May 14th, 2008

Certification in HIV Medicine — Another Try

In March, the American Board of Internal Medicine (ABIM) issued a proposal for a “Maintenance of Certification” (MOC) pathway in HIV medicine for general internists. This is the second such special pathway ABIM is considering (the first was hospitalist medicine). Regardless of whether you agree with the proposal, it’s a good read, providing an excellent snapshot of who’s providing care for HIV patients these days and how we got here.

Some of the interesting data:

  • Out of the 100,000 general internists in the U.S., 95% do not practice HIV medicine at all.
  • Only 4,000 U.S. MDs write prescriptions for antiretroviral agents.
  • Approximately half the MDs practicing HIV medicine in the U.S. are ID specialists; of the remaining group, 80% are general internists.

Since only a small proportion of internists provide HIV care, ABIM would like to give formal recognition to this group, allowing them to allocate a significant proportion of their recertification activities in HIV-related topics.

In broad strokes, the ABIM proposal suggests that internists with a clinical focus on HIV — defined as having 50 or more HIV patients per year and completing 50 or more HIV-related continuing medical education credits over 3 years — would be eligible to devote a portion of their recertification process to HIV-related content. Recent graduates of medical residencies would not be eligible, since they would not have accumulated sufficient clinical experience in managing HIV and also would not have formal training in HIV.

I’m all for some sort of formal recognition of HIV medicine. The data are unequivocal that HIV care by an experienced provider is associated with better outcomes — improved survival, more concordance with treatment guidelines, lower cost, just better in every way. In addition, this proposal has the advantage of coming from the ABIM, which is a widely recognized certifying body (not the case for AAHIVM, which is predominantly a membership organization). To its credit, ABIM assembled a diverse task force to draft this proposal, with representatives from general internal medicine, infectious disease, and even a chief medical resident who plans a career in HIV medicine without specializing in ID.

This proposal is emphatically not inclusive — it is only for the general internist with substantial HIV experience. It’s not for oncologists, obstetrician-gynecologists, dermatologists, family practitioners, or nurse practitioners — in other words, it’s not for the wide range of practitioners who could be heavily involved in HIV care. Many got their start with HIV in the bad old days before effective therapy, when lots of clinicians (including, shamefully, many ID doctors) didn’t want anything to do with HIV.

And, importantly, it’s not for Infectious Diseases specialists, since already “the knowledge and skills required for treating patients living with HIV/AIDS constitute a significant proportion of fellowship training, certification, and Maintenance of Certification in Infectious Disease.”

Um, maybe. While most clinical ID specialists consider HIV medicine as something that falls under their purview, a significant minority do not — especially in academic medical centers, where many ID docs limit their clinical activities to the inpatient setting, whereas the bulk of HIV care is now outpatient-based. So that’s my feedback to ABIM (who have requested input on their proposal): let this be part of ID recertification too.  You just might be letting us ID docs off the hook too easily.

(For the record, I’m completely biased — my ID and internal medicine recertification are due in 2010.  It will be my second time recertifying.)

One HIV organization, the HIV Medicine Association (HIVMA), has just weighed in quite favorably on the proposal. Somehow I suspect that AAHIVM may not be quite so supportive …

3 Responses to “Certification in HIV Medicine — Another Try”

  1. Joe Nussbaum, MD says:

    I live and work in urban southern California, so the proposed ABIM recognition of special focus of practice in HIV has already been superceded by the state requirements of “HIV specialist”. The state requirements implicy preference to AAHIVM certification. HIVMA, and the specialty of ID, have missed the boat on this one.

  2. Paul Sax says:

    >>HIVMA, and the specialty of ID, have missed the boat on this one.

    Maybe so. But what about ABIM and Internal Medicine?

    And interesting comment about California. What are the other states that officially recognize AAHIVM credentialing?

  3. Still ceritified says:

    I tried doing the HIV MOC but ended up canceling it. It was a very superficial assessment (are patients with CD4 <200 on PCP prophylaxis etc.) and the two areas identified for me to improve “performance” were 1) getting patients whose viral loads were detectable to undetectable. It did not adjust for the fact that under the current guidelines all but one of those patients were not supposed to be on ART.
    2) getting patients CD4 counts to go over 500 (even if their viral loads were undetectable). If the ABIM can tell us how to do that I would have been delighted to.
    So the principle is a great but there needs to be more clinical input from actual clinicians.
    And although the intent is great – to make sure that patients get their care from knowledgeable doctors – I am concerned that the quota of minimum number of patients to be considered competent might have deleterious effects on underserved rural communities and also in communities with high rates of uninsured. There are places in the United States (I’m not talking about Boston, New York, Los Angeles etc.) where physicians cannot afford to take care of large volumes of uninsured HIV patients. Should there be a requirement that the HIVMA board members maintain their certification? If so, how many would meet the patient volume criteria? (Really.)
    Lastly, we all know that ID certification does not AT ALL mean someone is competent to care for a patient with HIV.

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

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