Core competencies peripheral in practice

The Society of Hospital Medicine considers nine procedures to be “core competencies” for hospitalists. Yet, according to a new study, many hospitalists perform these procedures so rarely that it would be difficult to maintain competency.

The study, based on a survey of ACP members and published by the Journal of General Internal Medicine in March, found that only 11% of respondent hospitalists had performed all nine procedures in the past year. (See box, below, for a list of the nine core competencies.)

Internists brush up on practical skills at the Waxman Learning Center during Internal Medicine 2010 Photo by Kevin Berne
Internists brush up on practical skills at the Waxman Learning Center during Internal Medicine 2010. Photo by Kevin Berne.

There was also variation among the procedures. While almost 90% of the hospitalists surveyed had read an electrocardiogram in the past year, fewer than one-third had performed an intubation. Hospitalists were significantly more likely to have done a procedure than nonhospitalists, only 3% of whom reported performing all the core procedures.

Patrick Alguire, FACP, one of the study authors and director of education and career development for ACP, recently spoke with ACP Hospitalist about the implications of the findings for hospitalist practice.

Q: How did the findings compare to your expectations?

A: We were surprised. I would have assumed early on that hospitalists did lots of procedures all the time and that's just not the case, at least in the data that we've collected.

Q: What are some possible reasons that hospitalists aren't doing procedures?

A: No one knows for sure because we haven't systematically studied this. But there are a lot of hypotheses. One is that they're not trained to do the procedures, and therefore they are referring the procedures that need to be done to specialists.

The second possibility is that there may be a financial disincentive to do the procedures, for example, if the procedures take time and the reimbursement is not adequate for the time. They could be doing something else—taking care of another patient—and it may be more cost-effective for them to not do the procedure, and again, have someone else do the procedure.

For other procedures, such as endotracheal intubation, hospital guidelines may specify that another specialty, such as anesthesiology, is responsible for performing the procedure.

Some people have hypothesized that we have all sorts of other diagnostic tests so that procedures don't need to be done. To me, that doesn't make a lot of sense because if you have an infected joint, for example, getting an X-ray is not going to tell you what the bacteria is in the joint and won't help you select the correct antibiotic.

Q: Which explanation do you find most likely?

A: My personal opinion is that the financial incentive probably plays no role. It's a possibility, but I don't think that is something that physicians think about when they're taking care of a patient that's sick in the hospital.

It's much more likely that the physician is thinking “I've never been trained to do this procedure” or “I was trained 10 years ago to do this procedure and I've only done one or two procedures a year since that time. I'm not the best person to do this procedure.” I think doctors realize the more frequently you do a procedure, the more competent you are, the less likely you are to have side effects. They're probably opting in favor of having someone who has done a lot of these procedures do it for the safety of the patient.

Q: Why haven't hospitalists received training and experience in these procedures?

A: Training and volume are the two issues, and the training issue is important because it becomes a vicious cycle. If you're a hospitalist, and you do a lot of teaching of residents and you're not comfortable with the procedure, you're not going to teach the residents how to do the procedure. If those residents become hospitalists, they're also going to have the lack of confidence and proficiency to do the procedure.

Even for people who have been adequately trained, if they don't have the sufficient volume—maybe their clinical activity in that hospital is such that they are only there 50% of a working week or they share the hospital wards with six other people—then you can quickly see how the opportunity to do procedures will soon become diluted either because of your unavailability or the presence of other physicians. That's really the worst of all possible situations, where you have a large number of physicians doing a small number of procedures.

Q: What are the possible consequences of hospitalists not performing procedures?

A: One of the downsides would be that the procedure doesn't get done as quickly as it should be. This may be an extreme example, [but for] a person with suspected meningitis, if you can't do a lumbar puncture, make the diagnosis, select the proper treatment, that's a potentially lethal disease. It's hard for me to imagine that situation actually exists, but for thoracentesis, maybe paracentesis, maybe arthrocentesis—it may not be a lethal event, but you could certainly rapidly destroy a joint if that infection isn't treated immediately.

If, on the other hand, there are people readily available who can do the procedure, and that referral can be made and the procedure done expeditiously, that doesn't present a problem. Each hospital system basically has to look at the availability of people to do these procedures rather rapidly, particularly if the absence can result in increased morbidity or even mortality.

Q: What are potential solutions to this issue?

A: I'm not absolutely sure that all solutions will fit all hospital systems. [For] huge hospital systems like we have here in Philadelphia—large university hospitals that see lots of patients, with many specialists available—their solution may be quite different than for the rural hospital that has maybe 30 beds.

As hospitalists study the system that they're in, they may have to make accommodations to provide the solution. If they're in a system that doesn't have readily available specialists who can perform the procedure when needed, it seems to me that they'll need to learn how to do the procedure themselves and become competent in it so they can do it safely.

If they're in a large hospital system, and there are physicians on call who can immediately do that procedure, that seems to be another solution that might work.

Q: How can hospitalists become competent at these procedures?

A: Once you leave your training program, it's not easy to learn how to do these procedures. At [ACP's] annual meeting, seven of the nine procedures that are listed by the Society of Hospital Medicine [are taught] in the Waxman Clinical Skills Center. Each year, we've added more procedures and more simulators at great cost to assist in this. But that's just a small part of this whole training process.

I think that simulators give physicians an understanding of the steps to do the procedure [and] may give them some confidence to do the procedure when they do it for the first time on a real patient. And for some physicians, they actually make an active decision not to do the procedure. They may find that they're uncomfortable doing the procedure; they find that it's beyond their psychomotor skills. It's good for somebody to realize where their limits are.

We are introducing people to the procedure. But to become competent, they need to practice under expert guidance on patients. There has to be a system of learning how to do the procedure and doing a certain number of procedures under the guidance and supervision of an expert. It's difficult to arrange, particularly after you've left a training program. It really has to take place at the home institution.