Chapter e4: The Core Competencies in Hospital Medicine

The Society of Hospital Medicine (SHM) defines hospital medicine as “a medical specialty dedicated to the delivery of comprehensive medical care to hospitalized patients.” The role of hospitalist was initially conceived to reduce length of stay and the cost of hospitalization by placing physicians dedicated to inpatient care in the hospital for most of the day. During the first decade of the hospitalist movement, the scope of work attributed to the hospitalist role varied considerably from one practice setting to another. At the same time, the Accreditation Council for Graduate Medical Education (ACGME) acknowledged training gaps in six main competency areas for the evaluation of medical trainees: patient care, medical knowledge, practice-based learning improvement, interpersonal and communication skills, professionalism, and system-based learning. Despite embracing the importance of evidence-based care and systems’ improvement, especially around transitions of care and the well-publicized safety and quality issues facing hospitalized patients, hospital medicine leaders were recruiting physicians from traditional residency programs that had not adequately prepared them for their new roles. These physicians required additional training as their roles evolved with the expectation that they would improve hospital processes that affect the quality of inpatient care, patient safety, and education of the next generation of physicians.

Competency-based education focuses on articulating specific learning outcomes and measurable levels of proficiency rather than summarizing general outcomes or learning processes. In palliative care as a case in point, learning statements such as “understand methods of palliation” and “increase understanding of palliative care approaches” are not carefully conceived competency-based objectives. In these examples, it is unclear what exactly constitutes “understand,” or how you would measure whether the learning objective has been achieved. Does generating a generic list of pharmacologic options for any category of patient qualify as understanding? Or, is the desired outcome something of a higher proficiency, such as the ability to develop a patient-specific palliation plan that takes into account functional status and patient- and family-established goals for pain management? Using well-written competencies, educators may clearly articulate expected outcomes and design evaluation strategies to gauge not only “understanding” of a concept, but competency at a specific level. Competencies are often classified within three domains of outcomes: cognitive (knowledge), psychomotor (skills), and affective (attitudes) (Table e4-1).

The Society of Hospital Medicine recognized the need to define specific competencies of hospitalists to establish performance standards, differentiate hospital medicine as a unique subspecialty, and create a framework for training programs. SHM hoped that the creation of a document detailing core competencies would further serve to standardize training programs, highlight training gaps within internal medicine residency programs, and identify the professional development needs of practicing hospitalists. In 2006, SHM developed and published The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (TCCs) in conjunction with more than 100 hospitalists and physician leaders from university and community hospitals, teaching and nonteaching programs, and for- and not-for-profit programs throughout the United States. This document is a compendium of competencies for the practice of hospital medicine (Figure e4-1).

The authors of TCCs of hospital medicine added a fourth domain of competencies, “system organization and improvement” to emphasize the important role hospitalists play in shaping care processes at the system level. Two examples—care of vulnerable populations and transitions of care—illustrate how the SHM core competencies align with ACGME outcome requirements (Table e4-2).

TCCs standardize expected learning outcomes for teaching hospital medicine in medical school, postgraduate (ie, residency, fellowship), and continuing medical education programs, while allowing flexibility for curriculum developers to customize instructional strategies and context, as they integrate the most timely literature and evidence into medical content. TCCs are divided into three sections: Clinical Conditions, Procedures, and Systems in Health Care. Within each section, chapter topics were selected based on relevance to hospital medicine; impact in terms of prevalence, economic costs, and effect on hospital systems. Each chapter demonstrates how the approach and orientation of hospitalists differ from those of traditional clinicians rotating through the hospital. See Table e4-3 using heart failure as an example.

The Procedures section provides some standardization of procedure performance. This section includes the core set of procedures most likely to be performed or supervised by hospitalists and acknowledges local and regional variations in who performs inpatient procedures. The Systems in Health Care section and the category Systems Organizations and Improvement in the other two sections describe mastery of multiple competencies across categories. The Systems in Health Care section includes clinical concepts that cross several disciplines such as the care of the older adult, infection control, nutrition, and palliative care; and educational concepts such as hospitalist as teacher, patient education, and evidenced-based medicine; and organizational topics such as teamwork, transitions of care, patient safety, and quality improvement.

Within each clinical, procedural, and systems chapter, TCCs highlight the expectation that hospitalists lead, coordinate, or participate in patient care and workflow efficiency improvement efforts. Recurring themes include an emphasis on the multidisciplinary approach, teamwork, inpatient quality and safety, and patient-centered communication to ensure safe and efficient care transitions and handoffs. When structured appropriately, a competency will indicate what a learner should be able to do as well as the level of proficiency that should be attained.

These examples clearly show the outcome and the level of proficiency that are expected. The first option, “explain the indications,” requires less processing then the second. It may be taught by lecture, webinar, and reading assignments. Evaluation may include verbal or written examination by simply restating the competency as a question. For example, “please explain the indications and limitations of opioid pharmacotherapy.”

The second competency, “Determine the appropriate route,” indicates that learners are expected to obtain a higher level of proficiency. Learners must apply what is known about the pharmacologic agents, the patient, and the specific disease and risk profile to develop a plan. Evaluation of this competency requires observing or assessing a treatment plan developed for a specific case study or patient. Similarly, instruction should provide opportunities to practice application of concepts to patient-specific examples.

The third competency, “promote the ethical imperative,” is an attitudinal competency. The verb, promote indicates that not only are learners expected to be knowledgeable about the value of determining patient-centered goals and closely monitoring pain control plans, but they are also expected to possess the motivation and ability to encourage others to adopt similar clinical care habits. Instruction for this competency would require exposing learners to scenarios that allow them to explore and discuss perspectives and values and develop empathy. Learners need to see instructors’ modeling behaviors and deconstruct how the behaviors led to or prevented specific outcomes. Evaluation of this competency would require a longer-term observation.

The core competencies are used to facilitate training of residents and medical students and form the backbone for initiatives to credential hospitalists. Since 2010, the American Board of Internal Medicine (ABIM) has conferred Internal Medicine Certification with a Focused Practice in hospital medicine. In order to be eligible for the Focused Practice in hospital medicine program, graduates of internal medicine residencies need to demonstrate the knowledge, skills, and attitudes defined by TCCs and acquired through practice dedicated to the hospital setting. SHM has created resources and educational programs based on TCCs, including resource rooms to guide improvement efforts, and mentored implementation programs to assist hospitalists in obtaining additional ABIM recognition.

Since the publication of TCCs, the evolution of the field of hospital medicine continues to present new opportunities not only for growth but for the development of expertise in areas not integrated into residency training. Hospitalists now specialize in the management of medical subspecialty patients, neurology patients, obstetrics, palliative care, critical care, and surgical co-management. Tertiary care settings have increasingly become large intensive care units with step-down capacity for every patient whose preexisting comorbidities shape recovery. Hospitalists working in community settings may become the teachers of the next generation of residents and medical students as they increasingly rotate through these settings. Although it may not be possible to predict the next stage of evolution, hospitalists are uniquely positioned to support accountable care and optimize integration and performance for the communities their hospitals serve. TCCs are the first step in the process of defining expectations for this young specialty and serve as a template for future educational initiatives.

Although TCCs provide a content framework for defining professional standards for hospital medicine, it is not a stand-alone document and cannot be a static document. The medical education community will need to continually develop and update competency-based curricula, training, and evaluation strategies to reflect evolutions in the science and practice of hospital medicine. Curricula should be accompanied by more robust evaluation strategies to assess the impact on individual learners and identify training gaps. This requires critically reviewing evaluation tools, providing hospital-specific data to physicians, identifying and lowering barriers to improvement, developing automatic reminder systems, and encouraging participation in quality improvement research. Educators should consider feedback from multiple sources, including receiving clinicians, nurses, care coordinators, and consultants. New and improved curriculum in health care systems and structured portfolios should promote competence as a physician and ultimately improve patient care. To serve as an effective tool, future revisions of TCCs will take into account how the field and practice of hospital medicine has evolved and the skills required of hospitalists to provide exceptional patient care and clinical care leadership into the future. A second edition of TCCs will become available online in 2017. Over time, there will always be opportunities to refine competencies in areas such as information transfer, care transitions, and communication with physicians, other hospital staff, and most importantly our patients.