Should Hospitalists Pursue the Focused Practice Option?

Shelly Reese


February 07, 2018

Hospitalists have a branding problem. Lacking clinical fellowships or residency programs dedicated to the field, they've struggled to assert their identity and demonstrate their skills as unique and different from those of physicians practicing in an outpatient setting.

The Focused Practice in Hospital Medicine (FPHM) pathway is an effort to address that. The FPHM Maintenance of Certification designation, which the American Board of Medical Specialties approved last year after a 7-year pilot, is a variation on the internal medicine MOC that tests hospitalists' understanding and mastery of hospital-based practice areas such as quality improvement, patient safety, palliative care, and perioperative medicine.

Not only does the FPHM enable hospitalist to take a MOC that more closely mirrors their workaday lives, but it also helps cement their identity as hospitalists, says Nick Marzano, director of education for the Society of Hospital Medicine (SHM). "It's another step to defining the specialty."

From Pilot to Pathway

Since the American Board of Internal Medicine (ABIM) and the American Board of Family Practice (ABFP) began piloting the focused practice designation in 2010, only a fraction of hospitalists have pursued it. As of February 2017, just over 1340 ABIM board-certified physicians in the United States held the FPHM designation. Another 380 took the FPHM exam last year. Even fewer ABFP board-certified physicians—just 217 since 2010—have sought the recognition in focused practice. That's partly due to the size and demographics of the group. When the pilot was launched, there were only about 30,000 hospitalists, roughly half the number that there are today.

Many of these doctors are young and often new to the field; more than a third (37%) of hospitalists are 40 years old or younger, and nearly a quarter (24%) say they've practiced hospital medicine for less than 5 years, according to Today's Hospitalist's 2017 Compensation and Career Survey. Consequently, they haven't needed to recertify yet or do not have the 3 years of hospital experience required to sit for the FPHM exam.

There was also a learning curve associated with the pilot, says Dr Jeffrey Wiese, a former SHM president who served on the ABIM's FPHM exam writing committee. When the pathway was initially piloted, it involved performance and practice improvement requirements that were likely too onerous, he says. In addition, the FPHM MOC was slightly more expensive than the traditional internal medicine MOC, creating a financial disincentive for would-be test takers.

Those obstacles have since been ironed out, he says. Today there's greater parity between the traditional program's requirements and those of the FPHM, greater access to specialized exam-preparation materials—SHM offers a self-assessment designed to be an FPHM exam and a suite of educational modules—and the cost of the traditional internal medicine MOC and the FPHM option are the same. (According to Robert Cattoi, ABFM Communications, doctors certified in family medicine must pay a $1300 exam fee on top of their ABFM recertification fees.)

Dr Andrew Auerbach, a hospitalist at University of California San Francisco Medical Center and a founding member of the FPHM Taskforce, says the pathway in place today is important not only to the professional development of individual hospitalists, but to the field itself. "People are putting their hands up and saying, 'This is what I want to do for a career,'" he says. "It's an external manifestation that this person is committed to the field."

To Focus or Not to Focus?

Although hospitalists appreciate the distinction that the pathway conveys on their field and welcome an exam that focuses on their specific skills and knowledge, they say the pathway needs to overcome some perceived hurdles if it is to gain wide acceptance.

I'd like to see ABIM recognize hospital medicine as a separate specialty; I think that would drive a lot of physicians and providers to pursue it.

Dr Umesh Sharma, chair of the division of community hospital medicine for the Mayo Clinic Health System in Rochester, Minnesota, opted to stick with the traditional internal medicine designation when he recertified in 2015, as have most of the hospitalists he knows. Dr Sharma says the physicians he's spoken with feel that the general certification affords them greater flexibility should they decide to return to outpatient care.

"I think the bottom line is that since hospital medicine is not a separate specialty, like emergency medicine or critical care, a lot of physicians don't see the FPHM as beneficial yet," says Dr Sharma, whose group includes 80 hospitalists. "I'd like to see ABIM recognize hospital medicine as a separate specialty; I think that would drive a lot of physicians and providers to pursue it."

In contrast, Dr Patrick Torcson, vice president of clinical integration at St. Tammany Parish Hospital outside of New Orleans, Louisiana, was one of the first hospitalists to sign up for the FPHM exam when he recertified in 2010 and says he will do so again when he recertifies in 2020.

"For me, the focused practice MOC was superior in terms of supporting and benefiting my practice as a hospitalist. With everything that is changing in the care of hospital patients—the emphasis on performance improvement, quality management, and ethics—it forces you to study and prepare for areas that don't always come up in day-to-day practice," he says.

Dr Torcson has touted the merits of the pathway to the 20-plus hospitalists practicing at his 250-bed community hospital. "Everyone is pretty much going the focused pathway route, and I think I may have had some impact on that," he says.

Still others see the merits of both sides. Dr Sendil Krishnan, medical director of Triad Hospitalists, a 70-provider group in Greensboro, North Carolina, chose the FPHM path when he recertified in 2014. "I absolutely took the focused exam, and I try to advocate for it. It was the easiest for me to study for because it covered a lot of stuff that I do every day. Those of us who have been doing hospital medicine for a long time prefer preparing for the hospitalist exam and not trying to remember immunization schedules."

In talking to his peers around the country, however, Dr Krishnan says most have opted for the traditional route because it is familiar, they think it gives them more professional flexibility, or they've heard rumors that it's easier. As a general rule, he says, "people have gravitated to the test with which they feel most comfortable. I haven't encountered anyone who wishes they had taken the other test."

The 2-Year Option

Physicians facing recertification in the next couple of years have another wrinkle to consider in deciding whether to pursue the FPHM.

This year, ABIM is rolling out a new every-2-year "Knowledge Check-In" option for its internal medicine MOC. The new option enables diplomates to maintain their certification by taking smaller, more frequent assessments rather than retesting once a decade. But the Knowledge Check-In option won't be available for the FPHM until 2020. That could be a disincentive for physicians facing near-term recertification who dread the prospect of prepping for a high-stakes exam.

For his part, Dr Krishnan doesn't think the delay will dissuade many physicians from pursuing the focused path. "Most of the doctors I speak with aren't big on the 2-year option," he says. The general consensus seems to be that "it's better to have a super-painful option every 10 years and get it over with. People go into a different mode around recertification time," he explains. "They feel like that time in their life is put on hold. I think doing that every 2 years would be hard."

Dr Torcson agrees. Although he will be able to choose between the two options when he takes his exam in 2020, "I'm definitely in tune with the 10-year cycle. For me personally, that works well, but I like that there's a flexible option."

The MOC Debate Continues

Even as hospitalists consider whether to pursue the FPHM pathway, the debate over the cost, burden, and value of MOC continues. Frustration over MOC spurred a group of physicians in 2015 to form the National Board of Physicians and Surgeons (NBPAS), an alternative certifying body. NBPAS diplomates must earn initial certification from the ABMS, but the group uses accredited continuing medical education, instead of MOC, as its primary measure for continued certification.

Although ABIM has since revised its MOC program, including developing the newly launched Knowledge Check-In, physicians are still frustrated, says Dr Krishnan, who is certified with the NBPAS as well as the ABIM. He argues that MOC remains too expensive, that exam pass rates should be based on absolute performance—not relative to other test takers—and that results should be instantaneous rather than weeks in coming.

The process may be better, and the FPHM option may mark a step forward for hospitalists, he says, but MOC is a long way from fixed.


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