Following the focused practice pathway

Hospitalists discuss pros and cons of recertification option.

Since 2010, hospitalists renewing their board certification have faced a choice: Stick with the specialty of their initial certification, internal medicine or family practice, or opt for the new focused pathway in hospital medicine. After evaluating the pros and cons of following the pathway or staying with general internal medicine, a small but growing number of hospitalists have opted for focused practice.

The pathway attracted about 150 internal medicine hospitalists each year in the first few years but there were 265 taking the focused practice exam through the American Board of Internal Medicine (ABIM) in 2015. (The American Board of Family Medicine administers its own portion of the focused practice pathway for family physicians.)

Photo by Thinkstock
Photo by Thinkstock

To understand what's driving hospitalists' decisions on this choice, ACP Hospitalist spoke with hospitalists who have recently recertified, including some of those who helped launch the pathway.

“For somebody that practices solely as a hospitalist, the idea of focused practice was to design an exam and a program that really reflected what they did and wasn't testing them on things they didn't do,” explained Jeffrey Wiese, MD, FACP, chair of the ABIM's internal medicine board and a creator of the focused practice pathway.

That goal appears to have been achieved, according to Patrick Torcson, MD, FACP, medical director for the department of hospital medicine at St. Tammany Parish Hospital in Covington, La., who took the exam in its first year.

“I was fortunate to have the vantage point of being able to compare the focused practice with the general internal medicine recertification process that I'd taken 10 years before,” he said. “I felt that the recertification process as a hospitalist was much more relevant and actually provided more of a knowledge update than the general internal medicine recertification process was relevant to my practice as a general internist at the time.”

Other hospitalists are not yet convinced. Gretchen Diemer, MD, FACP, opted to recertify in general internal medicine in 2014, despite being a hospitalist at Thomas Jefferson University Hospital in Philadelphia.

“I felt [the general exam] was very relevant.... I didn't feel like there was a whole lot on there that was not in my usual scope of practice, or at least things that I would have understood based on transitioning patients in and out of the hospital,” Dr. Diemer said.

On the other hand, she acknowledged, she doesn't know what it would have been like to take the focused practice exam. “I hadn't received a lot of information about it as an option,” she said. “I think there's not clear benefit from doing the hospitalist pathway, in terms of what it gets you.”

Many hospitalists may lack clarity on that question, agreed David Wooldridge, MD, FACP, a hospitalist at Saint Luke's Health System in Kansas City, Mo., who wrote questions for the focused practice exam. “I don't think that we've done a great job of marketing it within the hospitalist community,” he said.

The pathway leaders themselves are not yet entirely sure what the exam “gets” a hospitalist. “I can imagine a day where the focused practice in hospital medicine recertification is looked upon as something desirable by group directors for hospitalist practices or CEOs—whoever is doing the hiring,” said Dr. Wooldridge.

Right now, not enough hospitalists have had the option to take the exam—which is offered only on recertification, not initial certification—to create such an expectation. “Hospitalists compared to other specialties are reasonably young, so many of the people who we thought would immediately enter the pathway I think did, but they just weren't due for their 10-year exam for another 7, 8, 9, 10 years,” said Dr. Wiese.

The certification will probably not become a requirement of hospitalist employment anywhere, Dr. Wiese said, but it could convey a level of commitment to the field, by indicating “somebody that's not just doing it for a year or two, en route to going back for a cardiology fellowship, versus somebody who is committed: I'm going to do this as a professional endeavor for the rest of my life,” he described.

It could also help physicians distinguish themselves from the many types of physicians now calling themselves hospitalists, added Jeff Glasheen, MD, chief quality officer for the University of Colorado Hospital Authority, a member of the committee that created the pathway, and current chair of the test-writing committee.

“My wife, who is a gastroenterologist, in her 1 week every 8 weeks where she's in the hospital seeing patients, she'll call herself a ‘GI hospitalist,’” Dr. Glasheen said. “If all it takes to be a hospitalist is to be in the hospital, that tends to devalue what a hospitalist really means.”

However, some physicians see greater value in not making their status as a hospitalist so formal. Jonathan Stallkamp, MD, is a hospitalist with Main Line HealthCare in Wynnewood, Pa., who recertified in general internal medicine in 2013.

“I'm also a physician administrator,” he said. “One of my concerns on this focused practice and losing my generalist approach is that I would be more considered just a plain hospitalist: ‘Oh, you don't understand the world of a general internist,’” he said.

Similar concerns contributed to Dr. Diemer's choice. “As a program director, I felt I needed to make sure that I really had the medical knowledge through all aspects of internal medicine to adequately train all of our residents. I didn't really want to ‘specialize,’” she said.

Test length and pass rates also gave the hospitalists pause about the focused practice exam. “The exam is longer, but marginally so,” said Dr. Wiese. Because the pathway begins with recertification, questions can't be piloted on an initial board exam. “So when we test new questions for the hospital medicine Maintenance of Certification exam, it requires a few extra questions,” he said.

According to ABIM, pass rates for the focused practice exam were 88% in 2011, 86% in 2012 and 2013, and 85% in 2014 and 2015. (Rates among first-time takers of the general internal medicine exam were 87%, 84%, 78%, 80%, and 88%, respectively.)

Taking an exam specifically designed not to test initial medical knowledge was a boon for Christopher Sankey, MD, FACP, a hospitalist at Yale-New Haven Hospital in Connecticut who recertified under the pathway in 2015.

“In 2005, when I certified for the general internal medicine boards, I still remember the super-annoying questions like ‘What specific part of the nephron did this one kind of chemotherapy have a toxicity for?’” he said. By contrast, he found the focused practice exam to be “a fair representation of the inpatient practice of internal medicine, especially with there being a specific representation of quality, patient safety, and palliative care.”

That's just what the question-designers were aiming for, according to Dr. Glasheen. “A number of times we've gotten to the end of writing a question and we're like, ‘You know what, the average hospitalist in the community does not need to know this.’ And we throw the whole thing out,” he said.

The exam's focus on quality and safety was meant to encourage hospitalists in their work in those areas, program leaders said. Initially, the pathway included a requirement for a quality improvement project every 3 years, but that component was dropped.

Other concerns project leaders have heard from hospitalists considering the focused practice pathway include the cost ($2,060 versus $1,940 for general internal medicine), which is a part of the protocol for any new certification exam, according to Dr. Wiese.

There's also the issue of what to study for this new exam. “That's the nitty-gritty question hospitalists really want to know, once they decide to take the test,” said Dr. Sankey. He used learning modules from ABIM to prepare.

Another option is ACP's Medical Knowledge Self-Assessment Program (MKSAP). “The MKSAP 16 and 17 products were specifically designed with the ABIM examination blueprint for the focused examination in hospital medicine in mind, the very first product to do that,” said Patrick Alguire, MD, FACP, the College's Senior Vice President for Medical Education. The Society of Hospital Medicine also has a study resource for the exam, called SPARK.

Some hospitalists have also wondered about the future of this new certification and whether it could disappear or be replaced by a full subspecialty certification. If the former were to happen, certifications in the pathway would revert back to general internal medicine, Dr. Glasheen said.

Because this focused practice pathway is within internal medicine, there's also no need for physicians to recertify in both hospital medicine and general internal medicine, according to Dr. Wiese. As for becoming a full subspecialty, it's not likely, he said.

“There are absolutely no plans to expand the pathway into a separate subspecialty certification,” he said. “The focused practice in hospital medicine is much more like [a Master of Business Administration]. Anybody who teaches an MBA curriculum will tell you the last thing they want in an MBA classroom is somebody right out of college.... Every other specialty or focused practice in medicine is really hinged on some formal training right out of residency, and this is much more a demonstration of competence in the context of what you've done.”

Now the pathway creators just have to wait to see how many hospitalists choose this option of demonstrating their competence. “It'll be interesting to see what happens in the next few years as the younger crowd gets ready to take their first Maintenance of Certification exam,” said Dr. Wooldridge.