In a little over a decade, the field of hospital medicine has achieved most of the milestones that characterize a specialty: the field is the fastest growing specialty in medical history, it has achieved wide recognition and acceptance, and there are textbooks, journals, conferences (including my 13th annual CME conference in SF beginning tomorrow, with 600 attendees), a core curriculum, a thriving professional society…
In fact, about the only thing we’ve been missing has been board certification. As you know, the American Board of Internal Medicine has been considering this issue for several years, and has spent hundreds, if not thousands, of person-hours developing a way to recognize the special focus of hospitalists within the broader context of its Maintenance of Certification program. The plan we developed (I’m on the ABIM’s board) is called “Recognition of Focused Practice” (RFP) – a pathway for practicing hospitalists to complete their maintenance of certification in hospital medicine, rather than the whole of general internal medicine (IM).
We developed the outlines of RFP-HM about 2 years ago; I described it then in the Journal of Hospital Medicine (here). In brief, to qualify, a hospitalist who is certified in IM (it is possible, but not guaranteed, that family medicine and pediatrics will develop similar pathways) will have to meet a certain inpatient volume requirement for 3 years, participate in hospital-focused self-evaluation and quality improvement modules (“Practice Improvement Module”, or PIM), and then pass a hospital medicine-focused exam. A superb committee of leaders in our field, chaired by Tulane’s Jeff Wiese, has been hard at work developing this test and fleshing out the rest of the process.
The ABIM has been fully committed to this pathway (and, I have to say, incredibly supportive of hospitalists more generally – special thanks to Chris Cassel, Dan Duffy, Lynn Langdon, Paul Poniatowski, Rich Baron, John Popovich, and many others). But there was another hurdle to cross before ABIM could launch its RFP in Hospital Medicine (RFP-HM). You see, ABIM is part of an umbrella organization of certifying boards called the American Board of Medical Specialties. ABMS has been thinking hard about RFP – and for good reason. Traditionally, board certification has been reserved for specialties defined by a discrete training experience (i.e., a residency or fellowship), and hospital medicine is arguing for a new kind of certification based on expertise acquired and focus demonstrated while in practice. This is a big deal: in a world in which a general internist might want to say, “I’m a diabetes expert, borne of my extensive experience in my primary care practice,” (and, for the word, “diabetes”, you can substitute about 1000 different areas to get a sense of the breadth of the problem) there are obvious slippery slope concerns.
Yet ABMS recognized the unique aspects of hospital medicine, and embraced an algorithm that the ABIM has used in thinking about whether a field might qualify for RFP: many physicians in the originating specialty (in our case, general internal medicine) only practice in the focus area, and many physicians never practice in this area. This criterion allowed us to argue that hospital medicine – a field in which more than 25,000 internists now only practice in the hospital and at least that number of general internists never do – qualified, while diabetes, or heart failure, or depression does not. (HIV medicine might be another appropriate contender.)
I write today because I received a number of text messages from ABIM colleagues a few hours ago (all followed by multiple exclamation points) informing me that ABMS has approved a pilot program of Recognition of Focused Practice in Hospital Medicine. As I understand it, the program will be ready to launch in about a year, and individuals interested in the specifics should keep their eyes on the ABIM website or contact the organization (some FAQs, not yet updated with today’s news, are here). I imagine that most of the initial participants will be folks nearing the end of their board certification cycle (i.e., approaching year 10), for whom doing MOC in hospital medicine will be more in sync with their professional focus than doing it in all of general medicine. Over time, if the market for hospitalists “values” this certificate, it’s possible that hospitalists will choose to pursue RFP before their initial certificate expires – time will tell.
In any case, this is an important milestone for the field. In fact, when I first began speaking to groups of hospitalists nearly 15 years ago, I often showed a slide listing the elements of a true specialty, and one-by-one we’ve ticked them off. The only unchecked box was recognition of the field as a legitimate “specialty,” as codified by the ABMS board certification process.
Unchecked, that is, until today.