Home Q&A Can a new document help bring hospitalists the respect they deserve?

Can a new document help bring hospitalists the respect they deserve?

May 2006

Published in the May 2006 issue of Today’s Hospitalist

When the Society of Hospital Medicine released a list of “core competencies” for hospitalists earlier this year, the goal was to give educators a template to use when training hospitalists. But leaders are also hoping that by defining an emerging specialty that is still largely misunderstood both inside and outside of medicine, the document will help raise the profile of the nation’s hospitalists.

In its most basic form, the core competencies outline the skills and knowledge that define hospitalists. The document’s 51 chapters catalogue clinical conditions like community-acquired pneumonia, procedures including arthrocentesis, and health care systems skills such as palliative care that are the bread and butter of hospital medicine.

The document does not prescribe exactly how hospitalists should be taught these skills, but instead lists broad learning objectives. In the chapter on community-acquired pneumonia, for example, the document says that hospitalists should be able to predict the risk of morbidity and mortality using an evidence-based tool like the pneumonia severity index.

The document promises to serve as a blueprint for educators who are training future hospitalists. If you’re creating a hospital medicine elective or fellowship, for example, the core competencies will help make sure that you cover the major points.

To emphasize the uniqueness of the care that hospitalists provide, the core competencies contains a section that focuses on system organization and improvement. In chapters on clinical skills and procedures, this section lists specific activities hospitalists can do that will improve quality and patient safety.

Leaders in hospital medicine hope that by spelling out what it is that hospitalists do “and emphasizing their unique ability to take the lead on quality improvement efforts, because of their constant presence in the hospital and emerging expertise “the document will give the growing hospitalist movement legitimacy and a sense of direction.

Sylvia C.W. McKean, MD, one of the document’s five editors, says there is still confusion about the role of hospitalists, even among internists who practice primary care. The core competencies, she predicts, will go a long way to helping standardize what hospital administrators, primary care physicians and even hospitalists expect of themselves and each other.

In an interview with Today’s Hospitalist, Dr. McKean, medical director of the Brigham and Women’s/Faulkner hospitalist service in Boston, explains why she thinks the core competencies will not only better define hospital medicine, but help hospitalists gain some respect within the hospital hierarchy.

Why do hospitalists need a document like the core competencies?

The role of the hospitalist is not clear to a lot of hospital administrators and people who are starting hospitalist programs. We’re being asked to provide all kinds of different services, but they don’t recognize that we have a level of expertise like other attending physicians in the hospital. In some academic medical centers, for example, hospitalists are viewed as doing little more than filling the role of residents.

Some of that stems from the fact that hospital medicine is a new specialty, and some of it stems from the fact that it’s a young specialty and most hospitalists are right out of training.

When people read the core competencies for the first time, the document will impress them as to what their role can potentially be in the hospital. Many of the people right out of training who are practicing hospital medicine are being asked to meet everyone else’s needs.

Naturally, residency directors turn to hospitalists to staff “nonteaching” services. The Society of Hospital Medicine included the “Hospitalist as Teacher” chapter to send the message that along with providing efficient care, teaching is also a key role for hospitalists.

Residency directors can turn to hospitalists, as leaders in quality improvement, to improve the education of the next generation of physicians in evidence-based clinical problem-solving and health care systems.

This document really says that hospital medicine is a specialty, and people are going to need your expertise. That’s a different perspective, and it gives people an opportunity to look at hospitalists as a resource without necessary being a Band-Aid to fill in gaps in service, but a resource to improve the hospital setting and residency training.

How will this document help the world understand what hospitalists do?

The purpose of the core competencies is to define the role of the hospitalist, to say that this is the ideal role. It’s also an excellent way to create a standard for prospective employers to know what to expect if they hire a hospitalist in the future.

Hospital medicine programs often reside in the division of general internal medicine. Most of those people are primary care physicians, not hospitalists, so they may not really understand the role. There can be a mismatch between how hospitalists perceive themselves and how prospective employers perceive them, and that mismatch can lead to problems in terms of job satisfaction.

What kinds of differences between hospitalists and other attending physicians do the core competencies highlight?

The selection of the chapters emphasizes the unique role that hospitalists play in the hospital, issues that internists or family physicians may not focus on when they’re working in the hospital. We’re all involved in diagnostic decision-making, for instance, but when it comes to issues like the equitable allocation of resources, hospitalists take care of a disproportionate number of free care and indigent patients. Caring for vulnerable patients is another example of the competencies hospitalists need to acquire to optimally care for this patient population.

The document has obvious uses for educators, but how will it help individual hospitalists?

Individual hospitalists will be able to point to the core competencies and explain to administrators that as hospitalists, they bring a certain expertise to the table. The point is that we don’t just want to sit on a committee. We want to be able to actively participate and lead a quality improvement initiative, and we have firsthand knowledge of what needs to be done and the tools to get it done.

The core competencies provide a forward-looking framework for curriculum development. This document says that we’re not only going to participate on these committees and try to improve things because we’re always in the hospital, but that we need to develop the skills, knowledge and competencies to lead improvements. Hospitalists should be given opportunities to lead, coordinate, or actively participate in activities that improve health care systems.

The core competencies spend a fair amount of time on hospitalists’ role in non-patient care activities. Why does nonpatient care have such a large emphasis?

Because hospital medicine is so intense, hospital work is not equivalent to office practice, and hospitalists should not work 47 weeks out of the year. This is something that primary care physicians and medical subspecialists may not appreciate. So one of the questions is what do hospitalists do with their administrative time, and the core competencies provide a framework.

Currently, hospitalists frequently function as informal consultants in the hospital. The core competencies articulate their potential leadership roles in systems improvement. The systems organization and procedure chapters strive to capture the essence of hospitalists, whose goals are to improve patient outcomes and provide patient centered care for all patients within the hospital.

Hospitalists who are teachers, for instance, might use the “As Teachers” chapter to develop a curriculum that they can use to teach residents and the other people on their multidisciplinary team. Hospitalists in community hospitals who do not work directly with residents may decide that what they really want to do is develop some type of quality improvement initiative.

Hospitalists commonly account for 50 percent or more of the general medical service in community hospitals, so they have an opportunity to standardize how they approach patient care, and to use the best evidence in tackling problems.

There has been talk about the need for hospitalists to seek board certification or some other formal type of recognition as a specialty. Is this document a first step on that path?

Yes. The American Board of Internal Medicine lists several requirements for a specialty to be eligible for board certification. One of those states that the discipline must have a distinct and unique body of knowledge. I think the core competencies clearly meets this aspect of the definition, although I cannot comment on exactly what type of recognition will evolve through the professional society of hospital medicine and the American Board of Internal Medicine.

For more information”¦

The full text of the Core Competencies in Hospital Medicine is available from the Society of Hospital Medicine’s Web site. Select Education from the box on the side of the page and then click on Core Competencies.