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Questions and Answers about ABIM Recognition of Focused Practice in Hospital Medicine

ABIM is developing a program to assess, set standards for, and recognize the proficiency of general internists who focus their practice in the care of hospitalized patients. The Board’s decision to advance this program is consistent with its primary role of certifying internal medicine physicians who meet the profession’s standards for focused practice in internal medicine.

In addition to certification in subspecialties of medicine, which requires additional fellowship training, the Board is offering a new initiative to recognize areas of “focused practice” through its Maintenance of Certification (MOC) program in internal medicine. 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; over time, ABIM will consider other areas that meet criteria it has developed to identify such major, emerging areas of practice focus within internal medicine.

As a new initiative, the proposal to recognize focused practice needs to be considered by the American Board of Medical Specialties (ABMS), which sets policies governing the certification and MOC programs of its 24 member boards. As a result of this review, the final disposition of a focused practice program for hospital medicine is subject to change; however, ABIM anticipates that the program will open for qualified diplomates by 2010. ABIM is posting the following Questions and Answers to help diplomates understand this evolving program. Diplomates should check this site for periodic updates.

1. Why is ABIM recognizing focused practice in hospital medicine?

   The practice of hospital medicine has reached a state of maturity within the discipline of internal medicine, as demonstrated by the large and growing numbers of physicians who have concentrated their practice in the hospital setting (along with large numbers of general internists who no longer practice in the hospital setting). The Board’s decision to recognize hospital medicine acknowledges the value that hospital-based internists can bring to improving patient care in this practice setting. The characteristics of focused hospital practice are described in the field’s published core curriculum (Journal of Hospital Medicine 2006 1(S1): 2-95). The rapid growth and development of this field is evidenced by the fact that there are currently about 20,000 hospitalists in the United States; approximately 85% are internists.

2. Why isn’t ABIM making hospital medicine a subspecialty of internal medicine?

   According to American Board of Medical Specialties (ABMS) policy, a subspecialty constitutes a body of knowledge or technique that is beyond that of the broad discipline of internal medicine. Acquiring the subspecialty knowledge and skill requires additional training and directly supervised performance of procedures or application of specific practice methods by experts in the field. Subspecialty practice involves applying internal medicine as well as specialized knowledge and procedures to a subset of internal medicine patients. In contrast, hospital medicine is the practice of internal medicine for patients during hospitalization. The recognition of focused practice through MOC provides a method for assessing proficiency in hospital care.

3. Will diplomates be eligible for recognition of focused practice in hospital medicine at the completion of internal medicine training?

   No. Developing a practice focus requires a period of experience in unsupervised practice and demonstration of proficiency beyond that expected in residency before it can be recognized by ABIM. The MOC program can recognize such practice differentiation through demonstration of proficiency acquired through practice and modification of the initial internal medicine certification to reflect the practice focus. So a typical internist seeking ABIM recognition of focused practice in hospital medicine must complete training in internal medicine, be certified in internal medicine, and engage in a practice that focuses primarily on hospital medicine for several years.

4. How will ABIM implement the MOC program for focused practice in hospital medicine?

   ABIM is one of 24 member boards of the American Board of Medical Specialties (ABMS), which sets the policies and processes governing certification of medical specialists in the United States. ABIM is working with ABMS to develop the process for recognizing focused practice through MOC. ABMS must determine how ABIM’s MOC program for recognizing focused practice in hospital medicine will affect the certification and MOC programs of the other member boards. The time frame for this ABMS process is uncertain. While the deliberations are ongoing, ABIM is further refining the focused practice concept, as well as defining the competencies and developing the assessment tools needed for its application to hospital medicine.

5. I’m a hospitalist with an internal medicine certificate expiring in 2009. Should I wait for the hospital medicine program before beginning Maintenance of Certification?

   The Board recommends that you not allow your internal medicine certification to lapse. However, as you complete the requirements to maintain your internal medicine certification, you can choose self-assessment options that are relevant to hospital practice, such as the Hospital-Based Internal Medicine medical knowledge modules and the Hospital-Based Patient Care Practice Improvement Module (PIM). In this way you will have completed MOC evaluations that will also count toward requirements for the hospital medicine focused practice program should you later choose to pursue this recognition.

6. How will the MOC program for focused practice in hospital medicine work?

   ABIM is working to define the needed evidence of proficiency in hospital medicine practice, developing the assessment tools, and setting appropriate requirements for the program. These requirements will likely 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. Completion of the program would identify diplomates as having maintained their internal medicine certification focused in hospital medicine.

7. As a hospitalist-internist, would I be able to also maintain separate certification in internal medicine (that is, without focused practice) if I qualify for and choose to pursue recognition of focused practice in hospital medicine?

   No. A separate certification in internal medicine will not be necessary, as MOC with focused practice in hospital medicine provides evidence of the type of general internal medicine you are practicing. Since you will have declared yourself as committed to focused practice in hospital medicine – a major component of internal medicine – meeting the standards for this program would indicate that your internal medicine certification remains active but has been focused; it has not been lost nor has it been augmented with another certification. Your primary ABIM certification would remain in internal medicine, but your MOC program would reflect and recognize your practice focus in hospital medicine. Of course, there is no obligation to pursue recognition of focused practice in hospital medicine. An internist who is practicing primarily as a hospitalist could maintain certification in internal medicine without the hospital medicine focus by completing the usual MOC requirements (including taking the secure examination in internal medicine rather than in hospital medicine).

8. I’m a hospital-based internist and executive director for a hospitalist program, with overall responsibility for quality assurance. I serve as a hospitalist for two to three months a year. Could I qualify for the hospital medicine focused practice program?

   Yes. The hospital medicine program is designed for internists who have focused their practice in hospital medicine. ABIM will provide a pathway within the program for part-time hospitalists who devote the majority of their professional activity to hospital medicine, including both clinical and non-clinical work. However, if you were to withdraw entirely from your clinical work to focus on leadership and systems work full time, you would not be eligible for recognition of focused practice in hospital medicine because practice is a key requirement of the program.

9. I’m a full-time, hospital-based subspecialist and also serve as a ward attending for one month a year. Could I qualify for the focused practice program for hospital medicine?

   No. Since hospital medicine is a subset of the broad discipline of internal medicine, the ABIM program is designed to recognize the proficiency of general internists who have focused their practice in the hospital setting. In general, subspecialty consultative patient encounters would not be sufficiently broad to reflect the spectrum of internal medicine practice. ABIM encourages diplomates to maintain certification in areas that are most relevant to their practice. For you, the most relevant area is your subspecialty. You do have the option to also maintain certification in internal medicine. If you were to spend about half of your professional time practicing as a subspecialist and the other half practicing as a hospitalist (for example, serving as physician-of-record for undifferentiated hospitalized patients for several months a year), you would likely meet the requirements for MOC in internal medicine with focused practice in hospital medicine (as well as your subspecialty requirements).

10. I’m currently a full-time hospitalist. If I decide in the future to change my practice focus and join a primary care office-based practice, what would I need to do to reinstate my internal medicine certification?

    The focused practice MOC program will be flexible in order to be responsive to anticipated changes in diplomates’ practice focus over time. MOC in internal medicine with focus on hospital medicine does not eliminate your certification in the broad field of internal medicine. Certification indicates continuing competence; however, evidence of your proficiency in office-based internal medicine will need to be developed through practice-based learning and improvement. Therefore, the recognition of your focus in practice will be reflected by the MOC evaluations (self-assessments and secure examination) you select to provide evidence of your current practice competency as you maintain your internal medicine certification. In this way, MOC remains a reflection of your current area of practice concentration.

11. Will there be a parallel ABIM process for recognizing general internists who focus their practice in office-based settings?

    Possibly. Concurrent with the growth of hospital medicine, many general internists now focus their practice on ambulatory primary care in office-based settings. The Board recognizes this practice differentiation within general internal medicine and appreciates that there are many efforts underway to support primary care practice. ABIM is also exploring ways to support and assess the competencies required for general internists who can provide comprehensive, longitudinal, and coordinated care for patients with chronic or complex problems. To meet this need, the Board has committed to developing tools to assess the competencies required for comprehensive care internal medicine practice; and to develop partnerships to establish such tools in the practice and educational domains. These efforts are not linked to or dependent on the time frame for developing the focused practice program for hospital medicine.