of specialization is directly related to three key factors: a well-defined area of practice to set boundaries around; enough people practicing in that area; and a public benefit to having a defined specialist in the area. The growth in hospital medicine over the last decade clearly addresses the first two criteria. As to the public benefit, Cassel says that is apparent as well.

“Right now, people are self-declared hospitalists,” she explains. “They can apply for a job with a hospital, and the hospital really doesn’t have any way other than checking references on their last job to see how good they are. And since hospital medicine is a field that has emerged dramatically over the last decade, there is now a set of knowledge standards and a volume of performance and experience to demonstrate a certain set of skills that are pretty well defined.”

Certification adds value, and caveats

Steve Stahl, MD, is a board-certified family physician who has worked as a hospitalist for the last four years and manages a six-physician hospitalist team for New West Physicians, the largest primary care group in Colorado. He agrees that patients are the primary beneficiaries of hospitalist certification, noting that patients often ask, “Why is someone other than my primary doctor taking care of me at the hospital?”

“I think that’s often confusing to patients,” Stahl says. “Certification helps to identify the reasons why patients would want to have a hospitalist caring for them rather than their regular physician.”

However, Stahl adds that hospitalist certification may actually end up hurting small, rural hospitals in the short run. He says that although small, rural hospitals are interested in hiring hospitalists as a means of standardizing care, the problem is that there are currently not enough physicians to fill hospitalist positions in large cities, let alone smaller rural areas. “Smaller hospitals may look at certification as a negative because there’s not going to be a supply of hospitalist physicians who want to live and work in rural areas.”

Felix Aguirre, MD, vice president of Medical Affairs for IPC, The Hospitalist Company, is also concerned. Aguirre agrees that becoming certified in hospital medicine would be a feather in the cap of internists, family practitioners, and pediatricians and garner public recognition for their focus on hospital medicine. The challenge for a company like IPC, he says, will be to ensure that its doctors obtain certification as quickly as possible.

“If you are a hospitalist company and you claim to be one of the leaders in the field, you may be expected to have a high number of your doctors board certified,” Aguirre says. “It takes time to get a large number of doctors to that level. And the initial problem is that there is already a shortage of hospitalists. To cut it up into an even smaller board-certified or focused recognition, hospital medicine business would restrict the amount of business that you can handle.”

Cassel acknowledges that 20,000-plus hospitalists cannot be evaluated in one year, but she hopes that people will understand that achieving focused practice recognition in hospital medicine is a process that will take time. That process, she adds, should start in 2010, and she estimates that ABIM could take care of all comers within about 18 months.

“It isn’t just an exam any more,” Cassel explains. “There are performance metrics. There are competencies that have to be demonstrated, and physicians have to show us that they’ve seen a certain number and type of patient.”

Certification criteria

The ABIM has been working closely with the Society of Hospital Medicine and the American Board of Medical Specialties—the umbrella organization overseeing ABIM, the American Board of Pediatrics, and the American Board of Family Medicine—to develop the focused practice criteria.

“We need to be solidified as a specialty to be able to move focused practice recognition forward,” says Aguirre, who, through SHM, is involved in the public policy committee. “If we’re disenfranchised or split or splintered, we’re not going to make as much progress on this as we need to.”

Joel Strohecker, DO, a board-certified family physician with New West Physicians, serves on an American Academy of Family Physicians committee examining the kind of added qualifications that might be established in family practice. He says the goal is to develop criteria that are uniform across the board.

“The reality is that there are pediatric hospitalists who will be doing something different than what family practice or your traditional internal medicine doctors will be doing,” Strohecker says. “Most family practice hospitalists want to do what the internal medicine docs do, which is typically inpatient adult medicine. Pediatricians already have their own separate criteria for their development, so it really just leaves family medicine and then internal medicine. I believe the family medicine percentage is small, maybe 5-10% of all hospitalists in the country. But the reality is that they’re all needed, so there’s a desire by the ABIM and the Society of Hospital Medicine to include family medicine as much as possible. And I think SHM is aware of what need to be our core competencies.”

ABIM is currently working to define the needed evidence of proficiency in hospital medicine practice and set appropriate requirements for the program. According to its website, the requirements are likely to include evidence of providing an appropriate volume of patient care focused in hospital medicine; assessment of new developments in hospital-based internal medicine; self-assessment of practice performance and quality improvement; and a secure examination of essential knowledge and clinical judgment.

Physicians will not be required, says Cassel, to go back and do a fellowship in their area of specialization. “For example, you can’t be board certified in cardiology unless you’ve had an additional three years of training in cardiology,” she explains. “Our board doesn’t think that’s necessary for hospital medicine.”

Competitive environment?

In January 2009, the American Board of Physician Specialties, a non-profit organization based in Tampa, FL, announced the new American Board of Hospital Medicine, offering board certification exclusively for hospitalists. According to the organization’s website, acquiring certification includes passing a multiple-choice and single-response written exam at a computer testing center, the cost for which is $1,575.

Wachter, a member of the ABIM board of directors, admits he’s biased, and says, “It’s America, and I hesitate to say that competition is unhealthy.” He adds, “I think people should have their eyes open. And when I thought of having board certification for the field of hospital medicine, my thought was the ABIM. That organization has tremendous credibility and recognition in the universe of healthcare.”

Jeanette Abell, MD, MBA, a board-certified internal medicine physician and head of the new hospitalist service for the Halley Consulting Group, a Columbus, OH-based physician practice management and consulting firm, is not a member of the ABIM board. However, her sentiments match Wachter’s. “Most of us in internal medicine consider being boarded through ABIM as the gold standard,” Abell notes. “We know they have very rigorous standards. I have some concerns with the American Board of Hospital Medicine; I’m not comfortable that it’s as rigorous of a process as my expectations would be if I was going to go that next step.”

The SHM, in an e-mail to its members, indicated that it has no affiliation with ABPS and was not involved in the creation of the American Board of Hospital Medicine. The e-mail further stated that “the best recognition for hospital medicine is the one that is the most rigorous and most widely accepted by hospitals, payers, employers, other physicians, and our patients. These are the boards that are sanctioned by ABMS, such as ABIM, ABP, and ABFM.”

Benefits outweigh pitfalls

Recognizing hospital medicine as a focused practice through the ABIM Maintenance of Certification program means establishing a clear set of guidelines for physicians who have embraced the hospitalist movement and recognizing that they’re not just going into the hospital, rounding and seeing patients. Wachter says that any time you set such a bar, there will be people who are not able to jump over it, for various reasons. But, he adds, that doesn’t mean you don’t set that bar.

“You can always argue that you shouldn’t set it because you’re going to disenfranchise somebody, or someone looking to hire a hospitalist can’t find people who have crossed that bar,” Wachter says. “In general, I don’t buy that. In general, I think that the process of setting standards and declaring what the field and other stakeholders believe sends the message that certain expectations of competency is healthy. It makes the world a better place to have that set of expectations.”

Those expectations, says Aguirre, will have positive long-term effects for hospital medicine. “In five or seven years, there will be as many hospitalists in the US as there are ER doctors. So, we’re definitely poised to be able to do a lot of good things for medicine in general.”

Ed Rabinowitz is a veteran healthcare journalist based in Bangor, PA.