Certifying in HIV – time to move

January 2005

Specialized training and certifying expertise in an area of medicine are accepted in fields as broad as internal medicine and as narrow as transplant hepatology. Certification brings recognition and attendant status to the physician so identified and, at times, benefits in salary or working conditions. Yet the true and intended “user” of certification is the patient, who gains trust that the credentialed physician has trained successfully in a specific field and has developed a fund of knowledge tested by an independent, rigorous process. The end result is patient confidence, key to the healing relationship.

Medical certification is granted by an organization independent from specialty societies. Groups such as the American Board of Internal Medicine (ABIM) develop and administer certifying and recertifying examinations and define the training requirements that allow one to sit for the examination. The certifying organization typically has a collegial relationship with professional societies, as these societies may require successful certification as a criterion of membership. Often, members of certifying organizations have had prominent roles in the respective societies; their selection for the certifying board reflects their leadership and expertise.

Examples of the structure and function of certifying groups and professional societies abound. In infectious diseases (ID), for example, the Infectious Disease Board of the ABIM writes and administers the certifying examination. Only fellows meeting established training expectations are allowed to take the certifying examinations. Although there is no formal relationship between the ABIM Infectious Disease Board and the leading professional society, the Infectious Diseases Society of America (IDSA), or others such as the American Society of Microbiology, members of the ABIM Board may well have had leadership roles in these groups.

In internal medicine, the full ABIM process – several years of post-residency fellowship followed by the board examination – holds for the recognized subspecialties. For some, more focused areas of medicine, an alternative process is followed, the Certificate of Additional Qualifications (CAQ). For example, certification in intensive care requires an additional year of training following prior certification in pulmonary medicine, surgery or anesthesiology. Each CAQ has its own training path leading to a certifying examination.

The complexity of HIV medicine

How do certifying groups come into being, and what about HIV? Here, the complexity begins. HIV medicine has evolved rapidly over the past 20 years. HIV care is provided by a wide spectrum of providers, including nonphysicians such as nurse practitioners and physician assistants. Physicians in HIV care may have been trained in internal medicine, family medicine, pediatrics or other fields. Many, but not most, are further certified in ID. Regardless, many have gained a very considerable degree of expertise in the course of providing this care. Knowledge may additionally be gained from many excellent continuing medical education activities and by following the several scientific journals devoted to this field. Professional membership societies have been created to represent HIV care providers. The HIV Medicine Association (HIVMA), which is affiliated with the IDSA, is open to physicians, ID trained or not, as well as nurse practitioners and physician assistants. Most of its members, however, are ID certified. The American Academy of HIV Medicine, again with an open membership, has attracted physicians largely not ID certified. It administers an open examination to its members as evidence of their expertise. Although not an independent process, as with the ABIM, this exam clearly reflects the belief that HIV medicine has its own body of knowledge and that there is a perceived advantage in documenting such expertise.

The pathway to a new certifying process in HIV medicine is becoming clearer and efforts are underway, but barriers have not yet been eliminated.

ID fellowship programs are required to provide continuity experience in HIV care, and the ID certifying examination covers much of HIV medicine. It is generally accepted that this training and certifying examination are evidence of competence in HIV care. ID program directors have limited capacity or funding to expand their fellowships, and many physicians who wish to specialize in HIV care do not desire a full infectious diseases training. For its part, the ABIM has been reluctant to recognize HIV care as a full subspecialty, as have organizations representing specialties outside internal medicine, such as family medicine.

A proposal

A way forward? An approach is being developed that might gain acceptance. Led by the HIVMA and others, HIV certification could be granted to physicians recently board certified in ID. Additionally, a one-year post-residency training followed by a certifying exam limited to HIV medicine could be developed for internists or other physicians desiring an HIV CAQ. This HIV training could either be in the setting of an ID fellowship program or freestanding, with preset national standards of continuity patient care, adequacy of supervision, etc. All training programs would themselves be certified by the American College of Graduate Medical Education. Provisions could also be made for HIV providers already in practice who would not be expected to undergo further training. Barriers to this proposal, now being evaluated by the ABIM, include identifying funding sources for the one-year training and its acceptance by the ABIM and other specialty boards, especially family medicine. It also does not address the certification of HIV expertise for other clinicians, including physician assistants and nurse practitioners, which would have to be developed through parallel mechanisms with certifying boards active for those providers.

While far from fully realized, the development of HIV certification is important and long overdue. It would recognize the rapid increase in the complexity of HIV care and the evidence that more completely trained providers will improve patient outcomes. Once established, this process will provide a coherent pathway to a career in HIV medicine as an alternative to a subspecialty in ID with a training curriculum that reflects advances in the field.

This alternative process is important, not only to certify the expertise of current non–ID physicians who specialize in HIV medicine, but also to help ensure an adequate pool of highly trained physicians to treat HIV/AIDS in the years to come. The care of HIV-positive people involves far more than the treatment of a single infection. The array of associated conditions and the depth of information in this care rival many traditional specialties. Our patients deserve to know that the care they receive is truly the best, and HIV specialists have the right to be recognized for their commitment to this demanding field.

Acknowledgement: thanks to Daniel Kuritzkes and Christine Lubinski for their helpful comments.

For more information:

• Paul A. Volberding, MD, is a professor and vice chair of the department of medicine and the director of the Center for AIDS Research at the University of California, San Francisco, and chief of medical service at San Francisco Veterans Affairs Medical Center.