For the first time in more than a decade, the Society of Hospital Medicine (SHM) recently updated its Core Competencies in Hospital Medicine, adjusting several of the skills and proficiencies expected of hospitalists.
The role-defining document, published as a supplement to the April Journal of Hospital Medicine, may be most useful for program directors and other physician educators, said ACP Member Satyen Nichani, MD, lead author of the updated version.
“It's essentially a shared understanding of the skills, knowledge, and attitudes that are expected of hospitalists,” he said. The resource was initially published in 2006 and features three sections—clinical conditions, procedures, and health care systems.
In 2012, the SHM education committee created a task force to update the core competencies and design the revision process itself for future iterations, Dr. Nichani said. “There have been significant changes in the hospitalist practice environment, and the number of hospitalists has tripled in the past 10 years, so we [needed] to re-evaluate our strategy moving forward,” he said. “That's what brought on this update.”
Dr. Nichani, an assistant professor of medicine and director of education for the hospital medicine division at the University of Michigan, Ann Arbor, recently spoke with ACP Hospitalist about the revamped areas in which hospitalists should be experts.
Q: Why is this resource important for hospitalists?
A: This is something that the SHM put forth back in 2006, when the field of hospital medicine was just evolving and taking root in the American health care system. Initially, when published, it set the framework for what the field is supposed to be and how it's supposed to grow. There were several topics that were identified as being key areas where hospitalists should really own that piece of it within the health care setting and then take it forward [by] developing expertise, both clinically and procedurally, but also being experts of the health care system in which they work. It also set the framework for developing curricula for people who are in the lead for educating future generations of physicians who plan to become hospitalists … educators who are residency program directors, medical school clerkship directors, or hospital medicine fellowship directors, physicians who are developing continuing medical education (CME) programs.
Q: What are the biggest changes with this update?
A: There are 21 clinical topics—there were 19 previously; syncope and hyponatremia are the additional two—and then there are eight procedures and 24 [topics on] health care systems. The health care systems section includes aspects of the practice of hospital medicine that don't follow a specific clinical condition or procedure. For example, there's patient safety, quality improvement, palliative care. … This is the section where we call on most hospitalists to participate in these multidisciplinary teams and hopefully evolve as leaders of those teams to guide the field of hospital medicine towards making health care safer and more cost-effective.
Q: How did you decide which topics to add or refine?
A: It started off with looking at the current topics that were present in the core competencies to see if each one was relevant, and we found that each one was. We knew that there were areas of new opportunities and growth, so the second part of it was to look for new topics that should be included in this version. One of the challenges that faced the task force was developing the criteria for what is considered significant enough to be included. There are many topics that aren't in the core competencies that hospitalists still are perfectly capable of or even expert at performing.
The criteria that we used … were that it should be a commonly encountered situation, [and] we also quantified the amount of overlap with other medical or surgical specialties, for which there may be already guidance or competencies published. Finally, we wanted to particularly choose topics that had key areas for hospitalists to lead or participate at their institutions in terms of quality and safety.
Q: What were some of the topics you considered?
A: We came up with a list of about 18 to 20 different topics that we considered. Some of the clinical conditions were pancreatitis, anemia, diarrhea, decompensated cirrhosis. For example, there is a significant variability in how pancreatitis is managed across the United States. Sometimes it's the surgeons who are the primary treating teams for patients admitted with pancreatitis, so we felt like that may be a future topic, but not at this point. Diarrhea was another example where we felt like that's an extremely common condition that's often managed by hospitalists, but then again, what is really the key message for hospitalists? Is there a quality improvement need? Is there a patient safety concern? Probably not.
For the procedures, there were several considered, like nasogastric intubation is common, insertion of a urinary catheter we decided is a very basic requirement that hospitalists should know. But then, when we deliberated more, most urinary catheters are commonly inserted by other health care providers like nurses or ED personnel. We did identify the use of point-of-care ultrasound as a significant development in the practice of hospital medicine over the past few years, and that this is something that we would expect all hospitalists to participate in as the practice evolves and it becomes more of a mainstream instrument. Rather than developing a core competency around that, because that itself is a topic that requires a significant amount of guidance, the SHM education committee decided that it would be better first to create a separate task force that's looking at developing a guideline for the use of point-of-care ultrasound by hospitalists.
There aren't any new health care system topics. We made a few modifications to the names just to reflect current practices. Many of the things we describe, like health care reform in terms of payment models, etc., are what we would consider content. So it doesn't really change the learning objectives of each competency itself.
Q: What was the rationale for adding syncope and hyponatremia?
A: A lot of patients present to the ED with syncope, and many get admitted when the cause of syncope is not clearly identified at the outset. The key aspect for the hospitalist is to try to figure out the cause of the syncope to ensure that this is not a first sign of something more sinister that can eventually lead to an adverse outcome. The workup for syncope can vary depending on the initial impression, and there are a lot of areas where inappropriate testing can be performed, often at the detriment of cost. There is a certain pathway for which we can be a lot more cost-effective in our management of patients with syncope … and we think that there is a fair amount of patient safety issues, as well as opportunity for the hospitalists to develop quality improvement initiatives. The same can be said for hyponatremia, as well.
Q: What does each chapter include?
A: Each chapter has an introduction that sets the tone for why the topic belongs in the core competencies and the key role that hospitalists should play in this particular area. Then there are a few sections afterward, broken down according to the educational theory of cognitive, psychomotor, and affective domains as sections on knowledge, skills, and attitudes, respectively. Then, for the clinical topics and the procedure topics, there's a separate section called systems organization and improvement, where we're asking hospitalists to get involved at their local institutions to either participate [in or] coordinate or lead interdisciplinary teams in improving the care of all patients with that particular condition. For the health care systems, we don't have that separate section of systems organization and improvement because the subject itself represents that. Each chapter can stand alone, depending on what the immediate need for the learner is, but there is significant overlap between the topics.
Q: How can hospitalists use this in practice?
A: The core competencies are a set of learning objectives. … For the practicing hospitalists, it's not going to tell you the evidence behind the testing that you're supposed to do, but it does call upon hospitalists to recognize what the recommended strategy for testing or treating is. Every hospitalist, when reviewing these new topics or any of the existing topics, should reflect on their own skills and their own knowledge and their own attitudes in managing these conditions, and if they find that there is a gap, then they would go and seek content to fill that need using textbooks, literature searches, CME programs, or workshops. The practice of medicine evolves and changes, but the underlying learning objectives that guide patient management don't.
Q: When will the next update be published?
A: This first update took time because we also had to develop the process through which the updates should occur. Moving forward, this will be easier, and we can focus more on developing new content areas where hospitalists are encouraged to take the lead in those venues. We hope to be able to add to the core competencies on an ad hoc basis, based on how the field evolves, so there may be additional chapters introduced outside of a major revision.