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.
TABLE e4-3Levels of Proficiency: An Example Using the Topic Heart Failure |Favorite Table|Download (.pdf) TABLE e4-3 Levels of Proficiency: An Example Using the Topic Heart Failure
|Knowledge: the second-year medical student is able to recite the causes of heart failure (HF) or list the different randomized controlled trials studying different drugs for the treatment of HF. |
|Comprehension: the third-year student is able to predict the consequences of untreated HF or explain which drugs are preferable in the treatment of HF based on knowledge of the medical literature. |
|Application: the fourth-year student is able to use the American College of Cardiology practice guideline on HF to consistently appropriately test and treat patients with HF. |
|Analysis: the intern is able to detect hypothyroidism and HF by history and physical examination of a patient and connect their relationship to the patient’s presenting complaint of shortness of breath. |
|Synthesis: the senior resident is able to develop a research proposal involving patients with HF to address unanswered questions and possibly create a new scheme for classifying HF. |
|Evaluation: the senior attending cardiologist is able to judge the value of the research project and recommend revisions of the methodology. |
|Skills: the hospitalist is able to diagnose HF on the basis of a chest x-ray and triage the patient appropriately based on triage criteria that incorporate a 2-min bedside assessment of the hemodynamic profile looking for evidence of low perfusion and/or congestion at rest. |
|Attitudes: the hospitalist assumes responsibility for patient care, shows appreciation for and respect for cultural differences, adheres to practice-based guidelines, provides comprehensive patient and family education, demonstrates effective communication with the primary-care physician, cardiologist, and other members of the care team so that the patient has a safe transition to home. |
|Systems-based practice: the hospitalist recognizes the importance of consulting with interdisciplinary teams (eg, social work to obtain a scale for daily weights, nutrition to advise on a low-salt diet, pharmacy to review and reconcile medications that might negatively impact HF, and physical therapy to assess ability to climb stairs) to facilitate discharge planning and to reduce the chances of readmission. The hospitalist may also lead a hospital interdisciplinary initiative to improve the performance measures relating to prevention of deep venous thrombosis, readmission, and assessment of ejection fraction. |
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.
PRACTICE POINT TCC palliative care example: competencies in each category
Knowledge: Describe the mechanisms that cause pain.
Skill: Conduct a physical examination to determine the likely source of pain.
Attitude: Promote the ethical imperative of accounting for patient-centered goals of care, frequent pain assessment and adequate control.
System organization and improvement: Lead, coordinate, or participate in efforts to establish or support existing multidisciplinary pain control teams.
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.
PRACTICE POINT TCC pain management example: “explain the indications and limitations of nonpharmacologic methods of pain control available in the inpatient setting.”
The above competency standardizes the expectation that a physician be familiar with nonpharmacologic pain control methods and available local resources, relate the evidence base for each approach, and apply those factors to determine the best option for a specific patient.
The competency allows an instructor to create curricula based on the most recent evidence-based literature on pain control options and tailor content around options available at that specific institution.
PRACTICE POINT TCC example of modification of palliative care competences
By the end of the training experience, physicians should be able to:
Explain the indications and limitations of opioid pharmacotherapy.
Determine the appropriate route, dosing, and frequency for pharmacologic agents based on patient-specific factors.
Promote the ethical imperative of accounting for patient-centered goals of care and frequent pain assessment and adequate control.
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.