If you want something done, the saying goes, ask a busy person to do it. That was precisely the situation when SHM’s Core Competencies Task Force editorial board was formed in May 2003. Charged with producing the society’s first-ever curriculum guidance document, the editorial team faced a daunting task: solicit, organize, and edit chapters for the competencies framework on topics from specific clinical conditions to ethical issues. Over the next two and a half years, each of the physician members contributed hundreds of hours of uncompensated time to the project, juggling work, family, and other professional obligations.
Because they are so involved with their own institutions and the future of hospital medicine, the physicians tapped to guide the core competencies to reality were the right pick.
“Working with the four of them was phenomenal,” says SHM staff member Tina Budnitz, MPH, who serves on both the Education Committee and the Core Competencies Task Force. “They are all incredibly hard working, driven, and intelligent. I think the hardest thing was just the logistics of coordinating schedules, since this was a volunteer activity for them.” Budnitz points out that the original target date for completion of the core competencies was early 2005. Instead, the sheer bulk of editing work pushed the deadline back to early 2006, when release of The Core Competencies in Hospital Medicine: A Framework for Curriculum Development by the Society of Hospital Medicine coincides with the premiere of the Journal of Hospital Medicine.
Recently, The Hospitalist caught up with each of the editorial board members, who divulged some of their personal motivations for participating in the ambitious core competencies project. They also discussed the workings of the editorial board and assessed the success of their efforts.
—Daniel D. Dressler, MD, MSc
Genesis and Vision
During a July 2002 Educational Summit the SHM Education Committee and Board of Directors determined that one element necessary to evolve SHM’s educational offerings would be a framework to guide and prioritize their efforts. A parallel conversation within the Education Committee, according to Budnitz, revolved around the need to better define hospital medicine. “We’re frequently asked, ‘what differentiates a hospitalist from other general internists? What exactly should the expectations be for a practicing hospitalist?’ ” she explains.
The Editorial Board
Michael J. Pistoria, DO, FACP, associate program director, Internal Medicine Residency, and medical director of both the Hospitalist Services and the Express Admission Unit at Lehigh Valley Hospital in Allentown, Pa., began his journey as chair of the Core Competencies Task Force shortly after SHM’s September 2002 Education Summit retreat.
Dr. Pistoria also serves on SHM’s Education Committee and admits that his allegiance to the field was a strong motivation for agreeing to participate in generating the Core Competencies.
“In my mind, hospital medicine is one of the neatest things in medicine to come along in a long time,” says Dr. Pistoria. “Hospital medicine has the potential to make a significant, positive difference in the way healthcare is delivered in the United States. And to have the opportunity to be a part of a process that helps define hospital medicine, to me, was just something almost too good to be true.”
A very active SHM member, Alpesh Amin, MD, MBA, FACP, is the associate program director for the Internal Medicine Residency Program and the medicine clerkship director at the University of California Irvine (UCI), where he also founded the UCI hospitalist program in 1998. His role in education at his institution informed his active participation in SHM’s Education Committee, which he chaired for four years, and his key role in the Core Competencies Task Force editorial board.
“It was one of my goals—while chairing the Education Committee—for our society to put together the core competencies for hospital medicine,” says Dr. Amin. “I felt that if we had core competencies, this would be the next step to move us toward defining the field of hospital medicine.”
Accordingly, Dr. Amin was instrumental during the first and second SHM Education Summits in securing both committee and SHM Board of Directors’ buy-in of such a project.
For Daniel D. Dressler, MD, MSc, director of hospital medicine at Emory University Hospital and assistant professor of medicine at Emory University School of Medicine, involvement with SHM’s (and formerly NAIP’s) Education Committee was a natural extension of his own interests in medical education. At Emory University Hospital, Dr. Dressler conducts a hospital medicine elective for house staff, “to give them a better understanding of what hospital medicine is and what we do, both in the community setting and in the academic setting.”
“I thought that [development of core competencies] was something that hospitalists as a group needed to do in order to a) become recognized and b) to clarify our own understanding and expectations of hospitalist physicians around the country,” he says.
—Tina Budnitz, MPH
Like her colleagues on the editorial board, Sylvia C.W. McKean, MD, FACP, medical director, Brigham and Women’s Hospital/Faulkner Hospitalist (BWF) Service (Boston), attended the 2002 SHM Education Summit and subsequently joined the Core Competencies Task Force. She is also co-chair of the society’s Career Satisfaction Task Force and views this role as linked to the missions of core competencies and education because education is a key component of professional advancement and engagement in the field. The Career Satisfaction Task Force, she notes, examines what components contribute to a long and satisfying career in hospital medicine.
Dr. McKean’s personal motivation for participation on the Core Competencies Task Force relates directly to her love of teaching. Having developed two hospitalist programs (one with physicians Andy Halpert, former chief of medicine for Harvard Vanguard Associations and subsequently the BWF program in 1998) she has seen firsthand that “people right out of residency do not have all the skills that they need in order to be effective hospitalists.”
As medical director of the BWF Hospitalist Service, Dr. McKean developed a weekly Harvard Medical School CME conference Update in Hospital Medicine for members of the hospitalist service, as well a medical consultation syllabus for the newest members of the hospitalist service to distribute to residents.
“I identified what the newest members of our service right out of residency didn’t learn during their residency training and tried to make sure that we would have people come in and teach them about hospital medicine,” she explains.
As the hospitalist service matured, hospitalists developed significant expertise in these topics and frequently participate in this didactic series of lectures.
“Initially,” recounts Dr. McKean, “I was the only senior physician with experience in hospital medicine, but now my job is much easier, as I continue to learn from other hospitalists in our program.”
—Sylvia C.W. McKean, MD, FACP
A Framework, Not a Text
“We have a great team,” says Dr. Amin of the Task Force editorial board. “I think our goals were clear. We wanted to develop a set of competencies that would be unique and offer 1) an opportunity to define the space that we, as hospitalists, lead in system-based practice; and 2) a framework that would cross over the span of time, so that others could use that framework to develop future curricula.
“Once you write a book, the context is fixed. We thought this [framework for curriculum development] was a creative way of facilitating future projects and ideas,” he continues. “It becomes more of a bible for competencies in hospital medicine.”
Budnitz says the idea was to develop an enduring, flexible blueprint. “We set out to develop a guide that would serve as a blueprint for curricular development in hospital medicine,” she explains. “We wanted to standardize the expectations for learning outcomes but still allow curriculum developers to add their expertise of content and context. Each chapter of the guide is written as a set of learning objectives. We crafted these objectives to clearly indicate a proficiency level.
“For example,” says Budnitz, “it is a different expectation that someone can list the drugs that they might order for a particular condition, versus analyzing the benefits and limitations of different therapeutic approaches. And in both scenarios we have left it up to the content and curriculum developers to determine the precise list of therapeutic agents that are included in curricula and the educational approach that will most likely yield the intended learning outcome.”
Dr. Dressler elaborates on his colleagues’ characterizations of the document: “We weren’t planning on this being an overarching, comprehensive text on hospital medicine. We were not trying to develop or even provide content.”
Instead, he says, the aim was to provide medical educators with a relatively generic framework that would retain flexibility for change. “For instance,” he explains, “if a new drug comes out that is useful for [treating] heart failure, the expectation is that hospitalists should be able to explain and utilize the new and useful medications, but that we were not going to list every drug in the Core Competencies compendium.”
“The one idea that we kept coming back to is that we wanted to design a set of competencies,” said Dr. Pistoria. “We didn’t want to publish a textbook; we didn’t want to come up with a curriculum per se. We wanted to come up with a framework that someone could use to develop their own hospitalist program in their own institution.”
The Core Competencies Task Force developed an initial organizational structure for the guide and a list of chapter topics. The resulting chapter list was turned into a survey and sent to the SHM Board of Directors, Core Competencies Task Force, and Education Committee. The survey was also sent to a sample of members within each SHM region or chapter via its chapter or region director. A review of core competencies generated by other medical specialties and allied health professional societies followed.
Then, the task force put out a call for nominations of chapter contributors. Budnitz judges that there were between 150-200 responses for potential contributors. Reviewing all the nominations was no small task. In some cases the editorial board deemed it necessary to recruit non-hospitalist content experts to generate some chapters, such as those dealing with medical-legal issues. In those instances, the “outside expert” was often paired with a hospitalist to ensure that the hospitalist perspective was included.
Strategies for Content Inclusion
Dr. Amin points out that the task force “went as broad and as wide as we could to get feedback on the content for the Core Competencies.” However, it was simply not possible—nor was it the editorial board’s intent—to compile an exhaustive list of all the hundreds of diagnoses that hospitalists may see on a regular basis. The editorial board identified common diagnoses from the top 15-20 DRGs from the Medicare database. The task was then to communicate the most important aspects of what hospitalists do, in the domains of knowledge, skills, and attitudes.
To manage the sheer bulk of solicited CVs and potential chapter authors, the editorial board used a divide-and-conquer strategy. Even so, says Dr. Pistoria, this process took a fair amount of time. When chapters began arriving and the task force was reduced to the core editorial board, “the homework started kicking up, with a lot of home editing time, telephone and e-mail editing, and some face-to-face meetings to ensure that chapters were standardized and had the same format.”
Once the editorial board began its work, it was relatively easy to decide that majority rule would be the best process for resolving differences of opinion, “but honestly,” says Dr. McKean, “only a handful of issues were generated. If we didn’t develop a consensus or if we were not all in agreement, then we sometimes looked for feedback from experts outside of the task force and the editorial board.”
Keeping with the ethos of inclusion, most board members consulted with other experts at their institution about key elements to include in the document.
Regarding the “majority rules” process, “Everyone had the chance during the editorial process to voice their opinions,” says Dr. Pistoria. “If they had concerns and were able to persuade enough people, the appropriate change would be made. I think, in the end, that everyone in the core editorial group felt that their opinions were heard, and I think that lends itself to the pride that we all feel in the final product.”
—Alpesh Amin, MD, MBA, FACP
A Work in Progress
Budnitz contributed critical guidance when the board generated writing guidelines for chapter authors. Each received a template for their chapter: a document instructing them how to write a competency, and a letter indicating the intent for their particular chapter. The template went through several iterations, she says, as early chapters were returned and the board began their editing.
For example, each clinical condition is discussed through the domains of knowledge, skills, and attitudes. It was the board’s job to ensure that concepts consistently appeared in the same domain across chapters with a similar degree of specificity and in the same order. “Partway through the process, we refined our template and made it more specific,” reports Budnitz. “We were able to give the second round of contributors a little more guidance as a result.
“We originally thought the document would be ready in early 2005,” she explains. “I think we were under the misimpression that the chapters would come back, that we’d read through them in a month or two, and it would be done. It turns out that just the sheer logistics of editing four or five versions of 70 chapters was quite a process.”
“I think [the Core Competencies] is something that SHM can be proud of,” said Dr. Pistoria of the group’s efforts. “But this is by no means the end of the project – it’s only the beginning. It is a work in progress.”
Dr. Dressler agreed with Dr. Pistoria’s characterization of the Core Competencies as a work in progress.
“I am pretty satisfied with what we’ve accomplished,” says Dr. Dressler. “By no means do I feel that this is the end-all, be-all for hospital medicine, or even for education in hospital medicine. It’s a start. We expect comment. We expect criticism. Being hospitalists, we are all open and aware and willing to make changes. And so we make a start, our initial best effort to get something out there that hospitalists can look at, utilize, and then offer feedback. Our primary goal is to provide a structure for consistency in practice and consistency in expectations. We would like to make [the Core Competencies] something that hospitalists and hospitalist educators feel is useful and that can change with the needs of our specialty.”
—Michael Pistoria, DO, FACP
“[Working on the Core Competencies] was an exciting project,” says Dr. Amin. “It took a lot of time. We had to spend a fair amount of time learning before we could actually define what we wanted from our chapter authors. But it was a good process. It was a four-year process to develop a document that would be worthwhile and hopefully stand the test of time in defining the core aspects of the field of hospital medicine. It was great to be chairing [the] education [committee] and seeing the value of helping to facilitate this project, and now looking more broadly across how to apply this project to future educational efforts.”
The project certainly had its challenges, most of which were related to time constraints.
“All of us were working very hard in our respective programs,” notes Dr. McKean, “and we were doing this on a volunteer basis. I think we had 10 face-to-face meetings, and sat at our computers on Saturday afternoons for conference calls using a Web-based editing program.”
For her part, Dr. McKean found working on the core competencies “very satisfying. I think I learned a lot from other people on this task force, editorial board, and the organization of the Society of Hospital Medicine. This project helped me reflect upon skills that I should try to obtain, and to think about more global issues than the day-to-day hospital politics in which I was involved. I did more strategic planning and thinking about retreats. So, it was a learning experience for me, and I also felt that I was contributing to something worthwhile. It was a chance to make a difference.
“From my own professional experience, the development process has helped me here, at Brigham and Women’s Hospital, so I hope that anyone who wants to apply the core competencies would feel free to e-mail us or contact us if they have any questions at all,” she says.
Dr. Pistoria agrees with Dr. McKean’s observations. “Working on the Core Competencies had a really big impact on me, both personally and professionally,” he says. “The process helped me mature in how I deal with running a project like this because I have been given the opportunity to do some similar things at my institution. Some of the ideas that we hit upon as we were editing and developing these competencies make one think, ‘We need to do this at our institution.’ Let’s take a strong look at, say, discharge processes, get a group together, and generate some recommendations that we can then institute.”
Other editorial board members also acknowledged that their participation gave them new insights into their own practice of hospital medicine.
“It’s easy to have in your head what you think is the right thing to do,” notes Dr. Dressler, “But until you actually have to try to develop consistency in wording and expectations, to put a process together that can result in a protocol, you realize that sometimes some elements get left out—for instance, the importance of family communication in the setting of DVT.”
Regarding the board members’ hard work, Budnitz remarks, “I can’t say enough about the dedication of the editorial board. They volunteered a tremendous amount of time and stuck with the project for three years. Since the board lived in multiple time zones, we often had calls where people would be participating at 6 a.m. or 9 p.m. We convened on weekends in multiple cities across the U.S. I sincerely enjoyed the opportunity to be a part of this project and hopefully impact the future of medical education.
“I think the document makes a bold statement. It defines the hospitalist as the captain of the ship—and calls on hospitalists to lead multidisciplinary teams to improve the quality of care. I hope it sparks interest and debate about how we recruit, train, prepare, and certify physicians in hospital medicine.”
Dr. Pistoria believes that the Core Competencies will advance hospitalist programs. In fact, he says, hospitalists around the country have already affected improvements in care coordination. The hospitalist movement in general furnishes hospitals with physicians who say, “ ‘I’m going to take ownership of what happens within the four walls of this hospital,’ ” says Dr. Pistoria. “Previous to that, people obviously cared about what happened in the hospital, but they also worried about their office practices. This is our office practice. We want it to work as well as it can for our patients, for us, for our nursing colleagues, for our janitors—everybody needs to, and should, benefit from this.” TH
Writer Gretchen Henkel wrote about cultural competency in the September issue of The Hospitalist.