“You must be the change you wish to see in the world.” This famous quote from Mahatma Gandhi has inspired many to transform their work and personal space into an eternal quest for improvement. We hospitalists are now well-recognized agents of change in our work environment, improving the quality and safety of inpatient care, striving to create increased value, and promoting the delivery of cost-effective care.
Much has changed in the U.S. health care and hospital practice environment over the past decade. The 2017 revision of the Core Competencies seeks to maintain its relevance, value and more importantly, highlight areas for future growth and innovation.
What does the “Core Competencies” represent and who should use it?
It comprises a set of competency-based learning objectives that present a shared understanding of the knowledge, skills, and attitudes expected of physicians practicing hospital medicine in the United States.
A common misconception is that every hospitalist can be expected to demonstrate proficiency in all topics in the Core Competencies. While every item in the compendium is highly relevant to the field as a whole, its significance for individual hospitalists will vary depending on their practice pattern, leadership role, and local culture.
It also is noteworthy to indicate that it is not a set of practice guidelines that provide recommendations based on the latest scientific evidence, nor does it represent any legal standard of care. Rather, the Core Competencies offers an agenda for curricular training and to broadly influence the direction of the field. It also is important to realize that the Core Competencies is not an all-inclusive list that restricts a hospitalist’s scope of practice. Instead, hospitalists should use the Core Competencies as an educational and professional benchmark with the ultimate goal of providing safe, efficient, and high-value care using interdisciplinary collaboration when necessary.
As a core set of attributes, all hospitalists can use it to reflect on their knowledge, skills, and attitudes, as well as those of their group or practice collectively. The Core Competencies highlights areas within the field that are prime for further research and quality improvement initiatives on a national, regional, and local level. Thus, they also should be of interest to health care administrators and a variety of stakeholders looking to support and fund such efforts in enhancing health care value and quality for all.
It is also a framework for the development of curricula for both education and professional development purposes for use by hospitalists, hospital medicine programs, and health care institutions. Course Directors of Continuing Medical Education programs can use the Core Competencies to identify learning objectives that fulfill the goal of the educational program. Similarly, residency and fellowship program directors and medical school clerkship directors can use it to develop course syllabi targeted to the needs of their learner groups.
The structure and format of the Core Competencies in Hospital Medicine
The 53 chapters in the 2017 revision are divided into three sections – Clinical Conditions, Procedures, and Healthcare Systems, all integral to the practice of hospital medicine. Each chapter starts with an introductory paragraph that discusses the relevance and importance of the subject. Each competency-based learning objective describes a particular concept coupled with an action verb that specifies an expected level of proficiency.
For example, the action verb “explain” that requires a mere description of a subject denotes a lower competency level, compared with the verb “evaluate,” which implies not only an understanding of the matter but also the ability to assess its value for a particular purpose. These learning objectives are further categorized into knowledge, skills, and attitudes subsections to reflect the cognitive, psychomotor, and affective domains of learning.
Because hospitalists are the experts in complex hospital systems, the clinical and procedural sections have an additional subsection, “System Organization and Improvement.” The objectives in this paragraph emphasize the critical role that hospitalists can play as leaders of multidisciplinary teams to improve the quality of care of all patients with a similar condition or undergoing the same procedure.
Examples of everyday use of the Core Competencies for practicing hospitalists
A hospitalist looking to improve her performance of bedside thoracentesis reviews the chapter on Thoracentesis. She then decides to enhance her skills by attending an educational workshop on the use of point-of-care ultrasonography.
A hospital medicine group interested in improving the rate of common hospital-acquired infections reviews the Urinary Tract Infection, Hospital-Acquired and Healthcare-Associated Pneumonia, and Prevention of Healthcare-Associated Infections and Antimicrobial Resistance chapters to identify possible gaps in practice patterns. The group also goes through the chapters on Quality Improvement, Practice-based Learning and Improvement, and Hospitalist as Educator, to further reflect upon the characteristics of their practice environment. The group then adopts a separate strategy to address identified gaps by finding suitable evidence-based content in a format that best fits their need.
An attending physician leading a team of medical residents and students reviews the chapter on Syncope to identify the teaching objectives for each learner. He decides that the medical student should be able to “define syncope” and “explain the physiologic mechanisms that lead to reflex or neurally mediated syncope.” He determines that the intern on the team should be able to “differentiate syncope from other causes of loss of consciousness,” and the senior resident should be able to “formulate a logical diagnostic plan to determine the cause of syncope while avoiding rarely indicated diagnostic tests … ”
New chapters in the 2017 revision
SHM’s Core Competencies Task Force (CCTF) considered several topics as potential new chapters for the 2017 Revision. The SHM Education Committee judged each for its value as a “core” subject by its relevance, intersection with other specialties, and its scope as a stand-alone chapter.
There are two new clinical conditions – hyponatremia and syncope – mainly chosen because of their clinical importance, the risk of complications, and management inconsistencies that offer hospitalists great opportunities for quality improvement initiatives. The CCTF also identified the use of point-of-care ultrasonography as a notable advancement in the field. A separate task force is working to evaluate best practices and develop a practice guideline that hospitalists can use. The CCTF expects to add more chapters as the field of hospital medicine continues to advance and transform the delivery of health care globally.
The 2017 Revision of the Core Competencies in Hospital Medicine is located online ator using the URL shortener
Dr. Nichani is assistant professor of medicine and director of education for the division of hospital medicine at Michigan Medicine, University of Michigan, Ann Arbor. He serves as the chair of the SHM Education Committee.