Sylvia C. W. McKean, MD

The seminal article that coined the term hospitalist, in 1996, attributed the role of the hospitalist to enhancing throughput and cost reduction, primarily through reduction in length of stay, accomplished by having a dedicated clinician on site in the hospital.1 Since that time the role of the hospitalist has evolved to address the needs of multiple stakeholders at a time when traditional residency programs in inpatient adult medicine do not adequately train physicians to become effective agents of change in complex and potentially unsafe hospital systems. Continuing the trend of pediatrics, obstetrics, gynecology, and geriatrics, hospitalists have emerged as a distinct group of physicians who fill a needed clinical niche and are demonstrating the benefits of bringing a unique role and skill sets to the general hospital ward.2

The eligibility requirements for certification by the American Board of Internal Medicine specify that the discipline must 1) have a distinct and unique body of knowledge, 2) have clinical applicability sufficient to support a distinct clinical practice, 3) generate new information and research, 4) require a minimum training period of 12 months, and 5) have a substantial number of trainees and training programs nationwide.3 The Society of Hospital Medicine (SHM), the national professional organization of hospitalists, commissioned a task force to develop The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (referred to from here on as the Core Competencies) to standardize the expectations of practicing hospitalists, serve as a foundation for curricula and other professional development experiences, prioritize educational scholarship and research strategies, and assess the adequacy and improvement opportunities for current training and accreditation of hospital medicine physicians.4 The preceding companion article The Core Competencies in Hospital Medicine: Development and Methodology, describes in detail the rationale for the development of the Core Competencies and the methods by which the document was created.5

PURPOSE

The purpose of this article is to illustrate how curriculum developers can apply the Core Competencies in Hospital Medicine to educate trainees and faculty, to prioritize educational scholarship and research strategies, and thus to improve the care of our patients.

TARGET AUDIENCE

The Core Competencies specifically targets directors of continuing medical education (CME), hospitalist programs and fellowships, residency programs, and medical school internal medicine clerkships. It is also intended for health educators, hospital administrators, potential employers, policy makers, and agencies funding quality‐improvement initiatives in the hospital setting. For residency program directors and clerkship directors, the chapters can guide in the development of curricula for inpatient medicine rotations or in meeting the Accreditation Council on Graduate Medical Education's Outcomes Project. For directors developing medical education curricula, The Core Competencies in Hospital Medicine can serve as a template for CME. For hospitalists, hospital administrators, and potential employers, the Core Competencies can be used to as the starting point in local program development and as a resource for refining the skills of all hospitalists, even very experienced practicing clinicians.

DEFINITION OF CORE COMPETENCIES IN HOSPITAL MEDICINE

The Core Competencies in Hospital Medicine provides a framework for curricular development based on a shared understanding of the essential knowledge, skills, and attitudes expected of physicians working as hospitalists. The development process will be ongoing, with revisions reflecting the evolving specialty of hospital medicine, the needs of practicing hospitalists, and feedback from users of the Core Competencies.

PROBLEM IDENTIFICATION AND GENERAL NEEDS ASSESSMENT

Delivery of health care has large gaps compared to ideal performance. Since the publication by the Institute of Medicine of To Err Is Human, in 1999, multiple agencies including the American Hospital Association, the National Quality Forum, and the U.S. Agency for Health Care Research and Quality (AHRQ) have reported on the incidence of medical errors in U.S. hospitals.6, 7 Recognizing that medical errors represent a major health concern in the United States, the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) now requires patient safety initiatives for hospital accreditation.8 Problem‐based learning and improvement and systems based practice are now required competencies in medical residency curricula by the Accreditation Council for Graduate Medical Education (ACGME) and these requirements have led to the development of continuous quality techniques for preventing errors and a variety of patient safety initiatives.9

In 2002 the SHM recognized the need for identifying a distinct set of competencies in hospital medicine. The published competencies highlight the current gap in training of hospitalists and the imperative for revising curricula relating to inpatient care, hospital systems, and teaching.4 With adequate training and preparation, hospitalists can take the lead in implementing systems for best practices from admission through discharge and care transition, and they can direct the development of a safer, more patient‐centered, and cost‐efficient culture.

By defining the role of the hospitalist, the Core Competencies reflects the view of the SHM about what is possible but does not suggest how a training program might be modified to achieve desired outcomes or provide any content, resources, or teaching strategies. It will be up to curriculum developers to determine the scope of cognitive, psychomotor, and affective objectives that targeted learnershospitalists, residents, and other members of the multidisciplinary teamshould be required to acquire through lectures, discussions, syllabus material, clinical experience, and other venues. We agree with a broader definition of the term curriculum for graduate medical education, one that goes beyond curriculum as a plan and takes into account the learners' experiences, both planned and unplanned in the hospital setting.10 In contrast to the technologic theory of curriculum, in which lists of knowledge and skills represent final destinations, in the experiential model of curriculum, the lists provide only points of departure.11 The goal of the Core Competencies is to facilitate curriculum development using complex teaching environments as building blocks through which learning can occur.

CORE COMPETENCIES FOR HOSPITALISTS: OVERVIEW

The Core Competencies in Hospital Medicine is the first published competency‐based framework for professional development of hospitalists and provides the basis for accreditation in hospital medicine.12 The Core Competencies is organized into three sectionsClinical Conditions, Procedures, and Healthcare Systems. The supplement intentionally does not focus on content; rather, specific competencies describe unambiguous, measurable learning objectives. Each chapter can be used as a stand‐alone chapter to develop training and curricula for a particular topic area. Each chapter divides competencies into three domains of educational outcomes: cognitive (knowledge), affective (attitudes), and psychomotor (skills). Each domain has defined levels of proficiency going from knowledge, the lowest level, to evaluation, the highest.12, 13 A specific level of proficiency is articulated in the competencies through careful selection of corresponding action verbs, which clearly indicate how mastery could be assessed (see Table 1).

In addition to specific competencies in these commonly accepted learning domains, the Clinical Conditions and Procedure sections of the Core Competencies articulate the proficiencies that hospitalists should possess in systems organization and improvement. The clinical topics were selected to set expectations of leading or participating in system improvements specific to a clinical area and to prevent predictable complications of acute illness. Competencies in the Systems Organization and Improvement section indicate mastery of multiple competencies across categories. The Core Competencies describes how the hospitalist approach facilitates coordination among all participants within the hospital system (clinical and nonclinical) and effects system changes that improve patient care processes. At the same time, the statements indicate a range of involvement from participation to leadership. For example, lead, coordination or participate in acknowledges the unique needs of different practice settings and suggests a potential professional evolution. The Systems Organization and Improvement competencies of each clinical and procedure chapter strive to capture the essence of hospitalists whose goals are to improve patient outcomes for a specific population of patients. Hospitalists do not solely focus on the care of the patient with x disease, but rather develop systems to provide the best and most efficient care for all patients with x disease, successfully transitioning these patients to outpatient care and avoiding readmission.

The third section of chapters in the Core Competencies, Healthcare Systems, distinguishes a hospitalist from others working in the inpatient setting whether practicing at academic medical centers, community hospitals, teaching hospitals, managed‐care settings, or for‐profit settings. The Healthcare Systems section identifies the integral components of the successful practice of hospital medicine and mastery of multiple competencies. This section highlights how hospitalists can facilitate coordination among all care providers within the hospital and with outpatient care providers. Hospitalists can effect system changes that improve complex care processes. It is likely that additional work experience and training beyond residency are required to attain global proficiency in the care of hospital medicine patients.

HOW TO USE THE CORE COMPETENCIES TO DEVELOP A CURRICULUM

The whole document, three sections and 51 chapters, develops expectations about the role of the hospitalist. Proficiency can be acquired through multiple means and should match the needs of the targeted learners in order to develop and maintain the necessary level of performance within the discipline of hospital medicine. Specific cases that hospitalists may encounter in their daily practice are used to illustrate how the Core Competencies can be applied to curriculum development.

The cases will employ the following six‐step approach described in Curriculum Development in Medical Education14:

• 1

  A problem and a need for improvement (the actual case and quality gap)

• 2

  Needs assessment of targeted learners (hospitalists, clinicians‐in‐training)

• 3

  Goals and specific measurable objectives (with competencies bridging the gap between traditional roles and setting expectations about the hospitalist role)

• 4

  Educational strategies (with competencies providing structure and guidance to educational efforts)

• 5

  Implementation (applying competencies to a variety of training opportunities and curricula)

• 6

  Evaluation and feedback (ongoing nationally, regionally, locally).

Like any quality‐improvement educational initiative, subsequent steps in curriculum development for hospitalists should include, after evaluation and feedback, dissemination of core competencies and promotion of rigorous ongoing evaluation and adaptation as needs and expectations evolve.

The first case example, failure to prevent and diagnose pulmonary embolism (see Table 2), illustrates quality issues relating to prevention of predictable complications of illness, clinical problem solving in complex conditions of uncertainty, repetitive and nondiagnostic testing, and triage of a critically ill patient between services. The Core Competencies sets expectations about the ideal role of the hospitalist that might lead to improved outcomes.

Using this case example, the Evidence‐Based Medicine (EBM) chapter establishes explicit expectations for hospitalists in clinical problem solving, including 1) explaining how the tests help to verify a suspected diagnosis, 2) describing the human factor in test interpretation (e.g., technical limitations of the most recent multi‐detector‐row spiral CT), and 3) explaining how timing relative to the onset of symptoms affects test results. Rather than an overreliance on technology, leading to repeating the chest CT with PE protocol and subsequent excessive nondiagnostic testing, the hospitalist would use knowledge of pretest probability and test characteristics to determine the best diagnostic strategy. The hospitalist approach to patient care, articulated in the affective (attitudes) domains of each chapter, integrates the application of EBM principles to clinical problem solving with deliberation of cost effectiveness and efficiency.

Continuing with this case example, the Team Approach and Communication chapters establish explicit expectations for practicing hospitalists who would take the extra steps to communicate with multiple members of the care team. Knowledgeable about the hospital, the hospitalist would review the chest CT with a radiologist skilled in chest interpretation and specifically query about the significance of an enlarged right atrium and right ventricle in the setting of a high pretest clinical probability of PE. Together the radiologist and hospitalist would consider a different imaging modality if the patient flunked the chest CT when the pretest probability was high. Rather than simply deferring to the medical specialist who is consulting, the hospitalist would be expected to improve the efficiency of care and reduce cost by only ordering tests that would change clinical management, perhaps with improved outcomes.

The Hospitalist as Teacher chapter provides a frameworkcore competencies for impromptu learningbased on the patient encounter. Members of the multidisciplinary care team can be exposed to explicit clinical decision making, an approach made possible by hospitalists on site, who can provide teaching moments in real time when decisions have to be made and educational feedback is needed. Teaching expectations for hospitalists include unambiguous clinical problem solving at the bedside and possibly directing the education of residents, physician assistants, and nurses on how to initiate a quality improvement (QI) project in a hospital setting.

The Quality Improvement and Venous Thromboembolism chapters clarify the role of the hospitalist, who should direct therapy against predictable complications of serious illness, critically review prophylaxis, provide hospital‐specific data to clinicians, identify and lower barriers to prevention, devise strategies to bridge the gap between knowledge and practice, develop automated reminder systems, and participate in clinical research.

The SHM has used the Core Competencies to develop educational resources to better meet the needs of the healthcare system. Although patient safety initiatives are mandated by JCAHO for hospital accreditation and AHRQ has identified areas for safety improvement that lists venous thromboembolism (VTE) prevention as the number one priority, VTE prophylaxis is still underutilized in the United States. Although some mechanisms are in place to educate residents and hospitalists about how to manage a specific disease, traditional medical education does not focus on teaching students and residents how to manage complex patients with multiple comorbidities, to prevent predictable complications of illness, and to examine and improve care processes.15, 16 When it comes to leading quality improvement (QI), individual feedback and traditional curricula, which may include didactic lectures on the pathophysiology of VTE and morbidity and mortality conferences, have not demonstrated improved outcomes.17

The SHM QI Web‐based resource rooms offer support to any QI effort and raise collective awareness of a performance gap.18 Each resource room will describe the evidence‐based practices that should be put into effect and will leverage experience with the disease as well as with the improvement process. The underlying goal of the resource rooms is to enhance the ability of hospitalists to actually improve inpatient outcomes through self‐directed learning (see Fig. 1).

Figure 1

Hospitalists, residency directors, and directors of hospitalist fellowships and continuing education can use The Core Competencies in Hospital Medicine to develop curricula for their local hospitalist service and request that invited speakers develop learning objectives and content based on core competencies rather than giving a prepared lecture on a specific clinical condition. This case of PE illustrates that risk assessment, prophylaxis, EBM clinical problem solving, and QI are core topics that should be emphasized in the training of hospitalists and physicians in training.0

The second case example, the hand‐off (see Table 3), illustrates quality issues related to transfer of care from one physician to another. In this example, if the patient with moderate pleural effusion had been signed out, an earlier thoracentesis to drain a presumptive parapneumonic infection might have relieved this patient's shortness of breath and saved her from undergoing a subsequent VATS procedure. This case also demonstrates the importance of correlating imaging abnormalities with a patient's clinical presentation rather than using the traditional approach of just ruling out potential diagnoses to determine the cause of a problem. This case highlights elements of the process and system of care that can be modified to improve patient outcomes. Being proficient in transferring care of patients can save the hospitalist from error and prevent adverse events.

The Team Approach chapter establishes the need to acquire proficiencies not ordinarily obtained during residency in order to lead a multidisciplinary care team. This role requires a level of functioning beyond that of simply being the attending of record. The hospitalist must be able to synthesize information rather than simply defer to the consultant. Competencies specified in the Diagnostic Decision‐Making chapter can be used to identify the educational needs of hospitalists, who are expected to minimize diagnostic errors by knowing when to ask for help and where to get it, recognizing common diseases with uncommon presentations, and generating a broad differential diagnosis where there is uncertainty. The Patient Handoff chapter defines the proficiencies hospitalists need to facilitate the safe transfer of patients to other physicians on their service.0

The third case example, which expands the responsibilities of hospitalist to include meeting important needs in the hospital (see Table 4), illustrates that hospitalist services cannot succeed by offering all things to all people, a distraction that that keeps the members of these services from concentrating on their goals. Always saying yes to whoever asks for help is a band‐aid, a short‐term fix that impedes the effort and creativity required for durable long‐term solutions to problems.

The Core Competencies sets expectations about the roles of hospitalists, who serve as well‐informed clinicians and clinical opinion leaders; effective educators, mentors, and role models; empathetic and timely communicators; efficient caregivers; and creative problem solvers arriving at durable, longer‐term solutions. The competencies demonstrate the knowledge, skills, and attitudes required to be effective agents of change. Changing business as usual almost always requires significant improvements in the underlying system, however uncomfortable. The Leadership chapter articulates competencies that hospitalists need in order to define their roles within the hospital, promote group cohesiveness, expand their practices intelligently, and anticipate and respond to change. This chapter details the proficiencies that hospitalists need in order to develop personal, team, and program goals and to identify and resolve conflicts using specific negotiation techniques. The Business Practices chapter articulates the fundamental skills needed to enhance program development and growth. Hospitalists can use the Core Competencies to identify educational needs and develop curricula to enhance their leadership and business skill sets.0

Medical educators should examine the outcomes of current training practices and assess what modifications of objectives, content, and instructional strategies should be made to better prepare the current and next generations of physicians to practice hospital medicine and to improve the hospital setting. Given the scope of the field of hospital medicine, the Core Competencies should guide: 1) what to teach and how much to teach; 2) how to teach and assess trainees, and how to assess and compare faculty development programs; 3) how to design systems for improving quality of care and assuring patient safety; and 4) how to establish priorities for hospital medicine research.

TRANSLATING A SET OF COMPETENCIES INTO CURRICULA: POTENTIAL BENEFITS

The Core Competencies in Hospital Medicine transcends hospital type, size, and setting and standardizes what the expectations for and proficiencies of a practicing hospitalist should be. By defining the role of the hospitalist, the Core Competencies serves as a resource for refining inpatient skills and assists in program development at the local, regional, and national levels. In addition, by using the Core Competencies as the standard and framework for the development of preparatory curricula, hospital administrators and other employers can rely on hospitalists having had a common preparation.

The medical profession is constantly evolving. Internal medicine curricula address the challenges hospital medicine physicians faced yesterday but could improve the training and preparation of physicians to serve in their new and emerging roles as leaders of multidisciplinary healthcare teams working to improve patient outcomes and the system of inpatient care. Hospital medicine no longer represents a group of physicians merely supporting other specialists and primary care physicians; it is itself a specialty, composed of physicians leading, directing, and improving inpatient care. The competencies presented in The Core Competencies in Hospital Medicine: A Framework for Curriculum Development, by the Society of Hospital Medicine, should spark debate about the adequacy and appropriateness of current training and certification expectations and serve as a foundation for the development of curricula to improve hospital medicine education.

The seminal article that coined the term hospitalist, in 1996, attributed the role of the hospitalist to enhancing throughput and cost reduction, primarily through reduction in length of stay, accomplished by having a dedicated clinician on site in the hospital.1 Since that time the role of the hospitalist has evolved to address the needs of multiple stakeholders at a time when traditional residency programs in inpatient adult medicine do not adequately train physicians to become effective agents of change in complex and potentially unsafe hospital systems. Continuing the trend of pediatrics, obstetrics, gynecology, and geriatrics, hospitalists have emerged as a distinct group of physicians who fill a needed clinical niche and are demonstrating the benefits of bringing a unique role and skill sets to the general hospital ward.2

The eligibility requirements for certification by the American Board of Internal Medicine specify that the discipline must 1) have a distinct and unique body of knowledge, 2) have clinical applicability sufficient to support a distinct clinical practice, 3) generate new information and research, 4) require a minimum training period of 12 months, and 5) have a substantial number of trainees and training programs nationwide.3 The Society of Hospital Medicine (SHM), the national professional organization of hospitalists, commissioned a task force to develop The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (referred to from here on as the Core Competencies) to standardize the expectations of practicing hospitalists, serve as a foundation for curricula and other professional development experiences, prioritize educational scholarship and research strategies, and assess the adequacy and improvement opportunities for current training and accreditation of hospital medicine physicians.4 The preceding companion article The Core Competencies in Hospital Medicine: Development and Methodology, describes in detail the rationale for the development of the Core Competencies and the methods by which the document was created.5

PURPOSE

The purpose of this article is to illustrate how curriculum developers can apply the Core Competencies in Hospital Medicine to educate trainees and faculty, to prioritize educational scholarship and research strategies, and thus to improve the care of our patients.

TARGET AUDIENCE

The Core Competencies specifically targets directors of continuing medical education (CME), hospitalist programs and fellowships, residency programs, and medical school internal medicine clerkships. It is also intended for health educators, hospital administrators, potential employers, policy makers, and agencies funding quality‐improvement initiatives in the hospital setting. For residency program directors and clerkship directors, the chapters can guide in the development of curricula for inpatient medicine rotations or in meeting the Accreditation Council on Graduate Medical Education's Outcomes Project. For directors developing medical education curricula, The Core Competencies in Hospital Medicine can serve as a template for CME. For hospitalists, hospital administrators, and potential employers, the Core Competencies can be used to as the starting point in local program development and as a resource for refining the skills of all hospitalists, even very experienced practicing clinicians.

DEFINITION OF CORE COMPETENCIES IN HOSPITAL MEDICINE

The Core Competencies in Hospital Medicine provides a framework for curricular development based on a shared understanding of the essential knowledge, skills, and attitudes expected of physicians working as hospitalists. The development process will be ongoing, with revisions reflecting the evolving specialty of hospital medicine, the needs of practicing hospitalists, and feedback from users of the Core Competencies.

PROBLEM IDENTIFICATION AND GENERAL NEEDS ASSESSMENT

Delivery of health care has large gaps compared to ideal performance. Since the publication by the Institute of Medicine of To Err Is Human, in 1999, multiple agencies including the American Hospital Association, the National Quality Forum, and the U.S. Agency for Health Care Research and Quality (AHRQ) have reported on the incidence of medical errors in U.S. hospitals.6, 7 Recognizing that medical errors represent a major health concern in the United States, the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) now requires patient safety initiatives for hospital accreditation.8 Problem‐based learning and improvement and systems based practice are now required competencies in medical residency curricula by the Accreditation Council for Graduate Medical Education (ACGME) and these requirements have led to the development of continuous quality techniques for preventing errors and a variety of patient safety initiatives.9

In 2002 the SHM recognized the need for identifying a distinct set of competencies in hospital medicine. The published competencies highlight the current gap in training of hospitalists and the imperative for revising curricula relating to inpatient care, hospital systems, and teaching.4 With adequate training and preparation, hospitalists can take the lead in implementing systems for best practices from admission through discharge and care transition, and they can direct the development of a safer, more patient‐centered, and cost‐efficient culture.

By defining the role of the hospitalist, the Core Competencies reflects the view of the SHM about what is possible but does not suggest how a training program might be modified to achieve desired outcomes or provide any content, resources, or teaching strategies. It will be up to curriculum developers to determine the scope of cognitive, psychomotor, and affective objectives that targeted learnershospitalists, residents, and other members of the multidisciplinary teamshould be required to acquire through lectures, discussions, syllabus material, clinical experience, and other venues. We agree with a broader definition of the term curriculum for graduate medical education, one that goes beyond curriculum as a plan and takes into account the learners' experiences, both planned and unplanned in the hospital setting.10 In contrast to the technologic theory of curriculum, in which lists of knowledge and skills represent final destinations, in the experiential model of curriculum, the lists provide only points of departure.11 The goal of the Core Competencies is to facilitate curriculum development using complex teaching environments as building blocks through which learning can occur.

CORE COMPETENCIES FOR HOSPITALISTS: OVERVIEW

The Core Competencies in Hospital Medicine is the first published competency‐based framework for professional development of hospitalists and provides the basis for accreditation in hospital medicine.12 The Core Competencies is organized into three sectionsClinical Conditions, Procedures, and Healthcare Systems. The supplement intentionally does not focus on content; rather, specific competencies describe unambiguous, measurable learning objectives. Each chapter can be used as a stand‐alone chapter to develop training and curricula for a particular topic area. Each chapter divides competencies into three domains of educational outcomes: cognitive (knowledge), affective (attitudes), and psychomotor (skills). Each domain has defined levels of proficiency going from knowledge, the lowest level, to evaluation, the highest.12, 13 A specific level of proficiency is articulated in the competencies through careful selection of corresponding action verbs, which clearly indicate how mastery could be assessed (see Table 1).

In addition to specific competencies in these commonly accepted learning domains, the Clinical Conditions and Procedure sections of the Core Competencies articulate the proficiencies that hospitalists should possess in systems organization and improvement. The clinical topics were selected to set expectations of leading or participating in system improvements specific to a clinical area and to prevent predictable complications of acute illness. Competencies in the Systems Organization and Improvement section indicate mastery of multiple competencies across categories. The Core Competencies describes how the hospitalist approach facilitates coordination among all participants within the hospital system (clinical and nonclinical) and effects system changes that improve patient care processes. At the same time, the statements indicate a range of involvement from participation to leadership. For example, lead, coordination or participate in acknowledges the unique needs of different practice settings and suggests a potential professional evolution. The Systems Organization and Improvement competencies of each clinical and procedure chapter strive to capture the essence of hospitalists whose goals are to improve patient outcomes for a specific population of patients. Hospitalists do not solely focus on the care of the patient with x disease, but rather develop systems to provide the best and most efficient care for all patients with x disease, successfully transitioning these patients to outpatient care and avoiding readmission.

The third section of chapters in the Core Competencies, Healthcare Systems, distinguishes a hospitalist from others working in the inpatient setting whether practicing at academic medical centers, community hospitals, teaching hospitals, managed‐care settings, or for‐profit settings. The Healthcare Systems section identifies the integral components of the successful practice of hospital medicine and mastery of multiple competencies. This section highlights how hospitalists can facilitate coordination among all care providers within the hospital and with outpatient care providers. Hospitalists can effect system changes that improve complex care processes. It is likely that additional work experience and training beyond residency are required to attain global proficiency in the care of hospital medicine patients.

HOW TO USE THE CORE COMPETENCIES TO DEVELOP A CURRICULUM

The whole document, three sections and 51 chapters, develops expectations about the role of the hospitalist. Proficiency can be acquired through multiple means and should match the needs of the targeted learners in order to develop and maintain the necessary level of performance within the discipline of hospital medicine. Specific cases that hospitalists may encounter in their daily practice are used to illustrate how the Core Competencies can be applied to curriculum development.

The cases will employ the following six‐step approach described in Curriculum Development in Medical Education14:

• 1

  A problem and a need for improvement (the actual case and quality gap)

• 2

  Needs assessment of targeted learners (hospitalists, clinicians‐in‐training)

• 3

  Goals and specific measurable objectives (with competencies bridging the gap between traditional roles and setting expectations about the hospitalist role)

• 4

  Educational strategies (with competencies providing structure and guidance to educational efforts)

• 5

  Implementation (applying competencies to a variety of training opportunities and curricula)

• 6

  Evaluation and feedback (ongoing nationally, regionally, locally).

Like any quality‐improvement educational initiative, subsequent steps in curriculum development for hospitalists should include, after evaluation and feedback, dissemination of core competencies and promotion of rigorous ongoing evaluation and adaptation as needs and expectations evolve.

The first case example, failure to prevent and diagnose pulmonary embolism (see Table 2), illustrates quality issues relating to prevention of predictable complications of illness, clinical problem solving in complex conditions of uncertainty, repetitive and nondiagnostic testing, and triage of a critically ill patient between services. The Core Competencies sets expectations about the ideal role of the hospitalist that might lead to improved outcomes.

Using this case example, the Evidence‐Based Medicine (EBM) chapter establishes explicit expectations for hospitalists in clinical problem solving, including 1) explaining how the tests help to verify a suspected diagnosis, 2) describing the human factor in test interpretation (e.g., technical limitations of the most recent multi‐detector‐row spiral CT), and 3) explaining how timing relative to the onset of symptoms affects test results. Rather than an overreliance on technology, leading to repeating the chest CT with PE protocol and subsequent excessive nondiagnostic testing, the hospitalist would use knowledge of pretest probability and test characteristics to determine the best diagnostic strategy. The hospitalist approach to patient care, articulated in the affective (attitudes) domains of each chapter, integrates the application of EBM principles to clinical problem solving with deliberation of cost effectiveness and efficiency.

Continuing with this case example, the Team Approach and Communication chapters establish explicit expectations for practicing hospitalists who would take the extra steps to communicate with multiple members of the care team. Knowledgeable about the hospital, the hospitalist would review the chest CT with a radiologist skilled in chest interpretation and specifically query about the significance of an enlarged right atrium and right ventricle in the setting of a high pretest clinical probability of PE. Together the radiologist and hospitalist would consider a different imaging modality if the patient flunked the chest CT when the pretest probability was high. Rather than simply deferring to the medical specialist who is consulting, the hospitalist would be expected to improve the efficiency of care and reduce cost by only ordering tests that would change clinical management, perhaps with improved outcomes.

The Hospitalist as Teacher chapter provides a frameworkcore competencies for impromptu learningbased on the patient encounter. Members of the multidisciplinary care team can be exposed to explicit clinical decision making, an approach made possible by hospitalists on site, who can provide teaching moments in real time when decisions have to be made and educational feedback is needed. Teaching expectations for hospitalists include unambiguous clinical problem solving at the bedside and possibly directing the education of residents, physician assistants, and nurses on how to initiate a quality improvement (QI) project in a hospital setting.

The Quality Improvement and Venous Thromboembolism chapters clarify the role of the hospitalist, who should direct therapy against predictable complications of serious illness, critically review prophylaxis, provide hospital‐specific data to clinicians, identify and lower barriers to prevention, devise strategies to bridge the gap between knowledge and practice, develop automated reminder systems, and participate in clinical research.

The SHM has used the Core Competencies to develop educational resources to better meet the needs of the healthcare system. Although patient safety initiatives are mandated by JCAHO for hospital accreditation and AHRQ has identified areas for safety improvement that lists venous thromboembolism (VTE) prevention as the number one priority, VTE prophylaxis is still underutilized in the United States. Although some mechanisms are in place to educate residents and hospitalists about how to manage a specific disease, traditional medical education does not focus on teaching students and residents how to manage complex patients with multiple comorbidities, to prevent predictable complications of illness, and to examine and improve care processes.15, 16 When it comes to leading quality improvement (QI), individual feedback and traditional curricula, which may include didactic lectures on the pathophysiology of VTE and morbidity and mortality conferences, have not demonstrated improved outcomes.17

The SHM QI Web‐based resource rooms offer support to any QI effort and raise collective awareness of a performance gap.18 Each resource room will describe the evidence‐based practices that should be put into effect and will leverage experience with the disease as well as with the improvement process. The underlying goal of the resource rooms is to enhance the ability of hospitalists to actually improve inpatient outcomes through self‐directed learning (see Fig. 1).

Figure 1

Hospitalists, residency directors, and directors of hospitalist fellowships and continuing education can use The Core Competencies in Hospital Medicine to develop curricula for their local hospitalist service and request that invited speakers develop learning objectives and content based on core competencies rather than giving a prepared lecture on a specific clinical condition. This case of PE illustrates that risk assessment, prophylaxis, EBM clinical problem solving, and QI are core topics that should be emphasized in the training of hospitalists and physicians in training.0

The second case example, the hand‐off (see Table 3), illustrates quality issues related to transfer of care from one physician to another. In this example, if the patient with moderate pleural effusion had been signed out, an earlier thoracentesis to drain a presumptive parapneumonic infection might have relieved this patient's shortness of breath and saved her from undergoing a subsequent VATS procedure. This case also demonstrates the importance of correlating imaging abnormalities with a patient's clinical presentation rather than using the traditional approach of just ruling out potential diagnoses to determine the cause of a problem. This case highlights elements of the process and system of care that can be modified to improve patient outcomes. Being proficient in transferring care of patients can save the hospitalist from error and prevent adverse events.

The Team Approach chapter establishes the need to acquire proficiencies not ordinarily obtained during residency in order to lead a multidisciplinary care team. This role requires a level of functioning beyond that of simply being the attending of record. The hospitalist must be able to synthesize information rather than simply defer to the consultant. Competencies specified in the Diagnostic Decision‐Making chapter can be used to identify the educational needs of hospitalists, who are expected to minimize diagnostic errors by knowing when to ask for help and where to get it, recognizing common diseases with uncommon presentations, and generating a broad differential diagnosis where there is uncertainty. The Patient Handoff chapter defines the proficiencies hospitalists need to facilitate the safe transfer of patients to other physicians on their service.0

The third case example, which expands the responsibilities of hospitalist to include meeting important needs in the hospital (see Table 4), illustrates that hospitalist services cannot succeed by offering all things to all people, a distraction that that keeps the members of these services from concentrating on their goals. Always saying yes to whoever asks for help is a band‐aid, a short‐term fix that impedes the effort and creativity required for durable long‐term solutions to problems.

The Core Competencies sets expectations about the roles of hospitalists, who serve as well‐informed clinicians and clinical opinion leaders; effective educators, mentors, and role models; empathetic and timely communicators; efficient caregivers; and creative problem solvers arriving at durable, longer‐term solutions. The competencies demonstrate the knowledge, skills, and attitudes required to be effective agents of change. Changing business as usual almost always requires significant improvements in the underlying system, however uncomfortable. The Leadership chapter articulates competencies that hospitalists need in order to define their roles within the hospital, promote group cohesiveness, expand their practices intelligently, and anticipate and respond to change. This chapter details the proficiencies that hospitalists need in order to develop personal, team, and program goals and to identify and resolve conflicts using specific negotiation techniques. The Business Practices chapter articulates the fundamental skills needed to enhance program development and growth. Hospitalists can use the Core Competencies to identify educational needs and develop curricula to enhance their leadership and business skill sets.0

Medical educators should examine the outcomes of current training practices and assess what modifications of objectives, content, and instructional strategies should be made to better prepare the current and next generations of physicians to practice hospital medicine and to improve the hospital setting. Given the scope of the field of hospital medicine, the Core Competencies should guide: 1) what to teach and how much to teach; 2) how to teach and assess trainees, and how to assess and compare faculty development programs; 3) how to design systems for improving quality of care and assuring patient safety; and 4) how to establish priorities for hospital medicine research.

TRANSLATING A SET OF COMPETENCIES INTO CURRICULA: POTENTIAL BENEFITS

The Core Competencies in Hospital Medicine transcends hospital type, size, and setting and standardizes what the expectations for and proficiencies of a practicing hospitalist should be. By defining the role of the hospitalist, the Core Competencies serves as a resource for refining inpatient skills and assists in program development at the local, regional, and national levels. In addition, by using the Core Competencies as the standard and framework for the development of preparatory curricula, hospital administrators and other employers can rely on hospitalists having had a common preparation.

The medical profession is constantly evolving. Internal medicine curricula address the challenges hospital medicine physicians faced yesterday but could improve the training and preparation of physicians to serve in their new and emerging roles as leaders of multidisciplinary healthcare teams working to improve patient outcomes and the system of inpatient care. Hospital medicine no longer represents a group of physicians merely supporting other specialists and primary care physicians; it is itself a specialty, composed of physicians leading, directing, and improving inpatient care. The competencies presented in The Core Competencies in Hospital Medicine: A Framework for Curriculum Development, by the Society of Hospital Medicine, should spark debate about the adequacy and appropriateness of current training and certification expectations and serve as a foundation for the development of curricula to improve hospital medicine education.

The seminal article that coined the term hospitalist, in 1996, attributed the role of the hospitalist to enhancing throughput and cost reduction, primarily through reduction in length of stay, accomplished by having a dedicated clinician on site in the hospital.1 Since that time the role of the hospitalist has evolved to address the needs of multiple stakeholders at a time when traditional residency programs in inpatient adult medicine do not adequately train physicians to become effective agents of change in complex and potentially unsafe hospital systems. Continuing the trend of pediatrics, obstetrics, gynecology, and geriatrics, hospitalists have emerged as a distinct group of physicians who fill a needed clinical niche and are demonstrating the benefits of bringing a unique role and skill sets to the general hospital ward.2

The eligibility requirements for certification by the American Board of Internal Medicine specify that the discipline must 1) have a distinct and unique body of knowledge, 2) have clinical applicability sufficient to support a distinct clinical practice, 3) generate new information and research, 4) require a minimum training period of 12 months, and 5) have a substantial number of trainees and training programs nationwide.3 The Society of Hospital Medicine (SHM), the national professional organization of hospitalists, commissioned a task force to develop The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (referred to from here on as the Core Competencies) to standardize the expectations of practicing hospitalists, serve as a foundation for curricula and other professional development experiences, prioritize educational scholarship and research strategies, and assess the adequacy and improvement opportunities for current training and accreditation of hospital medicine physicians.4 The preceding companion article The Core Competencies in Hospital Medicine: Development and Methodology, describes in detail the rationale for the development of the Core Competencies and the methods by which the document was created.5

PURPOSE

The purpose of this article is to illustrate how curriculum developers can apply the Core Competencies in Hospital Medicine to educate trainees and faculty, to prioritize educational scholarship and research strategies, and thus to improve the care of our patients.

TARGET AUDIENCE

The Core Competencies specifically targets directors of continuing medical education (CME), hospitalist programs and fellowships, residency programs, and medical school internal medicine clerkships. It is also intended for health educators, hospital administrators, potential employers, policy makers, and agencies funding quality‐improvement initiatives in the hospital setting. For residency program directors and clerkship directors, the chapters can guide in the development of curricula for inpatient medicine rotations or in meeting the Accreditation Council on Graduate Medical Education's Outcomes Project. For directors developing medical education curricula, The Core Competencies in Hospital Medicine can serve as a template for CME. For hospitalists, hospital administrators, and potential employers, the Core Competencies can be used to as the starting point in local program development and as a resource for refining the skills of all hospitalists, even very experienced practicing clinicians.

DEFINITION OF CORE COMPETENCIES IN HOSPITAL MEDICINE

The Core Competencies in Hospital Medicine provides a framework for curricular development based on a shared understanding of the essential knowledge, skills, and attitudes expected of physicians working as hospitalists. The development process will be ongoing, with revisions reflecting the evolving specialty of hospital medicine, the needs of practicing hospitalists, and feedback from users of the Core Competencies.

PROBLEM IDENTIFICATION AND GENERAL NEEDS ASSESSMENT

Delivery of health care has large gaps compared to ideal performance. Since the publication by the Institute of Medicine of To Err Is Human, in 1999, multiple agencies including the American Hospital Association, the National Quality Forum, and the U.S. Agency for Health Care Research and Quality (AHRQ) have reported on the incidence of medical errors in U.S. hospitals.6, 7 Recognizing that medical errors represent a major health concern in the United States, the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) now requires patient safety initiatives for hospital accreditation.8 Problem‐based learning and improvement and systems based practice are now required competencies in medical residency curricula by the Accreditation Council for Graduate Medical Education (ACGME) and these requirements have led to the development of continuous quality techniques for preventing errors and a variety of patient safety initiatives.9

In 2002 the SHM recognized the need for identifying a distinct set of competencies in hospital medicine. The published competencies highlight the current gap in training of hospitalists and the imperative for revising curricula relating to inpatient care, hospital systems, and teaching.4 With adequate training and preparation, hospitalists can take the lead in implementing systems for best practices from admission through discharge and care transition, and they can direct the development of a safer, more patient‐centered, and cost‐efficient culture.

By defining the role of the hospitalist, the Core Competencies reflects the view of the SHM about what is possible but does not suggest how a training program might be modified to achieve desired outcomes or provide any content, resources, or teaching strategies. It will be up to curriculum developers to determine the scope of cognitive, psychomotor, and affective objectives that targeted learnershospitalists, residents, and other members of the multidisciplinary teamshould be required to acquire through lectures, discussions, syllabus material, clinical experience, and other venues. We agree with a broader definition of the term curriculum for graduate medical education, one that goes beyond curriculum as a plan and takes into account the learners' experiences, both planned and unplanned in the hospital setting.10 In contrast to the technologic theory of curriculum, in which lists of knowledge and skills represent final destinations, in the experiential model of curriculum, the lists provide only points of departure.11 The goal of the Core Competencies is to facilitate curriculum development using complex teaching environments as building blocks through which learning can occur.

CORE COMPETENCIES FOR HOSPITALISTS: OVERVIEW

The Core Competencies in Hospital Medicine is the first published competency‐based framework for professional development of hospitalists and provides the basis for accreditation in hospital medicine.12 The Core Competencies is organized into three sectionsClinical Conditions, Procedures, and Healthcare Systems. The supplement intentionally does not focus on content; rather, specific competencies describe unambiguous, measurable learning objectives. Each chapter can be used as a stand‐alone chapter to develop training and curricula for a particular topic area. Each chapter divides competencies into three domains of educational outcomes: cognitive (knowledge), affective (attitudes), and psychomotor (skills). Each domain has defined levels of proficiency going from knowledge, the lowest level, to evaluation, the highest.12, 13 A specific level of proficiency is articulated in the competencies through careful selection of corresponding action verbs, which clearly indicate how mastery could be assessed (see Table 1).

In addition to specific competencies in these commonly accepted learning domains, the Clinical Conditions and Procedure sections of the Core Competencies articulate the proficiencies that hospitalists should possess in systems organization and improvement. The clinical topics were selected to set expectations of leading or participating in system improvements specific to a clinical area and to prevent predictable complications of acute illness. Competencies in the Systems Organization and Improvement section indicate mastery of multiple competencies across categories. The Core Competencies describes how the hospitalist approach facilitates coordination among all participants within the hospital system (clinical and nonclinical) and effects system changes that improve patient care processes. At the same time, the statements indicate a range of involvement from participation to leadership. For example, lead, coordination or participate in acknowledges the unique needs of different practice settings and suggests a potential professional evolution. The Systems Organization and Improvement competencies of each clinical and procedure chapter strive to capture the essence of hospitalists whose goals are to improve patient outcomes for a specific population of patients. Hospitalists do not solely focus on the care of the patient with x disease, but rather develop systems to provide the best and most efficient care for all patients with x disease, successfully transitioning these patients to outpatient care and avoiding readmission.

The third section of chapters in the Core Competencies, Healthcare Systems, distinguishes a hospitalist from others working in the inpatient setting whether practicing at academic medical centers, community hospitals, teaching hospitals, managed‐care settings, or for‐profit settings. The Healthcare Systems section identifies the integral components of the successful practice of hospital medicine and mastery of multiple competencies. This section highlights how hospitalists can facilitate coordination among all care providers within the hospital and with outpatient care providers. Hospitalists can effect system changes that improve complex care processes. It is likely that additional work experience and training beyond residency are required to attain global proficiency in the care of hospital medicine patients.

HOW TO USE THE CORE COMPETENCIES TO DEVELOP A CURRICULUM

The whole document, three sections and 51 chapters, develops expectations about the role of the hospitalist. Proficiency can be acquired through multiple means and should match the needs of the targeted learners in order to develop and maintain the necessary level of performance within the discipline of hospital medicine. Specific cases that hospitalists may encounter in their daily practice are used to illustrate how the Core Competencies can be applied to curriculum development.

The cases will employ the following six‐step approach described in Curriculum Development in Medical Education14:

• 1

  A problem and a need for improvement (the actual case and quality gap)

• 2

  Needs assessment of targeted learners (hospitalists, clinicians‐in‐training)

• 3

  Goals and specific measurable objectives (with competencies bridging the gap between traditional roles and setting expectations about the hospitalist role)

• 4

  Educational strategies (with competencies providing structure and guidance to educational efforts)

• 5

  Implementation (applying competencies to a variety of training opportunities and curricula)

• 6

  Evaluation and feedback (ongoing nationally, regionally, locally).

Like any quality‐improvement educational initiative, subsequent steps in curriculum development for hospitalists should include, after evaluation and feedback, dissemination of core competencies and promotion of rigorous ongoing evaluation and adaptation as needs and expectations evolve.

The first case example, failure to prevent and diagnose pulmonary embolism (see Table 2), illustrates quality issues relating to prevention of predictable complications of illness, clinical problem solving in complex conditions of uncertainty, repetitive and nondiagnostic testing, and triage of a critically ill patient between services. The Core Competencies sets expectations about the ideal role of the hospitalist that might lead to improved outcomes.

Using this case example, the Evidence‐Based Medicine (EBM) chapter establishes explicit expectations for hospitalists in clinical problem solving, including 1) explaining how the tests help to verify a suspected diagnosis, 2) describing the human factor in test interpretation (e.g., technical limitations of the most recent multi‐detector‐row spiral CT), and 3) explaining how timing relative to the onset of symptoms affects test results. Rather than an overreliance on technology, leading to repeating the chest CT with PE protocol and subsequent excessive nondiagnostic testing, the hospitalist would use knowledge of pretest probability and test characteristics to determine the best diagnostic strategy. The hospitalist approach to patient care, articulated in the affective (attitudes) domains of each chapter, integrates the application of EBM principles to clinical problem solving with deliberation of cost effectiveness and efficiency.

Continuing with this case example, the Team Approach and Communication chapters establish explicit expectations for practicing hospitalists who would take the extra steps to communicate with multiple members of the care team. Knowledgeable about the hospital, the hospitalist would review the chest CT with a radiologist skilled in chest interpretation and specifically query about the significance of an enlarged right atrium and right ventricle in the setting of a high pretest clinical probability of PE. Together the radiologist and hospitalist would consider a different imaging modality if the patient flunked the chest CT when the pretest probability was high. Rather than simply deferring to the medical specialist who is consulting, the hospitalist would be expected to improve the efficiency of care and reduce cost by only ordering tests that would change clinical management, perhaps with improved outcomes.

The Hospitalist as Teacher chapter provides a frameworkcore competencies for impromptu learningbased on the patient encounter. Members of the multidisciplinary care team can be exposed to explicit clinical decision making, an approach made possible by hospitalists on site, who can provide teaching moments in real time when decisions have to be made and educational feedback is needed. Teaching expectations for hospitalists include unambiguous clinical problem solving at the bedside and possibly directing the education of residents, physician assistants, and nurses on how to initiate a quality improvement (QI) project in a hospital setting.

The Quality Improvement and Venous Thromboembolism chapters clarify the role of the hospitalist, who should direct therapy against predictable complications of serious illness, critically review prophylaxis, provide hospital‐specific data to clinicians, identify and lower barriers to prevention, devise strategies to bridge the gap between knowledge and practice, develop automated reminder systems, and participate in clinical research.

The SHM has used the Core Competencies to develop educational resources to better meet the needs of the healthcare system. Although patient safety initiatives are mandated by JCAHO for hospital accreditation and AHRQ has identified areas for safety improvement that lists venous thromboembolism (VTE) prevention as the number one priority, VTE prophylaxis is still underutilized in the United States. Although some mechanisms are in place to educate residents and hospitalists about how to manage a specific disease, traditional medical education does not focus on teaching students and residents how to manage complex patients with multiple comorbidities, to prevent predictable complications of illness, and to examine and improve care processes.15, 16 When it comes to leading quality improvement (QI), individual feedback and traditional curricula, which may include didactic lectures on the pathophysiology of VTE and morbidity and mortality conferences, have not demonstrated improved outcomes.17

The SHM QI Web‐based resource rooms offer support to any QI effort and raise collective awareness of a performance gap.18 Each resource room will describe the evidence‐based practices that should be put into effect and will leverage experience with the disease as well as with the improvement process. The underlying goal of the resource rooms is to enhance the ability of hospitalists to actually improve inpatient outcomes through self‐directed learning (see Fig. 1).

Figure 1

Hospitalists, residency directors, and directors of hospitalist fellowships and continuing education can use The Core Competencies in Hospital Medicine to develop curricula for their local hospitalist service and request that invited speakers develop learning objectives and content based on core competencies rather than giving a prepared lecture on a specific clinical condition. This case of PE illustrates that risk assessment, prophylaxis, EBM clinical problem solving, and QI are core topics that should be emphasized in the training of hospitalists and physicians in training.0

The second case example, the hand‐off (see Table 3), illustrates quality issues related to transfer of care from one physician to another. In this example, if the patient with moderate pleural effusion had been signed out, an earlier thoracentesis to drain a presumptive parapneumonic infection might have relieved this patient's shortness of breath and saved her from undergoing a subsequent VATS procedure. This case also demonstrates the importance of correlating imaging abnormalities with a patient's clinical presentation rather than using the traditional approach of just ruling out potential diagnoses to determine the cause of a problem. This case highlights elements of the process and system of care that can be modified to improve patient outcomes. Being proficient in transferring care of patients can save the hospitalist from error and prevent adverse events.

The Team Approach chapter establishes the need to acquire proficiencies not ordinarily obtained during residency in order to lead a multidisciplinary care team. This role requires a level of functioning beyond that of simply being the attending of record. The hospitalist must be able to synthesize information rather than simply defer to the consultant. Competencies specified in the Diagnostic Decision‐Making chapter can be used to identify the educational needs of hospitalists, who are expected to minimize diagnostic errors by knowing when to ask for help and where to get it, recognizing common diseases with uncommon presentations, and generating a broad differential diagnosis where there is uncertainty. The Patient Handoff chapter defines the proficiencies hospitalists need to facilitate the safe transfer of patients to other physicians on their service.0

The third case example, which expands the responsibilities of hospitalist to include meeting important needs in the hospital (see Table 4), illustrates that hospitalist services cannot succeed by offering all things to all people, a distraction that that keeps the members of these services from concentrating on their goals. Always saying yes to whoever asks for help is a band‐aid, a short‐term fix that impedes the effort and creativity required for durable long‐term solutions to problems.

The Core Competencies sets expectations about the roles of hospitalists, who serve as well‐informed clinicians and clinical opinion leaders; effective educators, mentors, and role models; empathetic and timely communicators; efficient caregivers; and creative problem solvers arriving at durable, longer‐term solutions. The competencies demonstrate the knowledge, skills, and attitudes required to be effective agents of change. Changing business as usual almost always requires significant improvements in the underlying system, however uncomfortable. The Leadership chapter articulates competencies that hospitalists need in order to define their roles within the hospital, promote group cohesiveness, expand their practices intelligently, and anticipate and respond to change. This chapter details the proficiencies that hospitalists need in order to develop personal, team, and program goals and to identify and resolve conflicts using specific negotiation techniques. The Business Practices chapter articulates the fundamental skills needed to enhance program development and growth. Hospitalists can use the Core Competencies to identify educational needs and develop curricula to enhance their leadership and business skill sets.0

Medical educators should examine the outcomes of current training practices and assess what modifications of objectives, content, and instructional strategies should be made to better prepare the current and next generations of physicians to practice hospital medicine and to improve the hospital setting. Given the scope of the field of hospital medicine, the Core Competencies should guide: 1) what to teach and how much to teach; 2) how to teach and assess trainees, and how to assess and compare faculty development programs; 3) how to design systems for improving quality of care and assuring patient safety; and 4) how to establish priorities for hospital medicine research.

TRANSLATING A SET OF COMPETENCIES INTO CURRICULA: POTENTIAL BENEFITS

The Core Competencies in Hospital Medicine transcends hospital type, size, and setting and standardizes what the expectations for and proficiencies of a practicing hospitalist should be. By defining the role of the hospitalist, the Core Competencies serves as a resource for refining inpatient skills and assists in program development at the local, regional, and national levels. In addition, by using the Core Competencies as the standard and framework for the development of preparatory curricula, hospital administrators and other employers can rely on hospitalists having had a common preparation.

The medical profession is constantly evolving. Internal medicine curricula address the challenges hospital medicine physicians faced yesterday but could improve the training and preparation of physicians to serve in their new and emerging roles as leaders of multidisciplinary healthcare teams working to improve patient outcomes and the system of inpatient care. Hospital medicine no longer represents a group of physicians merely supporting other specialists and primary care physicians; it is itself a specialty, composed of physicians leading, directing, and improving inpatient care. The competencies presented in The Core Competencies in Hospital Medicine: A Framework for Curriculum Development, by the Society of Hospital Medicine, should spark debate about the adequacy and appropriateness of current training and certification expectations and serve as a foundation for the development of curricula to improve hospital medicine education.

Identification of the core competencies of a medical specialty provides the necessary framework for that specialty to develop, refine itself, and evolve. It also provides a structure from which training, testing, and curricula can be developed and effectively utilized. For nearly a decade, since the coining of the term hospitalist,1 the field of hospital medicine has been emerging as the next generation of site‐defined specialties, after emergency medicine and critical care medicine. The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (referred to as the Core Competencies from this point on) introduces the expectations of hospitalists, helps to define their role, and suggests how knowledge, skill, and attitude acquisition might be evaluated. Furthermore, this document provides an initial structural framework from which curricula in adult hospital medicine may be developed.

The Core Competencies document, produced by the Society of Hospital Medicine (SHM) and published as a supplement to the first issue of the Journal of Hospital Medicine,2 is meant to serve as a framework for educators at all levels of medical education to develop curricula, training, and evaluations for students, clinicians‐in‐training, and practicing hospitalists. The Core Competencies document is not meant to contain a complete compilation of inpatient clinical topics or to re‐create what many residency training programs in adult inpatient care already provide. It should not limit and does not define every aspect of hospitalist practice. It includes the most common and fundamental elements of inpatient care without exhaustively listing every clinical entity that may be encountered by a hospitalist. Some of the more common clinical topics encountered by inpatient physicians are included, with an emphasis on subject areas that stress a systems‐based approach to health care, which is central to the practice of hospital medicine. This initial version of the Core Competencies document also focuses on potential areas of deficiency in the training of physicians to become hospitalists. It provides developers of curricula and content with a standardized set of measurable learning objectives, while allowing them the flexibility needed to address specific contexts and incorporate advances in medicine.

The SHM, the sole professional organization representing inpatient physicians, defines hospitalists as physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine.3 An estimated 12,000 hospitalists are currently practicing in the United States, with a projected workforce need of an estimated 20,00030,000 practicing hospitalists in the United States in the next 510 years.4 Various factors have contributed to the rapid growth and expansion of hospital medicine, including factors related to care efficiency, care quality, and inpatient teaching.512 The pressures that have contributed to the development of and evolution toward the hospitalist model of care over the past decade are facilitating the transformation from a traditional model of inpatient care to the care of inpatients by hospitalist physicians dedicated primarily to the inpatient setting. As a result of this growth in hospital medicine, the SHM realized that core competencies were needed to help define the field.

The purpose of this article is to describe the developmental process and content structure of the Core Competencies document. It delineates the process from initial needs assessment to topic list development to chapter production to internal and external review and revisions of individual chapters and the complete document. The supplement to this first issue of the Journal of Hospital Medicine contains 1) the Core Competencies,2 2) a reprint of this article, and 3) a reprint of the article by McKean et al. in this issue detailing how to use the Core Competencies,13 with examples and suggestions related to curriculum development. The authors propose that this combined compilation may spur curriculum development in hospital medicine that will help to define the field and set expectations for practice.

PROCESS AND TIMELINE

Education Summit

Early in the growth of hospital medicine, the Society of Hospital Medicine identified a need to better define a common educational and practice framework for hospitalist physicians. Such a framework could help to define hospitalists as a distinct group of practicing physicians with common goals and a common set of competencies. The importance of identifying and delineating the common knowledge, skills, and attitudes of hospitalists was paramount. Figure 1 shows the details of the 4‐year process of developing the Core Competencies.

Figure 1

In 2002, the SHM drew together educational leaders in hospital medicine in its first educational summit. One of the primary charges that the SHM received from this summit was to develop the needed core curriculum in hospital medicine. After the summit, the SHM's Education Committee formed the Core Curriculum Task Force (CCTF), composed of approximately 15 member hospitalists, with representation from university and community hospitals, teaching and nonteaching programs, and for‐profit and not‐for‐profit settings from various geographic regions of the country. The selection process ensured that the task force was representative of practicing hospitalists and SHM membership throughout the United States.

CHAPTER CONTENT DESCRIPTION

As previously delineated, the Core Competencies document has three sections: Clinical Conditions, Procedures, and Healthcare Systems. The chapters in the entire compendium and within each section have been designed to stand alone and to be used either individually or collectively to assist with curriculum development in hospital medicine. However, each chapter should be used in the context of the entire document because a particular issue may only be touched on in one chapter but may be more elaborately detailed in another. For example, all clinical conditions chapters include a competency on the issue of care transitions, but the specific competencies for care transitions are presented in a separate Transitions of Care chapter.

All chapters in each section begin with an introduction that provides brief background information and establishes the relevance of the topic to practicing hospitalists. Each chapter then utilizes the educational theory of learning domains. The learning domains include the cognitive domain (knowledge), the psychomotor domain (skills), and the affective domain (attitudes). The companion article How to Use The Core Competencies in Hospital Medicine: A Framework for Curriculum Development13 describes in detail the educational theory guiding the development of the Core Competencies document and suggested methods for applying it to the development and revision of curricula and other training activities.

The task force further decided that each chapter in the Clinical Conditions and Procedures sections should include a subsection dedicated to system organization and improvement, an added domain that requires integration of knowledge, skills, and attitudes and the involvement of other medical services and disciplines for optimal patient care. The editorial board believed that system organization and improvement was already an intrinsic feature embedded in the chapters of the Healthcare Systems section. Therefore, this subsection was not included in those chapters.

Hospitalists subscribe to a systems organizational approach to clinical management and processes of care within the hospital. This systems approach, more than any level of knowledge or skill, is required to effectively and efficiently practice in the hospital setting. Practicing with a systems approach, with the interest of improving processes of care, is embedded throughout the Core Competencies document and is a practice method that all hospitalists may strive to achieve as they develop and improve their inpatient care. The competencies within the Systems Organization and Improvement section may contain a range of competency expectation (eg, lead, coordinate, or participate in) to acknowledge their uniqueness and variation according to practice settings and locally instituted responsibilities.

Each competency within a chapter details a level of proficiency, providing guidance on learning activities and potential evaluation strategies. Several overarching themes are followed in the chapters that help to define hospitalists as physicians who specialize in the care of hospitalized patients. First, hospitalists strive to support and adhere to a multidisciplinary approach for the patients under their care. Such an approach involves active interaction with and integration of other hospital medical staff (eg, nursing, rehabilitation therapies, social services) and of specialty medical or surgical services when indicated. Recognizing that hospitalists vary in experience and mastery of their field, the task force and editorial board believed that, at minimum, hospitalists would participate in multidisciplinary teams for improvement of the care and process related to the clinical conditions within their organization. However, they might also lead and/or coordinate teams in such efforts. Therefore, most chapters contain competencies that expect hospitalists to lead, coordinate, or participate in multidisciplinary teams or initiatives that will facilitate optimal care within their organization.

Second, because hospital medicine centers around the quality of inpatient care, participation in quality improvement (QI) initiatives, focusing on improving processes or systems of care in a local institution or organization, may be common in hospitalist practices. The level of involvement and role in QI initiatives may vary according to the particular system, the resources available, and a hospitalist's experience. Finally, because hospitalist care intrinsically involves an increase in the number of care transitions and handoffs, hospitalists need to remain sensitive to and focused on the care transitions that occur with their patients. Such transitions may occur as patients enter the hospital, move from one location to another within the hospital, or leave the hospital. This vulnerable time for patients requires hospitalists to be vigilant in their communication effortswith patients, with medical staff, and with outpatient clinicians.

Each competency was crafted to indicate the relevant concept, the level of proficiency expected, and a way to evaluate mastery. The teaching processes and learning experiences that must take place to achieve competency are left for curriculum developers and instructors to design. These core competencies represent an initial step in curriculum development, creating an identity and core set of expectations for hospitalists that we believe will lead to progress and maturity within the field.

SUMMARY AND FUTURE DIRECTIONS

The practice of hospital medicine requires proficiency of interrelated aspects of practiceclinical, procedural, and system‐based competencies. For practicing hospitalists, the Core Competencies document may serve as a resource to refine skills and assist in program development at individual institutions, both regionally and nationally. For residency program directors and clerkship directors, the Core Competencies document can function as a guide for developing the curriculum of inpatient medicine rotations or for meeting the requirements of the Outcomes Project of the Accreditation Council on Graduate Medical Education's. Last, for those developing continuing medical education programs, the Core Competencies document or individual chapters or topics within it may serve as an outline around which specific or broad‐based programs can be developed. Although the development of such curricula and the recipients of them should be evaluated, the actual evaluation is left to the curriculum developers.

Hospitalists are invested in making hospitals run better. They are positioned to take leadership roles in addressing quality, efficiency, and cost interests in both community and academic hospital settings. Their goals include improving care processes, hospital work life, and the setting in which they practice. The key core competencies described in this compendium define hospitalists as agents of change 1) to develop and implement systems to enable best practices to occur from admission through discharge, and 2) to promote the development of a safer culture within the hospital.

Hospital medicine remains an evolving specialty. Although great care was taken to construct these competencies so they would retain their relevance over time, SHM, the Core Curriculum Task Force, and the editorial board recognize the need for their continual reevaluation and modification in the context of advances and changes in the practice of hospital medicine. Our intent is that these competencies be a common reference and foundation for the creation of hospital medicine curricula and serve to standardize and improve training practices.

Identification of the core competencies of a medical specialty provides the necessary framework for that specialty to develop, refine itself, and evolve. It also provides a structure from which training, testing, and curricula can be developed and effectively utilized. For nearly a decade, since the coining of the term hospitalist,1 the field of hospital medicine has been emerging as the next generation of site‐defined specialties, after emergency medicine and critical care medicine. The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (referred to as the Core Competencies from this point on) introduces the expectations of hospitalists, helps to define their role, and suggests how knowledge, skill, and attitude acquisition might be evaluated. Furthermore, this document provides an initial structural framework from which curricula in adult hospital medicine may be developed.

The Core Competencies document, produced by the Society of Hospital Medicine (SHM) and published as a supplement to the first issue of the Journal of Hospital Medicine,2 is meant to serve as a framework for educators at all levels of medical education to develop curricula, training, and evaluations for students, clinicians‐in‐training, and practicing hospitalists. The Core Competencies document is not meant to contain a complete compilation of inpatient clinical topics or to re‐create what many residency training programs in adult inpatient care already provide. It should not limit and does not define every aspect of hospitalist practice. It includes the most common and fundamental elements of inpatient care without exhaustively listing every clinical entity that may be encountered by a hospitalist. Some of the more common clinical topics encountered by inpatient physicians are included, with an emphasis on subject areas that stress a systems‐based approach to health care, which is central to the practice of hospital medicine. This initial version of the Core Competencies document also focuses on potential areas of deficiency in the training of physicians to become hospitalists. It provides developers of curricula and content with a standardized set of measurable learning objectives, while allowing them the flexibility needed to address specific contexts and incorporate advances in medicine.

The SHM, the sole professional organization representing inpatient physicians, defines hospitalists as physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine.3 An estimated 12,000 hospitalists are currently practicing in the United States, with a projected workforce need of an estimated 20,00030,000 practicing hospitalists in the United States in the next 510 years.4 Various factors have contributed to the rapid growth and expansion of hospital medicine, including factors related to care efficiency, care quality, and inpatient teaching.512 The pressures that have contributed to the development of and evolution toward the hospitalist model of care over the past decade are facilitating the transformation from a traditional model of inpatient care to the care of inpatients by hospitalist physicians dedicated primarily to the inpatient setting. As a result of this growth in hospital medicine, the SHM realized that core competencies were needed to help define the field.

The purpose of this article is to describe the developmental process and content structure of the Core Competencies document. It delineates the process from initial needs assessment to topic list development to chapter production to internal and external review and revisions of individual chapters and the complete document. The supplement to this first issue of the Journal of Hospital Medicine contains 1) the Core Competencies,2 2) a reprint of this article, and 3) a reprint of the article by McKean et al. in this issue detailing how to use the Core Competencies,13 with examples and suggestions related to curriculum development. The authors propose that this combined compilation may spur curriculum development in hospital medicine that will help to define the field and set expectations for practice.

PROCESS AND TIMELINE

Education Summit

Early in the growth of hospital medicine, the Society of Hospital Medicine identified a need to better define a common educational and practice framework for hospitalist physicians. Such a framework could help to define hospitalists as a distinct group of practicing physicians with common goals and a common set of competencies. The importance of identifying and delineating the common knowledge, skills, and attitudes of hospitalists was paramount. Figure 1 shows the details of the 4‐year process of developing the Core Competencies.

Figure 1

In 2002, the SHM drew together educational leaders in hospital medicine in its first educational summit. One of the primary charges that the SHM received from this summit was to develop the needed core curriculum in hospital medicine. After the summit, the SHM's Education Committee formed the Core Curriculum Task Force (CCTF), composed of approximately 15 member hospitalists, with representation from university and community hospitals, teaching and nonteaching programs, and for‐profit and not‐for‐profit settings from various geographic regions of the country. The selection process ensured that the task force was representative of practicing hospitalists and SHM membership throughout the United States.

CHAPTER CONTENT DESCRIPTION

As previously delineated, the Core Competencies document has three sections: Clinical Conditions, Procedures, and Healthcare Systems. The chapters in the entire compendium and within each section have been designed to stand alone and to be used either individually or collectively to assist with curriculum development in hospital medicine. However, each chapter should be used in the context of the entire document because a particular issue may only be touched on in one chapter but may be more elaborately detailed in another. For example, all clinical conditions chapters include a competency on the issue of care transitions, but the specific competencies for care transitions are presented in a separate Transitions of Care chapter.

All chapters in each section begin with an introduction that provides brief background information and establishes the relevance of the topic to practicing hospitalists. Each chapter then utilizes the educational theory of learning domains. The learning domains include the cognitive domain (knowledge), the psychomotor domain (skills), and the affective domain (attitudes). The companion article How to Use The Core Competencies in Hospital Medicine: A Framework for Curriculum Development13 describes in detail the educational theory guiding the development of the Core Competencies document and suggested methods for applying it to the development and revision of curricula and other training activities.

The task force further decided that each chapter in the Clinical Conditions and Procedures sections should include a subsection dedicated to system organization and improvement, an added domain that requires integration of knowledge, skills, and attitudes and the involvement of other medical services and disciplines for optimal patient care. The editorial board believed that system organization and improvement was already an intrinsic feature embedded in the chapters of the Healthcare Systems section. Therefore, this subsection was not included in those chapters.

Hospitalists subscribe to a systems organizational approach to clinical management and processes of care within the hospital. This systems approach, more than any level of knowledge or skill, is required to effectively and efficiently practice in the hospital setting. Practicing with a systems approach, with the interest of improving processes of care, is embedded throughout the Core Competencies document and is a practice method that all hospitalists may strive to achieve as they develop and improve their inpatient care. The competencies within the Systems Organization and Improvement section may contain a range of competency expectation (eg, lead, coordinate, or participate in) to acknowledge their uniqueness and variation according to practice settings and locally instituted responsibilities.

Each competency within a chapter details a level of proficiency, providing guidance on learning activities and potential evaluation strategies. Several overarching themes are followed in the chapters that help to define hospitalists as physicians who specialize in the care of hospitalized patients. First, hospitalists strive to support and adhere to a multidisciplinary approach for the patients under their care. Such an approach involves active interaction with and integration of other hospital medical staff (eg, nursing, rehabilitation therapies, social services) and of specialty medical or surgical services when indicated. Recognizing that hospitalists vary in experience and mastery of their field, the task force and editorial board believed that, at minimum, hospitalists would participate in multidisciplinary teams for improvement of the care and process related to the clinical conditions within their organization. However, they might also lead and/or coordinate teams in such efforts. Therefore, most chapters contain competencies that expect hospitalists to lead, coordinate, or participate in multidisciplinary teams or initiatives that will facilitate optimal care within their organization.

Second, because hospital medicine centers around the quality of inpatient care, participation in quality improvement (QI) initiatives, focusing on improving processes or systems of care in a local institution or organization, may be common in hospitalist practices. The level of involvement and role in QI initiatives may vary according to the particular system, the resources available, and a hospitalist's experience. Finally, because hospitalist care intrinsically involves an increase in the number of care transitions and handoffs, hospitalists need to remain sensitive to and focused on the care transitions that occur with their patients. Such transitions may occur as patients enter the hospital, move from one location to another within the hospital, or leave the hospital. This vulnerable time for patients requires hospitalists to be vigilant in their communication effortswith patients, with medical staff, and with outpatient clinicians.

Each competency was crafted to indicate the relevant concept, the level of proficiency expected, and a way to evaluate mastery. The teaching processes and learning experiences that must take place to achieve competency are left for curriculum developers and instructors to design. These core competencies represent an initial step in curriculum development, creating an identity and core set of expectations for hospitalists that we believe will lead to progress and maturity within the field.

SUMMARY AND FUTURE DIRECTIONS

The practice of hospital medicine requires proficiency of interrelated aspects of practiceclinical, procedural, and system‐based competencies. For practicing hospitalists, the Core Competencies document may serve as a resource to refine skills and assist in program development at individual institutions, both regionally and nationally. For residency program directors and clerkship directors, the Core Competencies document can function as a guide for developing the curriculum of inpatient medicine rotations or for meeting the requirements of the Outcomes Project of the Accreditation Council on Graduate Medical Education's. Last, for those developing continuing medical education programs, the Core Competencies document or individual chapters or topics within it may serve as an outline around which specific or broad‐based programs can be developed. Although the development of such curricula and the recipients of them should be evaluated, the actual evaluation is left to the curriculum developers.

Hospitalists are invested in making hospitals run better. They are positioned to take leadership roles in addressing quality, efficiency, and cost interests in both community and academic hospital settings. Their goals include improving care processes, hospital work life, and the setting in which they practice. The key core competencies described in this compendium define hospitalists as agents of change 1) to develop and implement systems to enable best practices to occur from admission through discharge, and 2) to promote the development of a safer culture within the hospital.

Hospital medicine remains an evolving specialty. Although great care was taken to construct these competencies so they would retain their relevance over time, SHM, the Core Curriculum Task Force, and the editorial board recognize the need for their continual reevaluation and modification in the context of advances and changes in the practice of hospital medicine. Our intent is that these competencies be a common reference and foundation for the creation of hospital medicine curricula and serve to standardize and improve training practices.

Identification of the core competencies of a medical specialty provides the necessary framework for that specialty to develop, refine itself, and evolve. It also provides a structure from which training, testing, and curricula can be developed and effectively utilized. For nearly a decade, since the coining of the term hospitalist,1 the field of hospital medicine has been emerging as the next generation of site‐defined specialties, after emergency medicine and critical care medicine. The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (referred to as the Core Competencies from this point on) introduces the expectations of hospitalists, helps to define their role, and suggests how knowledge, skill, and attitude acquisition might be evaluated. Furthermore, this document provides an initial structural framework from which curricula in adult hospital medicine may be developed.

The Core Competencies document, produced by the Society of Hospital Medicine (SHM) and published as a supplement to the first issue of the Journal of Hospital Medicine,2 is meant to serve as a framework for educators at all levels of medical education to develop curricula, training, and evaluations for students, clinicians‐in‐training, and practicing hospitalists. The Core Competencies document is not meant to contain a complete compilation of inpatient clinical topics or to re‐create what many residency training programs in adult inpatient care already provide. It should not limit and does not define every aspect of hospitalist practice. It includes the most common and fundamental elements of inpatient care without exhaustively listing every clinical entity that may be encountered by a hospitalist. Some of the more common clinical topics encountered by inpatient physicians are included, with an emphasis on subject areas that stress a systems‐based approach to health care, which is central to the practice of hospital medicine. This initial version of the Core Competencies document also focuses on potential areas of deficiency in the training of physicians to become hospitalists. It provides developers of curricula and content with a standardized set of measurable learning objectives, while allowing them the flexibility needed to address specific contexts and incorporate advances in medicine.

The SHM, the sole professional organization representing inpatient physicians, defines hospitalists as physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine.3 An estimated 12,000 hospitalists are currently practicing in the United States, with a projected workforce need of an estimated 20,00030,000 practicing hospitalists in the United States in the next 510 years.4 Various factors have contributed to the rapid growth and expansion of hospital medicine, including factors related to care efficiency, care quality, and inpatient teaching.512 The pressures that have contributed to the development of and evolution toward the hospitalist model of care over the past decade are facilitating the transformation from a traditional model of inpatient care to the care of inpatients by hospitalist physicians dedicated primarily to the inpatient setting. As a result of this growth in hospital medicine, the SHM realized that core competencies were needed to help define the field.

The purpose of this article is to describe the developmental process and content structure of the Core Competencies document. It delineates the process from initial needs assessment to topic list development to chapter production to internal and external review and revisions of individual chapters and the complete document. The supplement to this first issue of the Journal of Hospital Medicine contains 1) the Core Competencies,2 2) a reprint of this article, and 3) a reprint of the article by McKean et al. in this issue detailing how to use the Core Competencies,13 with examples and suggestions related to curriculum development. The authors propose that this combined compilation may spur curriculum development in hospital medicine that will help to define the field and set expectations for practice.

PROCESS AND TIMELINE

Education Summit

Early in the growth of hospital medicine, the Society of Hospital Medicine identified a need to better define a common educational and practice framework for hospitalist physicians. Such a framework could help to define hospitalists as a distinct group of practicing physicians with common goals and a common set of competencies. The importance of identifying and delineating the common knowledge, skills, and attitudes of hospitalists was paramount. Figure 1 shows the details of the 4‐year process of developing the Core Competencies.

Figure 1

In 2002, the SHM drew together educational leaders in hospital medicine in its first educational summit. One of the primary charges that the SHM received from this summit was to develop the needed core curriculum in hospital medicine. After the summit, the SHM's Education Committee formed the Core Curriculum Task Force (CCTF), composed of approximately 15 member hospitalists, with representation from university and community hospitals, teaching and nonteaching programs, and for‐profit and not‐for‐profit settings from various geographic regions of the country. The selection process ensured that the task force was representative of practicing hospitalists and SHM membership throughout the United States.

CHAPTER CONTENT DESCRIPTION

As previously delineated, the Core Competencies document has three sections: Clinical Conditions, Procedures, and Healthcare Systems. The chapters in the entire compendium and within each section have been designed to stand alone and to be used either individually or collectively to assist with curriculum development in hospital medicine. However, each chapter should be used in the context of the entire document because a particular issue may only be touched on in one chapter but may be more elaborately detailed in another. For example, all clinical conditions chapters include a competency on the issue of care transitions, but the specific competencies for care transitions are presented in a separate Transitions of Care chapter.

All chapters in each section begin with an introduction that provides brief background information and establishes the relevance of the topic to practicing hospitalists. Each chapter then utilizes the educational theory of learning domains. The learning domains include the cognitive domain (knowledge), the psychomotor domain (skills), and the affective domain (attitudes). The companion article How to Use The Core Competencies in Hospital Medicine: A Framework for Curriculum Development13 describes in detail the educational theory guiding the development of the Core Competencies document and suggested methods for applying it to the development and revision of curricula and other training activities.

The task force further decided that each chapter in the Clinical Conditions and Procedures sections should include a subsection dedicated to system organization and improvement, an added domain that requires integration of knowledge, skills, and attitudes and the involvement of other medical services and disciplines for optimal patient care. The editorial board believed that system organization and improvement was already an intrinsic feature embedded in the chapters of the Healthcare Systems section. Therefore, this subsection was not included in those chapters.

Hospitalists subscribe to a systems organizational approach to clinical management and processes of care within the hospital. This systems approach, more than any level of knowledge or skill, is required to effectively and efficiently practice in the hospital setting. Practicing with a systems approach, with the interest of improving processes of care, is embedded throughout the Core Competencies document and is a practice method that all hospitalists may strive to achieve as they develop and improve their inpatient care. The competencies within the Systems Organization and Improvement section may contain a range of competency expectation (eg, lead, coordinate, or participate in) to acknowledge their uniqueness and variation according to practice settings and locally instituted responsibilities.

Each competency within a chapter details a level of proficiency, providing guidance on learning activities and potential evaluation strategies. Several overarching themes are followed in the chapters that help to define hospitalists as physicians who specialize in the care of hospitalized patients. First, hospitalists strive to support and adhere to a multidisciplinary approach for the patients under their care. Such an approach involves active interaction with and integration of other hospital medical staff (eg, nursing, rehabilitation therapies, social services) and of specialty medical or surgical services when indicated. Recognizing that hospitalists vary in experience and mastery of their field, the task force and editorial board believed that, at minimum, hospitalists would participate in multidisciplinary teams for improvement of the care and process related to the clinical conditions within their organization. However, they might also lead and/or coordinate teams in such efforts. Therefore, most chapters contain competencies that expect hospitalists to lead, coordinate, or participate in multidisciplinary teams or initiatives that will facilitate optimal care within their organization.

Second, because hospital medicine centers around the quality of inpatient care, participation in quality improvement (QI) initiatives, focusing on improving processes or systems of care in a local institution or organization, may be common in hospitalist practices. The level of involvement and role in QI initiatives may vary according to the particular system, the resources available, and a hospitalist's experience. Finally, because hospitalist care intrinsically involves an increase in the number of care transitions and handoffs, hospitalists need to remain sensitive to and focused on the care transitions that occur with their patients. Such transitions may occur as patients enter the hospital, move from one location to another within the hospital, or leave the hospital. This vulnerable time for patients requires hospitalists to be vigilant in their communication effortswith patients, with medical staff, and with outpatient clinicians.

Each competency was crafted to indicate the relevant concept, the level of proficiency expected, and a way to evaluate mastery. The teaching processes and learning experiences that must take place to achieve competency are left for curriculum developers and instructors to design. These core competencies represent an initial step in curriculum development, creating an identity and core set of expectations for hospitalists that we believe will lead to progress and maturity within the field.

SUMMARY AND FUTURE DIRECTIONS

The practice of hospital medicine requires proficiency of interrelated aspects of practiceclinical, procedural, and system‐based competencies. For practicing hospitalists, the Core Competencies document may serve as a resource to refine skills and assist in program development at individual institutions, both regionally and nationally. For residency program directors and clerkship directors, the Core Competencies document can function as a guide for developing the curriculum of inpatient medicine rotations or for meeting the requirements of the Outcomes Project of the Accreditation Council on Graduate Medical Education's. Last, for those developing continuing medical education programs, the Core Competencies document or individual chapters or topics within it may serve as an outline around which specific or broad‐based programs can be developed. Although the development of such curricula and the recipients of them should be evaluated, the actual evaluation is left to the curriculum developers.

Hospitalists are invested in making hospitals run better. They are positioned to take leadership roles in addressing quality, efficiency, and cost interests in both community and academic hospital settings. Their goals include improving care processes, hospital work life, and the setting in which they practice. The key core competencies described in this compendium define hospitalists as agents of change 1) to develop and implement systems to enable best practices to occur from admission through discharge, and 2) to promote the development of a safer culture within the hospital.

Hospital medicine remains an evolving specialty. Although great care was taken to construct these competencies so they would retain their relevance over time, SHM, the Core Curriculum Task Force, and the editorial board recognize the need for their continual reevaluation and modification in the context of advances and changes in the practice of hospital medicine. Our intent is that these competencies be a common reference and foundation for the creation of hospital medicine curricula and serve to standardize and improve training practices.

The seminal article that coined the term hospitalist, in 1996, attributed the role of the hospitalist to enhancing throughput and cost reduction, primarily through reduction in length of stay, accomplished by having a dedicated clinician on site in the hospital.1 Since that time the role of the hospitalist has evolved to address the needs of multiple stakeholders at a time when traditional residency programs in inpatient adult medicine do not adequately train physicians to become effective agents of change in complex and potentially unsafe hospital systems. Continuing the trend of pediatrics, obstetrics, gynecology, and geriatrics, hospitalists have emerged as a distinct group of physicians who fill a needed clinical niche and are demonstrating the benefits of bringing a unique role and skill sets to the general hospital ward.2

The eligibility requirements for certification by the American Board of Internal Medicine specify that the discipline must 1) have a distinct and unique body of knowledge, 2) have clinical applicability sufficient to support a distinct clinical practice, 3) generate new information and research, 4) require a minimum training period of 12 months, and 5) have a substantial number of trainees and training programs nationwide.3 The Society of Hospital Medicine (SHM), the national professional organization of hospitalists, commissioned a task force to develop The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (referred to from here on as the Core Competencies) to standardize the expectations of practicing hospitalists, serve as a foundation for curricula and other professional development experiences, prioritize educational scholarship and research strategies, and assess the adequacy and improvement opportunities for current training and accreditation of hospital medicine physicians.4 The preceding companion article The Core Competencies in Hospital Medicine: Development and Methodology, describes in detail the rationale for the development of the Core Competencies and the methods by which the document was created.5

PURPOSE

The purpose of this article is to illustrate how curriculum developers can apply the Core Competencies in Hospital Medicine to educate trainees and faculty, to prioritize educational scholarship and research strategies, and thus to improve the care of our patients.

TARGET AUDIENCE

The Core Competencies specifically targets directors of continuing medical education (CME), hospitalist programs and fellowships, residency programs, and medical school internal medicine clerkships. It is also intended for health educators, hospital administrators, potential employers, policy makers, and agencies funding quality‐improvement initiatives in the hospital setting. For residency program directors and clerkship directors, the chapters can guide in the development of curricula for inpatient medicine rotations or in meeting the Accreditation Council on Graduate Medical Education's Outcomes Project. For directors developing medical education curricula, The Core Competencies in Hospital Medicine can serve as a template for CME. For hospitalists, hospital administrators, and potential employers, the Core Competencies can be used to as the starting point in local program development and as a resource for refining the skills of all hospitalists, even very experienced practicing clinicians.

DEFINITION OF CORE COMPETENCIES IN HOSPITAL MEDICINE

The Core Competencies in Hospital Medicine provides a framework for curricular development based on a shared understanding of the essential knowledge, skills, and attitudes expected of physicians working as hospitalists. The development process will be ongoing, with revisions reflecting the evolving specialty of hospital medicine, the needs of practicing hospitalists, and feedback from users of the Core Competencies.

PROBLEM IDENTIFICATION AND GENERAL NEEDS ASSESSMENT

Delivery of health care has large gaps compared to ideal performance. Since the publication by the Institute of Medicine of To Err Is Human, in 1999, multiple agencies including the American Hospital Association, the National Quality Forum, and the U.S. Agency for Health Care Research and Quality (AHRQ) have reported on the incidence of medical errors in U.S. hospitals.6, 7 Recognizing that medical errors represent a major health concern in the United States, the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) now requires patient safety initiatives for hospital accreditation.8 Problem‐based learning and improvement and systems based practice are now required competencies in medical residency curricula by the Accreditation Council for Graduate Medical Education (ACGME) and these requirements have led to the development of continuous quality techniques for preventing errors and a variety of patient safety initiatives.9

In 2002 the SHM recognized the need for identifying a distinct set of competencies in hospital medicine. The published competencies highlight the current gap in training of hospitalists and the imperative for revising curricula relating to inpatient care, hospital systems, and teaching.4 With adequate training and preparation, hospitalists can take the lead in implementing systems for best practices from admission through discharge and care transition, and they can direct the development of a safer, more patient‐centered, and cost‐efficient culture.

By defining the role of the hospitalist, the Core Competencies reflects the view of the SHM about what is possible but does not suggest how a training program might be modified to achieve desired outcomes or provide any content, resources, or teaching strategies. It will be up to curriculum developers to determine the scope of cognitive, psychomotor, and affective objectives that targeted learnershospitalists, residents, and other members of the multidisciplinary teamshould be required to acquire through lectures, discussions, syllabus material, clinical experience, and other venues. We agree with a broader definition of the term curriculum for graduate medical education, one that goes beyond curriculum as a plan and takes into account the learners' experiences, both planned and unplanned in the hospital setting.10 In contrast to the technologic theory of curriculum, in which lists of knowledge and skills represent final destinations, in the experiential model of curriculum, the lists provide only points of departure.11 The goal of the Core Competencies is to facilitate curriculum development using complex teaching environments as building blocks through which learning can occur.

CORE COMPETENCIES FOR HOSPITALISTS: OVERVIEW

The Core Competencies in Hospital Medicine is the first published competency‐based framework for professional development of hospitalists and provides the basis for accreditation in hospital medicine.12 The Core Competencies is organized into three sectionsClinical Conditions, Procedures, and Healthcare Systems. The supplement intentionally does not focus on content; rather, specific competencies describe unambiguous, measurable learning objectives. Each chapter can be used as a stand‐alone chapter to develop training and curricula for a particular topic area. Each chapter divides competencies into three domains of educational outcomes: cognitive (knowledge), affective (attitudes), and psychomotor (skills). Each domain has defined levels of proficiency going from knowledge, the lowest level, to evaluation, the highest.12, 13 A specific level of proficiency is articulated in the competencies through careful selection of corresponding action verbs, which clearly indicate how mastery could be assessed (see Table 1).

In addition to specific competencies in these commonly accepted learning domains, the Clinical Conditions and Procedure sections of the Core Competencies articulate the proficiencies that hospitalists should possess in systems organization and improvement. The clinical topics were selected to set expectations of leading or participating in system improvements specific to a clinical area and to prevent predictable complications of acute illness. Competencies in the Systems Organization and Improvement section indicate mastery of multiple competencies across categories. The Core Competencies describes how the hospitalist approach facilitates coordination among all participants within the hospital system (clinical and nonclinical) and effects system changes that improve patient care processes. At the same time, the statements indicate a range of involvement from participation to leadership. For example, lead, coordination or participate in acknowledges the unique needs of different practice settings and suggests a potential professional evolution. The Systems Organization and Improvement competencies of each clinical and procedure chapter strive to capture the essence of hospitalists whose goals are to improve patient outcomes for a specific population of patients. Hospitalists do not solely focus on the care of the patient with x disease, but rather develop systems to provide the best and most efficient care for all patients with x disease, successfully transitioning these patients to outpatient care and avoiding readmission.

The third section of chapters in the Core Competencies, Healthcare Systems, distinguishes a hospitalist from others working in the inpatient setting whether practicing at academic medical centers, community hospitals, teaching hospitals, managed‐care settings, or for‐profit settings. The Healthcare Systems section identifies the integral components of the successful practice of hospital medicine and mastery of multiple competencies. This section highlights how hospitalists can facilitate coordination among all care providers within the hospital and with outpatient care providers. Hospitalists can effect system changes that improve complex care processes. It is likely that additional work experience and training beyond residency are required to attain global proficiency in the care of hospital medicine patients.

HOW TO USE THE CORE COMPETENCIES TO DEVELOP A CURRICULUM

The whole document, three sections and 51 chapters, develops expectations about the role of the hospitalist. Proficiency can be acquired through multiple means and should match the needs of the targeted learners in order to develop and maintain the necessary level of performance within the discipline of hospital medicine. Specific cases that hospitalists may encounter in their daily practice are used to illustrate how the Core Competencies can be applied to curriculum development.

The cases will employ the following six‐step approach described in Curriculum Development in Medical Education14:

• 1

  A problem and a need for improvement (the actual case and quality gap)

• 2

  Needs assessment of targeted learners (hospitalists, clinicians‐in‐training)

• 3

  Goals and specific measurable objectives (with competencies bridging the gap between traditional roles and setting expectations about the hospitalist role)

• 4

  Educational strategies (with competencies providing structure and guidance to educational efforts)

• 5

  Implementation (applying competencies to a variety of training opportunities and curricula)

• 6

  Evaluation and feedback (ongoing nationally, regionally, locally).

Like any quality‐improvement educational initiative, subsequent steps in curriculum development for hospitalists should include, after evaluation and feedback, dissemination of core competencies and promotion of rigorous ongoing evaluation and adaptation as needs and expectations evolve.

The first case example, failure to prevent and diagnose pulmonary embolism (see Table 2), illustrates quality issues relating to prevention of predictable complications of illness, clinical problem solving in complex conditions of uncertainty, repetitive and nondiagnostic testing, and triage of a critically ill patient between services. The Core Competencies sets expectations about the ideal role of the hospitalist that might lead to improved outcomes.

Using this case example, the Evidence‐Based Medicine (EBM) chapter establishes explicit expectations for hospitalists in clinical problem solving, including 1) explaining how the tests help to verify a suspected diagnosis, 2) describing the human factor in test interpretation (e.g., technical limitations of the most recent multi‐detector‐row spiral CT), and 3) explaining how timing relative to the onset of symptoms affects test results. Rather than an overreliance on technology, leading to repeating the chest CT with PE protocol and subsequent excessive nondiagnostic testing, the hospitalist would use knowledge of pretest probability and test characteristics to determine the best diagnostic strategy. The hospitalist approach to patient care, articulated in the affective (attitudes) domains of each chapter, integrates the application of EBM principles to clinical problem solving with deliberation of cost effectiveness and efficiency.

Continuing with this case example, the Team Approach and Communication chapters establish explicit expectations for practicing hospitalists who would take the extra steps to communicate with multiple members of the care team. Knowledgeable about the hospital, the hospitalist would review the chest CT with a radiologist skilled in chest interpretation and specifically query about the significance of an enlarged right atrium and right ventricle in the setting of a high pretest clinical probability of PE. Together the radiologist and hospitalist would consider a different imaging modality if the patient flunked the chest CT when the pretest probability was high. Rather than simply deferring to the medical specialist who is consulting, the hospitalist would be expected to improve the efficiency of care and reduce cost by only ordering tests that would change clinical management, perhaps with improved outcomes.

The Hospitalist as Teacher chapter provides a frameworkcore competencies for impromptu learningbased on the patient encounter. Members of the multidisciplinary care team can be exposed to explicit clinical decision making, an approach made possible by hospitalists on site, who can provide teaching moments in real time when decisions have to be made and educational feedback is needed. Teaching expectations for hospitalists include unambiguous clinical problem solving at the bedside and possibly directing the education of residents, physician assistants, and nurses on how to initiate a quality improvement (QI) project in a hospital setting.

The Quality Improvement and Venous Thromboembolism chapters clarify the role of the hospitalist, who should direct therapy against predictable complications of serious illness, critically review prophylaxis, provide hospital‐specific data to clinicians, identify and lower barriers to prevention, devise strategies to bridge the gap between knowledge and practice, develop automated reminder systems, and participate in clinical research.

The SHM has used the Core Competencies to develop educational resources to better meet the needs of the healthcare system. Although patient safety initiatives are mandated by JCAHO for hospital accreditation and AHRQ has identified areas for safety improvement that lists venous thromboembolism (VTE) prevention as the number one priority, VTE prophylaxis is still underutilized in the United States. Although some mechanisms are in place to educate residents and hospitalists about how to manage a specific disease, traditional medical education does not focus on teaching students and residents how to manage complex patients with multiple comorbidities, to prevent predictable complications of illness, and to examine and improve care processes.15, 16 When it comes to leading quality improvement (QI), individual feedback and traditional curricula, which may include didactic lectures on the pathophysiology of VTE and morbidity and mortality conferences, have not demonstrated improved outcomes.17

The SHM QI Web‐based resource rooms offer support to any QI effort and raise collective awareness of a performance gap.18 Each resource room will describe the evidence‐based practices that should be put into effect and will leverage experience with the disease as well as with the improvement process. The underlying goal of the resource rooms is to enhance the ability of hospitalists to actually improve inpatient outcomes through self‐directed learning (see Fig. 1).

Figure 1

Hospitalists, residency directors, and directors of hospitalist fellowships and continuing education can use The Core Competencies in Hospital Medicine to develop curricula for their local hospitalist service and request that invited speakers develop learning objectives and content based on core competencies rather than giving a prepared lecture on a specific clinical condition. This case of PE illustrates that risk assessment, prophylaxis, EBM clinical problem solving, and QI are core topics that should be emphasized in the training of hospitalists and physicians in training.0

The second case example, the hand‐off (see Table 3), illustrates quality issues related to transfer of care from one physician to another. In this example, if the patient with moderate pleural effusion had been signed out, an earlier thoracentesis to drain a presumptive parapneumonic infection might have relieved this patient's shortness of breath and saved her from undergoing a subsequent VATS procedure. This case also demonstrates the importance of correlating imaging abnormalities with a patient's clinical presentation rather than using the traditional approach of just ruling out potential diagnoses to determine the cause of a problem. This case highlights elements of the process and system of care that can be modified to improve patient outcomes. Being proficient in transferring care of patients can save the hospitalist from error and prevent adverse events.

The Team Approach chapter establishes the need to acquire proficiencies not ordinarily obtained during residency in order to lead a multidisciplinary care team. This role requires a level of functioning beyond that of simply being the attending of record. The hospitalist must be able to synthesize information rather than simply defer to the consultant. Competencies specified in the Diagnostic Decision‐Making chapter can be used to identify the educational needs of hospitalists, who are expected to minimize diagnostic errors by knowing when to ask for help and where to get it, recognizing common diseases with uncommon presentations, and generating a broad differential diagnosis where there is uncertainty. The Patient Handoff chapter defines the proficiencies hospitalists need to facilitate the safe transfer of patients to other physicians on their service.0

The third case example, which expands the responsibilities of hospitalist to include meeting important needs in the hospital (see Table 4), illustrates that hospitalist services cannot succeed by offering all things to all people, a distraction that that keeps the members of these services from concentrating on their goals. Always saying yes to whoever asks for help is a band‐aid, a short‐term fix that impedes the effort and creativity required for durable long‐term solutions to problems.

The Core Competencies sets expectations about the roles of hospitalists, who serve as well‐informed clinicians and clinical opinion leaders; effective educators, mentors, and role models; empathetic and timely communicators; efficient caregivers; and creative problem solvers arriving at durable, longer‐term solutions. The competencies demonstrate the knowledge, skills, and attitudes required to be effective agents of change. Changing business as usual almost always requires significant improvements in the underlying system, however uncomfortable. The Leadership chapter articulates competencies that hospitalists need in order to define their roles within the hospital, promote group cohesiveness, expand their practices intelligently, and anticipate and respond to change. This chapter details the proficiencies that hospitalists need in order to develop personal, team, and program goals and to identify and resolve conflicts using specific negotiation techniques. The Business Practices chapter articulates the fundamental skills needed to enhance program development and growth. Hospitalists can use the Core Competencies to identify educational needs and develop curricula to enhance their leadership and business skill sets.0

Medical educators should examine the outcomes of current training practices and assess what modifications of objectives, content, and instructional strategies should be made to better prepare the current and next generations of physicians to practice hospital medicine and to improve the hospital setting. Given the scope of the field of hospital medicine, the Core Competencies should guide: 1) what to teach and how much to teach; 2) how to teach and assess trainees, and how to assess and compare faculty development programs; 3) how to design systems for improving quality of care and assuring patient safety; and 4) how to establish priorities for hospital medicine research.

TRANSLATING A SET OF COMPETENCIES INTO CURRICULA: POTENTIAL BENEFITS

The Core Competencies in Hospital Medicine transcends hospital type, size, and setting and standardizes what the expectations for and proficiencies of a practicing hospitalist should be. By defining the role of the hospitalist, the Core Competencies serves as a resource for refining inpatient skills and assists in program development at the local, regional, and national levels. In addition, by using the Core Competencies as the standard and framework for the development of preparatory curricula, hospital administrators and other employers can rely on hospitalists having had a common preparation.

The medical profession is constantly evolving. Internal medicine curricula address the challenges hospital medicine physicians faced yesterday but could improve the training and preparation of physicians to serve in their new and emerging roles as leaders of multidisciplinary healthcare teams working to improve patient outcomes and the system of inpatient care. Hospital medicine no longer represents a group of physicians merely supporting other specialists and primary care physicians; it is itself a specialty, composed of physicians leading, directing, and improving inpatient care. The competencies presented in The Core Competencies in Hospital Medicine: A Framework for Curriculum Development, by the Society of Hospital Medicine, should spark debate about the adequacy and appropriateness of current training and certification expectations and serve as a foundation for the development of curricula to improve hospital medicine education.

The seminal article that coined the term hospitalist, in 1996, attributed the role of the hospitalist to enhancing throughput and cost reduction, primarily through reduction in length of stay, accomplished by having a dedicated clinician on site in the hospital.1 Since that time the role of the hospitalist has evolved to address the needs of multiple stakeholders at a time when traditional residency programs in inpatient adult medicine do not adequately train physicians to become effective agents of change in complex and potentially unsafe hospital systems. Continuing the trend of pediatrics, obstetrics, gynecology, and geriatrics, hospitalists have emerged as a distinct group of physicians who fill a needed clinical niche and are demonstrating the benefits of bringing a unique role and skill sets to the general hospital ward.2

The eligibility requirements for certification by the American Board of Internal Medicine specify that the discipline must 1) have a distinct and unique body of knowledge, 2) have clinical applicability sufficient to support a distinct clinical practice, 3) generate new information and research, 4) require a minimum training period of 12 months, and 5) have a substantial number of trainees and training programs nationwide.3 The Society of Hospital Medicine (SHM), the national professional organization of hospitalists, commissioned a task force to develop The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (referred to from here on as the Core Competencies) to standardize the expectations of practicing hospitalists, serve as a foundation for curricula and other professional development experiences, prioritize educational scholarship and research strategies, and assess the adequacy and improvement opportunities for current training and accreditation of hospital medicine physicians.4 The preceding companion article The Core Competencies in Hospital Medicine: Development and Methodology, describes in detail the rationale for the development of the Core Competencies and the methods by which the document was created.5

PURPOSE

The purpose of this article is to illustrate how curriculum developers can apply the Core Competencies in Hospital Medicine to educate trainees and faculty, to prioritize educational scholarship and research strategies, and thus to improve the care of our patients.

TARGET AUDIENCE

The Core Competencies specifically targets directors of continuing medical education (CME), hospitalist programs and fellowships, residency programs, and medical school internal medicine clerkships. It is also intended for health educators, hospital administrators, potential employers, policy makers, and agencies funding quality‐improvement initiatives in the hospital setting. For residency program directors and clerkship directors, the chapters can guide in the development of curricula for inpatient medicine rotations or in meeting the Accreditation Council on Graduate Medical Education's Outcomes Project. For directors developing medical education curricula, The Core Competencies in Hospital Medicine can serve as a template for CME. For hospitalists, hospital administrators, and potential employers, the Core Competencies can be used to as the starting point in local program development and as a resource for refining the skills of all hospitalists, even very experienced practicing clinicians.

DEFINITION OF CORE COMPETENCIES IN HOSPITAL MEDICINE

The Core Competencies in Hospital Medicine provides a framework for curricular development based on a shared understanding of the essential knowledge, skills, and attitudes expected of physicians working as hospitalists. The development process will be ongoing, with revisions reflecting the evolving specialty of hospital medicine, the needs of practicing hospitalists, and feedback from users of the Core Competencies.

PROBLEM IDENTIFICATION AND GENERAL NEEDS ASSESSMENT

Delivery of health care has large gaps compared to ideal performance. Since the publication by the Institute of Medicine of To Err Is Human, in 1999, multiple agencies including the American Hospital Association, the National Quality Forum, and the U.S. Agency for Health Care Research and Quality (AHRQ) have reported on the incidence of medical errors in U.S. hospitals.6, 7 Recognizing that medical errors represent a major health concern in the United States, the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) now requires patient safety initiatives for hospital accreditation.8 Problem‐based learning and improvement and systems based practice are now required competencies in medical residency curricula by the Accreditation Council for Graduate Medical Education (ACGME) and these requirements have led to the development of continuous quality techniques for preventing errors and a variety of patient safety initiatives.9

In 2002 the SHM recognized the need for identifying a distinct set of competencies in hospital medicine. The published competencies highlight the current gap in training of hospitalists and the imperative for revising curricula relating to inpatient care, hospital systems, and teaching.4 With adequate training and preparation, hospitalists can take the lead in implementing systems for best practices from admission through discharge and care transition, and they can direct the development of a safer, more patient‐centered, and cost‐efficient culture.

By defining the role of the hospitalist, the Core Competencies reflects the view of the SHM about what is possible but does not suggest how a training program might be modified to achieve desired outcomes or provide any content, resources, or teaching strategies. It will be up to curriculum developers to determine the scope of cognitive, psychomotor, and affective objectives that targeted learnershospitalists, residents, and other members of the multidisciplinary teamshould be required to acquire through lectures, discussions, syllabus material, clinical experience, and other venues. We agree with a broader definition of the term curriculum for graduate medical education, one that goes beyond curriculum as a plan and takes into account the learners' experiences, both planned and unplanned in the hospital setting.10 In contrast to the technologic theory of curriculum, in which lists of knowledge and skills represent final destinations, in the experiential model of curriculum, the lists provide only points of departure.11 The goal of the Core Competencies is to facilitate curriculum development using complex teaching environments as building blocks through which learning can occur.

CORE COMPETENCIES FOR HOSPITALISTS: OVERVIEW

The Core Competencies in Hospital Medicine is the first published competency‐based framework for professional development of hospitalists and provides the basis for accreditation in hospital medicine.12 The Core Competencies is organized into three sectionsClinical Conditions, Procedures, and Healthcare Systems. The supplement intentionally does not focus on content; rather, specific competencies describe unambiguous, measurable learning objectives. Each chapter can be used as a stand‐alone chapter to develop training and curricula for a particular topic area. Each chapter divides competencies into three domains of educational outcomes: cognitive (knowledge), affective (attitudes), and psychomotor (skills). Each domain has defined levels of proficiency going from knowledge, the lowest level, to evaluation, the highest.12, 13 A specific level of proficiency is articulated in the competencies through careful selection of corresponding action verbs, which clearly indicate how mastery could be assessed (see Table 1).

In addition to specific competencies in these commonly accepted learning domains, the Clinical Conditions and Procedure sections of the Core Competencies articulate the proficiencies that hospitalists should possess in systems organization and improvement. The clinical topics were selected to set expectations of leading or participating in system improvements specific to a clinical area and to prevent predictable complications of acute illness. Competencies in the Systems Organization and Improvement section indicate mastery of multiple competencies across categories. The Core Competencies describes how the hospitalist approach facilitates coordination among all participants within the hospital system (clinical and nonclinical) and effects system changes that improve patient care processes. At the same time, the statements indicate a range of involvement from participation to leadership. For example, lead, coordination or participate in acknowledges the unique needs of different practice settings and suggests a potential professional evolution. The Systems Organization and Improvement competencies of each clinical and procedure chapter strive to capture the essence of hospitalists whose goals are to improve patient outcomes for a specific population of patients. Hospitalists do not solely focus on the care of the patient with x disease, but rather develop systems to provide the best and most efficient care for all patients with x disease, successfully transitioning these patients to outpatient care and avoiding readmission.

The third section of chapters in the Core Competencies, Healthcare Systems, distinguishes a hospitalist from others working in the inpatient setting whether practicing at academic medical centers, community hospitals, teaching hospitals, managed‐care settings, or for‐profit settings. The Healthcare Systems section identifies the integral components of the successful practice of hospital medicine and mastery of multiple competencies. This section highlights how hospitalists can facilitate coordination among all care providers within the hospital and with outpatient care providers. Hospitalists can effect system changes that improve complex care processes. It is likely that additional work experience and training beyond residency are required to attain global proficiency in the care of hospital medicine patients.

HOW TO USE THE CORE COMPETENCIES TO DEVELOP A CURRICULUM

The whole document, three sections and 51 chapters, develops expectations about the role of the hospitalist. Proficiency can be acquired through multiple means and should match the needs of the targeted learners in order to develop and maintain the necessary level of performance within the discipline of hospital medicine. Specific cases that hospitalists may encounter in their daily practice are used to illustrate how the Core Competencies can be applied to curriculum development.

The cases will employ the following six‐step approach described in Curriculum Development in Medical Education14:

• 1

  A problem and a need for improvement (the actual case and quality gap)

• 2

  Needs assessment of targeted learners (hospitalists, clinicians‐in‐training)

• 3

  Goals and specific measurable objectives (with competencies bridging the gap between traditional roles and setting expectations about the hospitalist role)

• 4

  Educational strategies (with competencies providing structure and guidance to educational efforts)

• 5

  Implementation (applying competencies to a variety of training opportunities and curricula)

• 6

  Evaluation and feedback (ongoing nationally, regionally, locally).

Like any quality‐improvement educational initiative, subsequent steps in curriculum development for hospitalists should include, after evaluation and feedback, dissemination of core competencies and promotion of rigorous ongoing evaluation and adaptation as needs and expectations evolve.

The first case example, failure to prevent and diagnose pulmonary embolism (see Table 2), illustrates quality issues relating to prevention of predictable complications of illness, clinical problem solving in complex conditions of uncertainty, repetitive and nondiagnostic testing, and triage of a critically ill patient between services. The Core Competencies sets expectations about the ideal role of the hospitalist that might lead to improved outcomes.

Using this case example, the Evidence‐Based Medicine (EBM) chapter establishes explicit expectations for hospitalists in clinical problem solving, including 1) explaining how the tests help to verify a suspected diagnosis, 2) describing the human factor in test interpretation (e.g., technical limitations of the most recent multi‐detector‐row spiral CT), and 3) explaining how timing relative to the onset of symptoms affects test results. Rather than an overreliance on technology, leading to repeating the chest CT with PE protocol and subsequent excessive nondiagnostic testing, the hospitalist would use knowledge of pretest probability and test characteristics to determine the best diagnostic strategy. The hospitalist approach to patient care, articulated in the affective (attitudes) domains of each chapter, integrates the application of EBM principles to clinical problem solving with deliberation of cost effectiveness and efficiency.

Continuing with this case example, the Team Approach and Communication chapters establish explicit expectations for practicing hospitalists who would take the extra steps to communicate with multiple members of the care team. Knowledgeable about the hospital, the hospitalist would review the chest CT with a radiologist skilled in chest interpretation and specifically query about the significance of an enlarged right atrium and right ventricle in the setting of a high pretest clinical probability of PE. Together the radiologist and hospitalist would consider a different imaging modality if the patient flunked the chest CT when the pretest probability was high. Rather than simply deferring to the medical specialist who is consulting, the hospitalist would be expected to improve the efficiency of care and reduce cost by only ordering tests that would change clinical management, perhaps with improved outcomes.

The Hospitalist as Teacher chapter provides a frameworkcore competencies for impromptu learningbased on the patient encounter. Members of the multidisciplinary care team can be exposed to explicit clinical decision making, an approach made possible by hospitalists on site, who can provide teaching moments in real time when decisions have to be made and educational feedback is needed. Teaching expectations for hospitalists include unambiguous clinical problem solving at the bedside and possibly directing the education of residents, physician assistants, and nurses on how to initiate a quality improvement (QI) project in a hospital setting.

The Quality Improvement and Venous Thromboembolism chapters clarify the role of the hospitalist, who should direct therapy against predictable complications of serious illness, critically review prophylaxis, provide hospital‐specific data to clinicians, identify and lower barriers to prevention, devise strategies to bridge the gap between knowledge and practice, develop automated reminder systems, and participate in clinical research.

The SHM has used the Core Competencies to develop educational resources to better meet the needs of the healthcare system. Although patient safety initiatives are mandated by JCAHO for hospital accreditation and AHRQ has identified areas for safety improvement that lists venous thromboembolism (VTE) prevention as the number one priority, VTE prophylaxis is still underutilized in the United States. Although some mechanisms are in place to educate residents and hospitalists about how to manage a specific disease, traditional medical education does not focus on teaching students and residents how to manage complex patients with multiple comorbidities, to prevent predictable complications of illness, and to examine and improve care processes.15, 16 When it comes to leading quality improvement (QI), individual feedback and traditional curricula, which may include didactic lectures on the pathophysiology of VTE and morbidity and mortality conferences, have not demonstrated improved outcomes.17

The SHM QI Web‐based resource rooms offer support to any QI effort and raise collective awareness of a performance gap.18 Each resource room will describe the evidence‐based practices that should be put into effect and will leverage experience with the disease as well as with the improvement process. The underlying goal of the resource rooms is to enhance the ability of hospitalists to actually improve inpatient outcomes through self‐directed learning (see Fig. 1).

Figure 1

Hospitalists, residency directors, and directors of hospitalist fellowships and continuing education can use The Core Competencies in Hospital Medicine to develop curricula for their local hospitalist service and request that invited speakers develop learning objectives and content based on core competencies rather than giving a prepared lecture on a specific clinical condition. This case of PE illustrates that risk assessment, prophylaxis, EBM clinical problem solving, and QI are core topics that should be emphasized in the training of hospitalists and physicians in training.0

The second case example, the hand‐off (see Table 3), illustrates quality issues related to transfer of care from one physician to another. In this example, if the patient with moderate pleural effusion had been signed out, an earlier thoracentesis to drain a presumptive parapneumonic infection might have relieved this patient's shortness of breath and saved her from undergoing a subsequent VATS procedure. This case also demonstrates the importance of correlating imaging abnormalities with a patient's clinical presentation rather than using the traditional approach of just ruling out potential diagnoses to determine the cause of a problem. This case highlights elements of the process and system of care that can be modified to improve patient outcomes. Being proficient in transferring care of patients can save the hospitalist from error and prevent adverse events.

The Team Approach chapter establishes the need to acquire proficiencies not ordinarily obtained during residency in order to lead a multidisciplinary care team. This role requires a level of functioning beyond that of simply being the attending of record. The hospitalist must be able to synthesize information rather than simply defer to the consultant. Competencies specified in the Diagnostic Decision‐Making chapter can be used to identify the educational needs of hospitalists, who are expected to minimize diagnostic errors by knowing when to ask for help and where to get it, recognizing common diseases with uncommon presentations, and generating a broad differential diagnosis where there is uncertainty. The Patient Handoff chapter defines the proficiencies hospitalists need to facilitate the safe transfer of patients to other physicians on their service.0

The third case example, which expands the responsibilities of hospitalist to include meeting important needs in the hospital (see Table 4), illustrates that hospitalist services cannot succeed by offering all things to all people, a distraction that that keeps the members of these services from concentrating on their goals. Always saying yes to whoever asks for help is a band‐aid, a short‐term fix that impedes the effort and creativity required for durable long‐term solutions to problems.

The Core Competencies sets expectations about the roles of hospitalists, who serve as well‐informed clinicians and clinical opinion leaders; effective educators, mentors, and role models; empathetic and timely communicators; efficient caregivers; and creative problem solvers arriving at durable, longer‐term solutions. The competencies demonstrate the knowledge, skills, and attitudes required to be effective agents of change. Changing business as usual almost always requires significant improvements in the underlying system, however uncomfortable. The Leadership chapter articulates competencies that hospitalists need in order to define their roles within the hospital, promote group cohesiveness, expand their practices intelligently, and anticipate and respond to change. This chapter details the proficiencies that hospitalists need in order to develop personal, team, and program goals and to identify and resolve conflicts using specific negotiation techniques. The Business Practices chapter articulates the fundamental skills needed to enhance program development and growth. Hospitalists can use the Core Competencies to identify educational needs and develop curricula to enhance their leadership and business skill sets.0

Medical educators should examine the outcomes of current training practices and assess what modifications of objectives, content, and instructional strategies should be made to better prepare the current and next generations of physicians to practice hospital medicine and to improve the hospital setting. Given the scope of the field of hospital medicine, the Core Competencies should guide: 1) what to teach and how much to teach; 2) how to teach and assess trainees, and how to assess and compare faculty development programs; 3) how to design systems for improving quality of care and assuring patient safety; and 4) how to establish priorities for hospital medicine research.

TRANSLATING A SET OF COMPETENCIES INTO CURRICULA: POTENTIAL BENEFITS

The Core Competencies in Hospital Medicine transcends hospital type, size, and setting and standardizes what the expectations for and proficiencies of a practicing hospitalist should be. By defining the role of the hospitalist, the Core Competencies serves as a resource for refining inpatient skills and assists in program development at the local, regional, and national levels. In addition, by using the Core Competencies as the standard and framework for the development of preparatory curricula, hospital administrators and other employers can rely on hospitalists having had a common preparation.

The medical profession is constantly evolving. Internal medicine curricula address the challenges hospital medicine physicians faced yesterday but could improve the training and preparation of physicians to serve in their new and emerging roles as leaders of multidisciplinary healthcare teams working to improve patient outcomes and the system of inpatient care. Hospital medicine no longer represents a group of physicians merely supporting other specialists and primary care physicians; it is itself a specialty, composed of physicians leading, directing, and improving inpatient care. The competencies presented in The Core Competencies in Hospital Medicine: A Framework for Curriculum Development, by the Society of Hospital Medicine, should spark debate about the adequacy and appropriateness of current training and certification expectations and serve as a foundation for the development of curricula to improve hospital medicine education.

The seminal article that coined the term hospitalist, in 1996, attributed the role of the hospitalist to enhancing throughput and cost reduction, primarily through reduction in length of stay, accomplished by having a dedicated clinician on site in the hospital.1 Since that time the role of the hospitalist has evolved to address the needs of multiple stakeholders at a time when traditional residency programs in inpatient adult medicine do not adequately train physicians to become effective agents of change in complex and potentially unsafe hospital systems. Continuing the trend of pediatrics, obstetrics, gynecology, and geriatrics, hospitalists have emerged as a distinct group of physicians who fill a needed clinical niche and are demonstrating the benefits of bringing a unique role and skill sets to the general hospital ward.2

The eligibility requirements for certification by the American Board of Internal Medicine specify that the discipline must 1) have a distinct and unique body of knowledge, 2) have clinical applicability sufficient to support a distinct clinical practice, 3) generate new information and research, 4) require a minimum training period of 12 months, and 5) have a substantial number of trainees and training programs nationwide.3 The Society of Hospital Medicine (SHM), the national professional organization of hospitalists, commissioned a task force to develop The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (referred to from here on as the Core Competencies) to standardize the expectations of practicing hospitalists, serve as a foundation for curricula and other professional development experiences, prioritize educational scholarship and research strategies, and assess the adequacy and improvement opportunities for current training and accreditation of hospital medicine physicians.4 The preceding companion article The Core Competencies in Hospital Medicine: Development and Methodology, describes in detail the rationale for the development of the Core Competencies and the methods by which the document was created.5

PURPOSE

The purpose of this article is to illustrate how curriculum developers can apply the Core Competencies in Hospital Medicine to educate trainees and faculty, to prioritize educational scholarship and research strategies, and thus to improve the care of our patients.

TARGET AUDIENCE

The Core Competencies specifically targets directors of continuing medical education (CME), hospitalist programs and fellowships, residency programs, and medical school internal medicine clerkships. It is also intended for health educators, hospital administrators, potential employers, policy makers, and agencies funding quality‐improvement initiatives in the hospital setting. For residency program directors and clerkship directors, the chapters can guide in the development of curricula for inpatient medicine rotations or in meeting the Accreditation Council on Graduate Medical Education's Outcomes Project. For directors developing medical education curricula, The Core Competencies in Hospital Medicine can serve as a template for CME. For hospitalists, hospital administrators, and potential employers, the Core Competencies can be used to as the starting point in local program development and as a resource for refining the skills of all hospitalists, even very experienced practicing clinicians.

DEFINITION OF CORE COMPETENCIES IN HOSPITAL MEDICINE

The Core Competencies in Hospital Medicine provides a framework for curricular development based on a shared understanding of the essential knowledge, skills, and attitudes expected of physicians working as hospitalists. The development process will be ongoing, with revisions reflecting the evolving specialty of hospital medicine, the needs of practicing hospitalists, and feedback from users of the Core Competencies.

PROBLEM IDENTIFICATION AND GENERAL NEEDS ASSESSMENT

Delivery of health care has large gaps compared to ideal performance. Since the publication by the Institute of Medicine of To Err Is Human, in 1999, multiple agencies including the American Hospital Association, the National Quality Forum, and the U.S. Agency for Health Care Research and Quality (AHRQ) have reported on the incidence of medical errors in U.S. hospitals.6, 7 Recognizing that medical errors represent a major health concern in the United States, the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) now requires patient safety initiatives for hospital accreditation.8 Problem‐based learning and improvement and systems based practice are now required competencies in medical residency curricula by the Accreditation Council for Graduate Medical Education (ACGME) and these requirements have led to the development of continuous quality techniques for preventing errors and a variety of patient safety initiatives.9

In 2002 the SHM recognized the need for identifying a distinct set of competencies in hospital medicine. The published competencies highlight the current gap in training of hospitalists and the imperative for revising curricula relating to inpatient care, hospital systems, and teaching.4 With adequate training and preparation, hospitalists can take the lead in implementing systems for best practices from admission through discharge and care transition, and they can direct the development of a safer, more patient‐centered, and cost‐efficient culture.

By defining the role of the hospitalist, the Core Competencies reflects the view of the SHM about what is possible but does not suggest how a training program might be modified to achieve desired outcomes or provide any content, resources, or teaching strategies. It will be up to curriculum developers to determine the scope of cognitive, psychomotor, and affective objectives that targeted learnershospitalists, residents, and other members of the multidisciplinary teamshould be required to acquire through lectures, discussions, syllabus material, clinical experience, and other venues. We agree with a broader definition of the term curriculum for graduate medical education, one that goes beyond curriculum as a plan and takes into account the learners' experiences, both planned and unplanned in the hospital setting.10 In contrast to the technologic theory of curriculum, in which lists of knowledge and skills represent final destinations, in the experiential model of curriculum, the lists provide only points of departure.11 The goal of the Core Competencies is to facilitate curriculum development using complex teaching environments as building blocks through which learning can occur.

CORE COMPETENCIES FOR HOSPITALISTS: OVERVIEW

The Core Competencies in Hospital Medicine is the first published competency‐based framework for professional development of hospitalists and provides the basis for accreditation in hospital medicine.12 The Core Competencies is organized into three sectionsClinical Conditions, Procedures, and Healthcare Systems. The supplement intentionally does not focus on content; rather, specific competencies describe unambiguous, measurable learning objectives. Each chapter can be used as a stand‐alone chapter to develop training and curricula for a particular topic area. Each chapter divides competencies into three domains of educational outcomes: cognitive (knowledge), affective (attitudes), and psychomotor (skills). Each domain has defined levels of proficiency going from knowledge, the lowest level, to evaluation, the highest.12, 13 A specific level of proficiency is articulated in the competencies through careful selection of corresponding action verbs, which clearly indicate how mastery could be assessed (see Table 1).

In addition to specific competencies in these commonly accepted learning domains, the Clinical Conditions and Procedure sections of the Core Competencies articulate the proficiencies that hospitalists should possess in systems organization and improvement. The clinical topics were selected to set expectations of leading or participating in system improvements specific to a clinical area and to prevent predictable complications of acute illness. Competencies in the Systems Organization and Improvement section indicate mastery of multiple competencies across categories. The Core Competencies describes how the hospitalist approach facilitates coordination among all participants within the hospital system (clinical and nonclinical) and effects system changes that improve patient care processes. At the same time, the statements indicate a range of involvement from participation to leadership. For example, lead, coordination or participate in acknowledges the unique needs of different practice settings and suggests a potential professional evolution. The Systems Organization and Improvement competencies of each clinical and procedure chapter strive to capture the essence of hospitalists whose goals are to improve patient outcomes for a specific population of patients. Hospitalists do not solely focus on the care of the patient with x disease, but rather develop systems to provide the best and most efficient care for all patients with x disease, successfully transitioning these patients to outpatient care and avoiding readmission.

The third section of chapters in the Core Competencies, Healthcare Systems, distinguishes a hospitalist from others working in the inpatient setting whether practicing at academic medical centers, community hospitals, teaching hospitals, managed‐care settings, or for‐profit settings. The Healthcare Systems section identifies the integral components of the successful practice of hospital medicine and mastery of multiple competencies. This section highlights how hospitalists can facilitate coordination among all care providers within the hospital and with outpatient care providers. Hospitalists can effect system changes that improve complex care processes. It is likely that additional work experience and training beyond residency are required to attain global proficiency in the care of hospital medicine patients.

HOW TO USE THE CORE COMPETENCIES TO DEVELOP A CURRICULUM

The whole document, three sections and 51 chapters, develops expectations about the role of the hospitalist. Proficiency can be acquired through multiple means and should match the needs of the targeted learners in order to develop and maintain the necessary level of performance within the discipline of hospital medicine. Specific cases that hospitalists may encounter in their daily practice are used to illustrate how the Core Competencies can be applied to curriculum development.

The cases will employ the following six‐step approach described in Curriculum Development in Medical Education14:

• 1

  A problem and a need for improvement (the actual case and quality gap)

• 2

  Needs assessment of targeted learners (hospitalists, clinicians‐in‐training)

• 3

  Goals and specific measurable objectives (with competencies bridging the gap between traditional roles and setting expectations about the hospitalist role)

• 4

  Educational strategies (with competencies providing structure and guidance to educational efforts)

• 5

  Implementation (applying competencies to a variety of training opportunities and curricula)

• 6

  Evaluation and feedback (ongoing nationally, regionally, locally).

Like any quality‐improvement educational initiative, subsequent steps in curriculum development for hospitalists should include, after evaluation and feedback, dissemination of core competencies and promotion of rigorous ongoing evaluation and adaptation as needs and expectations evolve.

The first case example, failure to prevent and diagnose pulmonary embolism (see Table 2), illustrates quality issues relating to prevention of predictable complications of illness, clinical problem solving in complex conditions of uncertainty, repetitive and nondiagnostic testing, and triage of a critically ill patient between services. The Core Competencies sets expectations about the ideal role of the hospitalist that might lead to improved outcomes.

Using this case example, the Evidence‐Based Medicine (EBM) chapter establishes explicit expectations for hospitalists in clinical problem solving, including 1) explaining how the tests help to verify a suspected diagnosis, 2) describing the human factor in test interpretation (e.g., technical limitations of the most recent multi‐detector‐row spiral CT), and 3) explaining how timing relative to the onset of symptoms affects test results. Rather than an overreliance on technology, leading to repeating the chest CT with PE protocol and subsequent excessive nondiagnostic testing, the hospitalist would use knowledge of pretest probability and test characteristics to determine the best diagnostic strategy. The hospitalist approach to patient care, articulated in the affective (attitudes) domains of each chapter, integrates the application of EBM principles to clinical problem solving with deliberation of cost effectiveness and efficiency.

Continuing with this case example, the Team Approach and Communication chapters establish explicit expectations for practicing hospitalists who would take the extra steps to communicate with multiple members of the care team. Knowledgeable about the hospital, the hospitalist would review the chest CT with a radiologist skilled in chest interpretation and specifically query about the significance of an enlarged right atrium and right ventricle in the setting of a high pretest clinical probability of PE. Together the radiologist and hospitalist would consider a different imaging modality if the patient flunked the chest CT when the pretest probability was high. Rather than simply deferring to the medical specialist who is consulting, the hospitalist would be expected to improve the efficiency of care and reduce cost by only ordering tests that would change clinical management, perhaps with improved outcomes.

The Hospitalist as Teacher chapter provides a frameworkcore competencies for impromptu learningbased on the patient encounter. Members of the multidisciplinary care team can be exposed to explicit clinical decision making, an approach made possible by hospitalists on site, who can provide teaching moments in real time when decisions have to be made and educational feedback is needed. Teaching expectations for hospitalists include unambiguous clinical problem solving at the bedside and possibly directing the education of residents, physician assistants, and nurses on how to initiate a quality improvement (QI) project in a hospital setting.

The Quality Improvement and Venous Thromboembolism chapters clarify the role of the hospitalist, who should direct therapy against predictable complications of serious illness, critically review prophylaxis, provide hospital‐specific data to clinicians, identify and lower barriers to prevention, devise strategies to bridge the gap between knowledge and practice, develop automated reminder systems, and participate in clinical research.

The SHM has used the Core Competencies to develop educational resources to better meet the needs of the healthcare system. Although patient safety initiatives are mandated by JCAHO for hospital accreditation and AHRQ has identified areas for safety improvement that lists venous thromboembolism (VTE) prevention as the number one priority, VTE prophylaxis is still underutilized in the United States. Although some mechanisms are in place to educate residents and hospitalists about how to manage a specific disease, traditional medical education does not focus on teaching students and residents how to manage complex patients with multiple comorbidities, to prevent predictable complications of illness, and to examine and improve care processes.15, 16 When it comes to leading quality improvement (QI), individual feedback and traditional curricula, which may include didactic lectures on the pathophysiology of VTE and morbidity and mortality conferences, have not demonstrated improved outcomes.17

The SHM QI Web‐based resource rooms offer support to any QI effort and raise collective awareness of a performance gap.18 Each resource room will describe the evidence‐based practices that should be put into effect and will leverage experience with the disease as well as with the improvement process. The underlying goal of the resource rooms is to enhance the ability of hospitalists to actually improve inpatient outcomes through self‐directed learning (see Fig. 1).

Figure 1

Hospitalists, residency directors, and directors of hospitalist fellowships and continuing education can use The Core Competencies in Hospital Medicine to develop curricula for their local hospitalist service and request that invited speakers develop learning objectives and content based on core competencies rather than giving a prepared lecture on a specific clinical condition. This case of PE illustrates that risk assessment, prophylaxis, EBM clinical problem solving, and QI are core topics that should be emphasized in the training of hospitalists and physicians in training.0

The second case example, the hand‐off (see Table 3), illustrates quality issues related to transfer of care from one physician to another. In this example, if the patient with moderate pleural effusion had been signed out, an earlier thoracentesis to drain a presumptive parapneumonic infection might have relieved this patient's shortness of breath and saved her from undergoing a subsequent VATS procedure. This case also demonstrates the importance of correlating imaging abnormalities with a patient's clinical presentation rather than using the traditional approach of just ruling out potential diagnoses to determine the cause of a problem. This case highlights elements of the process and system of care that can be modified to improve patient outcomes. Being proficient in transferring care of patients can save the hospitalist from error and prevent adverse events.

The Team Approach chapter establishes the need to acquire proficiencies not ordinarily obtained during residency in order to lead a multidisciplinary care team. This role requires a level of functioning beyond that of simply being the attending of record. The hospitalist must be able to synthesize information rather than simply defer to the consultant. Competencies specified in the Diagnostic Decision‐Making chapter can be used to identify the educational needs of hospitalists, who are expected to minimize diagnostic errors by knowing when to ask for help and where to get it, recognizing common diseases with uncommon presentations, and generating a broad differential diagnosis where there is uncertainty. The Patient Handoff chapter defines the proficiencies hospitalists need to facilitate the safe transfer of patients to other physicians on their service.0

The third case example, which expands the responsibilities of hospitalist to include meeting important needs in the hospital (see Table 4), illustrates that hospitalist services cannot succeed by offering all things to all people, a distraction that that keeps the members of these services from concentrating on their goals. Always saying yes to whoever asks for help is a band‐aid, a short‐term fix that impedes the effort and creativity required for durable long‐term solutions to problems.

The Core Competencies sets expectations about the roles of hospitalists, who serve as well‐informed clinicians and clinical opinion leaders; effective educators, mentors, and role models; empathetic and timely communicators; efficient caregivers; and creative problem solvers arriving at durable, longer‐term solutions. The competencies demonstrate the knowledge, skills, and attitudes required to be effective agents of change. Changing business as usual almost always requires significant improvements in the underlying system, however uncomfortable. The Leadership chapter articulates competencies that hospitalists need in order to define their roles within the hospital, promote group cohesiveness, expand their practices intelligently, and anticipate and respond to change. This chapter details the proficiencies that hospitalists need in order to develop personal, team, and program goals and to identify and resolve conflicts using specific negotiation techniques. The Business Practices chapter articulates the fundamental skills needed to enhance program development and growth. Hospitalists can use the Core Competencies to identify educational needs and develop curricula to enhance their leadership and business skill sets.0

Medical educators should examine the outcomes of current training practices and assess what modifications of objectives, content, and instructional strategies should be made to better prepare the current and next generations of physicians to practice hospital medicine and to improve the hospital setting. Given the scope of the field of hospital medicine, the Core Competencies should guide: 1) what to teach and how much to teach; 2) how to teach and assess trainees, and how to assess and compare faculty development programs; 3) how to design systems for improving quality of care and assuring patient safety; and 4) how to establish priorities for hospital medicine research.

TRANSLATING A SET OF COMPETENCIES INTO CURRICULA: POTENTIAL BENEFITS

The Core Competencies in Hospital Medicine transcends hospital type, size, and setting and standardizes what the expectations for and proficiencies of a practicing hospitalist should be. By defining the role of the hospitalist, the Core Competencies serves as a resource for refining inpatient skills and assists in program development at the local, regional, and national levels. In addition, by using the Core Competencies as the standard and framework for the development of preparatory curricula, hospital administrators and other employers can rely on hospitalists having had a common preparation.

The medical profession is constantly evolving. Internal medicine curricula address the challenges hospital medicine physicians faced yesterday but could improve the training and preparation of physicians to serve in their new and emerging roles as leaders of multidisciplinary healthcare teams working to improve patient outcomes and the system of inpatient care. Hospital medicine no longer represents a group of physicians merely supporting other specialists and primary care physicians; it is itself a specialty, composed of physicians leading, directing, and improving inpatient care. The competencies presented in The Core Competencies in Hospital Medicine: A Framework for Curriculum Development, by the Society of Hospital Medicine, should spark debate about the adequacy and appropriateness of current training and certification expectations and serve as a foundation for the development of curricula to improve hospital medicine education.

Identification of the core competencies of a medical specialty provides the necessary framework for that specialty to develop, refine itself, and evolve. It also provides a structure from which training, testing, and curricula can be developed and effectively utilized. For nearly a decade, since the coining of the term hospitalist,1 the field of hospital medicine has been emerging as the next generation of site‐defined specialties, after emergency medicine and critical care medicine. The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (referred to as the Core Competencies from this point on) introduces the expectations of hospitalists, helps to define their role, and suggests how knowledge, skill, and attitude acquisition might be evaluated. Furthermore, this document provides an initial structural framework from which curricula in adult hospital medicine may be developed.

The Core Competencies document, produced by the Society of Hospital Medicine (SHM) and published as a supplement to the first issue of the Journal of Hospital Medicine,2 is meant to serve as a framework for educators at all levels of medical education to develop curricula, training, and evaluations for students, clinicians‐in‐training, and practicing hospitalists. The Core Competencies document is not meant to contain a complete compilation of inpatient clinical topics or to re‐create what many residency training programs in adult inpatient care already provide. It should not limit and does not define every aspect of hospitalist practice. It includes the most common and fundamental elements of inpatient care without exhaustively listing every clinical entity that may be encountered by a hospitalist. Some of the more common clinical topics encountered by inpatient physicians are included, with an emphasis on subject areas that stress a systems‐based approach to health care, which is central to the practice of hospital medicine. This initial version of the Core Competencies document also focuses on potential areas of deficiency in the training of physicians to become hospitalists. It provides developers of curricula and content with a standardized set of measurable learning objectives, while allowing them the flexibility needed to address specific contexts and incorporate advances in medicine.

The SHM, the sole professional organization representing inpatient physicians, defines hospitalists as physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine.3 An estimated 12,000 hospitalists are currently practicing in the United States, with a projected workforce need of an estimated 20,00030,000 practicing hospitalists in the United States in the next 510 years.4 Various factors have contributed to the rapid growth and expansion of hospital medicine, including factors related to care efficiency, care quality, and inpatient teaching.512 The pressures that have contributed to the development of and evolution toward the hospitalist model of care over the past decade are facilitating the transformation from a traditional model of inpatient care to the care of inpatients by hospitalist physicians dedicated primarily to the inpatient setting. As a result of this growth in hospital medicine, the SHM realized that core competencies were needed to help define the field.

The purpose of this article is to describe the developmental process and content structure of the Core Competencies document. It delineates the process from initial needs assessment to topic list development to chapter production to internal and external review and revisions of individual chapters and the complete document. The supplement to this first issue of the Journal of Hospital Medicine contains 1) the Core Competencies,2 2) a reprint of this article, and 3) a reprint of the article by McKean et al. in this issue detailing how to use the Core Competencies,13 with examples and suggestions related to curriculum development. The authors propose that this combined compilation may spur curriculum development in hospital medicine that will help to define the field and set expectations for practice.

PROCESS AND TIMELINE

Education Summit

Early in the growth of hospital medicine, the Society of Hospital Medicine identified a need to better define a common educational and practice framework for hospitalist physicians. Such a framework could help to define hospitalists as a distinct group of practicing physicians with common goals and a common set of competencies. The importance of identifying and delineating the common knowledge, skills, and attitudes of hospitalists was paramount. Figure 1 shows the details of the 4‐year process of developing the Core Competencies.

Figure 1

In 2002, the SHM drew together educational leaders in hospital medicine in its first educational summit. One of the primary charges that the SHM received from this summit was to develop the needed core curriculum in hospital medicine. After the summit, the SHM's Education Committee formed the Core Curriculum Task Force (CCTF), composed of approximately 15 member hospitalists, with representation from university and community hospitals, teaching and nonteaching programs, and for‐profit and not‐for‐profit settings from various geographic regions of the country. The selection process ensured that the task force was representative of practicing hospitalists and SHM membership throughout the United States.

CHAPTER CONTENT DESCRIPTION

As previously delineated, the Core Competencies document has three sections: Clinical Conditions, Procedures, and Healthcare Systems. The chapters in the entire compendium and within each section have been designed to stand alone and to be used either individually or collectively to assist with curriculum development in hospital medicine. However, each chapter should be used in the context of the entire document because a particular issue may only be touched on in one chapter but may be more elaborately detailed in another. For example, all clinical conditions chapters include a competency on the issue of care transitions, but the specific competencies for care transitions are presented in a separate Transitions of Care chapter.

All chapters in each section begin with an introduction that provides brief background information and establishes the relevance of the topic to practicing hospitalists. Each chapter then utilizes the educational theory of learning domains. The learning domains include the cognitive domain (knowledge), the psychomotor domain (skills), and the affective domain (attitudes). The companion article How to Use The Core Competencies in Hospital Medicine: A Framework for Curriculum Development13 describes in detail the educational theory guiding the development of the Core Competencies document and suggested methods for applying it to the development and revision of curricula and other training activities.

The task force further decided that each chapter in the Clinical Conditions and Procedures sections should include a subsection dedicated to system organization and improvement, an added domain that requires integration of knowledge, skills, and attitudes and the involvement of other medical services and disciplines for optimal patient care. The editorial board believed that system organization and improvement was already an intrinsic feature embedded in the chapters of the Healthcare Systems section. Therefore, this subsection was not included in those chapters.

Hospitalists subscribe to a systems organizational approach to clinical management and processes of care within the hospital. This systems approach, more than any level of knowledge or skill, is required to effectively and efficiently practice in the hospital setting. Practicing with a systems approach, with the interest of improving processes of care, is embedded throughout the Core Competencies document and is a practice method that all hospitalists may strive to achieve as they develop and improve their inpatient care. The competencies within the Systems Organization and Improvement section may contain a range of competency expectation (eg, lead, coordinate, or participate in) to acknowledge their uniqueness and variation according to practice settings and locally instituted responsibilities.

Each competency within a chapter details a level of proficiency, providing guidance on learning activities and potential evaluation strategies. Several overarching themes are followed in the chapters that help to define hospitalists as physicians who specialize in the care of hospitalized patients. First, hospitalists strive to support and adhere to a multidisciplinary approach for the patients under their care. Such an approach involves active interaction with and integration of other hospital medical staff (eg, nursing, rehabilitation therapies, social services) and of specialty medical or surgical services when indicated. Recognizing that hospitalists vary in experience and mastery of their field, the task force and editorial board believed that, at minimum, hospitalists would participate in multidisciplinary teams for improvement of the care and process related to the clinical conditions within their organization. However, they might also lead and/or coordinate teams in such efforts. Therefore, most chapters contain competencies that expect hospitalists to lead, coordinate, or participate in multidisciplinary teams or initiatives that will facilitate optimal care within their organization.

Second, because hospital medicine centers around the quality of inpatient care, participation in quality improvement (QI) initiatives, focusing on improving processes or systems of care in a local institution or organization, may be common in hospitalist practices. The level of involvement and role in QI initiatives may vary according to the particular system, the resources available, and a hospitalist's experience. Finally, because hospitalist care intrinsically involves an increase in the number of care transitions and handoffs, hospitalists need to remain sensitive to and focused on the care transitions that occur with their patients. Such transitions may occur as patients enter the hospital, move from one location to another within the hospital, or leave the hospital. This vulnerable time for patients requires hospitalists to be vigilant in their communication effortswith patients, with medical staff, and with outpatient clinicians.

Each competency was crafted to indicate the relevant concept, the level of proficiency expected, and a way to evaluate mastery. The teaching processes and learning experiences that must take place to achieve competency are left for curriculum developers and instructors to design. These core competencies represent an initial step in curriculum development, creating an identity and core set of expectations for hospitalists that we believe will lead to progress and maturity within the field.

SUMMARY AND FUTURE DIRECTIONS

The practice of hospital medicine requires proficiency of interrelated aspects of practiceclinical, procedural, and system‐based competencies. For practicing hospitalists, the Core Competencies document may serve as a resource to refine skills and assist in program development at individual institutions, both regionally and nationally. For residency program directors and clerkship directors, the Core Competencies document can function as a guide for developing the curriculum of inpatient medicine rotations or for meeting the requirements of the Outcomes Project of the Accreditation Council on Graduate Medical Education's. Last, for those developing continuing medical education programs, the Core Competencies document or individual chapters or topics within it may serve as an outline around which specific or broad‐based programs can be developed. Although the development of such curricula and the recipients of them should be evaluated, the actual evaluation is left to the curriculum developers.

Hospitalists are invested in making hospitals run better. They are positioned to take leadership roles in addressing quality, efficiency, and cost interests in both community and academic hospital settings. Their goals include improving care processes, hospital work life, and the setting in which they practice. The key core competencies described in this compendium define hospitalists as agents of change 1) to develop and implement systems to enable best practices to occur from admission through discharge, and 2) to promote the development of a safer culture within the hospital.

Hospital medicine remains an evolving specialty. Although great care was taken to construct these competencies so they would retain their relevance over time, SHM, the Core Curriculum Task Force, and the editorial board recognize the need for their continual reevaluation and modification in the context of advances and changes in the practice of hospital medicine. Our intent is that these competencies be a common reference and foundation for the creation of hospital medicine curricula and serve to standardize and improve training practices.

Identification of the core competencies of a medical specialty provides the necessary framework for that specialty to develop, refine itself, and evolve. It also provides a structure from which training, testing, and curricula can be developed and effectively utilized. For nearly a decade, since the coining of the term hospitalist,1 the field of hospital medicine has been emerging as the next generation of site‐defined specialties, after emergency medicine and critical care medicine. The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (referred to as the Core Competencies from this point on) introduces the expectations of hospitalists, helps to define their role, and suggests how knowledge, skill, and attitude acquisition might be evaluated. Furthermore, this document provides an initial structural framework from which curricula in adult hospital medicine may be developed.

The Core Competencies document, produced by the Society of Hospital Medicine (SHM) and published as a supplement to the first issue of the Journal of Hospital Medicine,2 is meant to serve as a framework for educators at all levels of medical education to develop curricula, training, and evaluations for students, clinicians‐in‐training, and practicing hospitalists. The Core Competencies document is not meant to contain a complete compilation of inpatient clinical topics or to re‐create what many residency training programs in adult inpatient care already provide. It should not limit and does not define every aspect of hospitalist practice. It includes the most common and fundamental elements of inpatient care without exhaustively listing every clinical entity that may be encountered by a hospitalist. Some of the more common clinical topics encountered by inpatient physicians are included, with an emphasis on subject areas that stress a systems‐based approach to health care, which is central to the practice of hospital medicine. This initial version of the Core Competencies document also focuses on potential areas of deficiency in the training of physicians to become hospitalists. It provides developers of curricula and content with a standardized set of measurable learning objectives, while allowing them the flexibility needed to address specific contexts and incorporate advances in medicine.

The SHM, the sole professional organization representing inpatient physicians, defines hospitalists as physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine.3 An estimated 12,000 hospitalists are currently practicing in the United States, with a projected workforce need of an estimated 20,00030,000 practicing hospitalists in the United States in the next 510 years.4 Various factors have contributed to the rapid growth and expansion of hospital medicine, including factors related to care efficiency, care quality, and inpatient teaching.512 The pressures that have contributed to the development of and evolution toward the hospitalist model of care over the past decade are facilitating the transformation from a traditional model of inpatient care to the care of inpatients by hospitalist physicians dedicated primarily to the inpatient setting. As a result of this growth in hospital medicine, the SHM realized that core competencies were needed to help define the field.

The purpose of this article is to describe the developmental process and content structure of the Core Competencies document. It delineates the process from initial needs assessment to topic list development to chapter production to internal and external review and revisions of individual chapters and the complete document. The supplement to this first issue of the Journal of Hospital Medicine contains 1) the Core Competencies,2 2) a reprint of this article, and 3) a reprint of the article by McKean et al. in this issue detailing how to use the Core Competencies,13 with examples and suggestions related to curriculum development. The authors propose that this combined compilation may spur curriculum development in hospital medicine that will help to define the field and set expectations for practice.

PROCESS AND TIMELINE

Education Summit

Early in the growth of hospital medicine, the Society of Hospital Medicine identified a need to better define a common educational and practice framework for hospitalist physicians. Such a framework could help to define hospitalists as a distinct group of practicing physicians with common goals and a common set of competencies. The importance of identifying and delineating the common knowledge, skills, and attitudes of hospitalists was paramount. Figure 1 shows the details of the 4‐year process of developing the Core Competencies.

Figure 1

In 2002, the SHM drew together educational leaders in hospital medicine in its first educational summit. One of the primary charges that the SHM received from this summit was to develop the needed core curriculum in hospital medicine. After the summit, the SHM's Education Committee formed the Core Curriculum Task Force (CCTF), composed of approximately 15 member hospitalists, with representation from university and community hospitals, teaching and nonteaching programs, and for‐profit and not‐for‐profit settings from various geographic regions of the country. The selection process ensured that the task force was representative of practicing hospitalists and SHM membership throughout the United States.

CHAPTER CONTENT DESCRIPTION

As previously delineated, the Core Competencies document has three sections: Clinical Conditions, Procedures, and Healthcare Systems. The chapters in the entire compendium and within each section have been designed to stand alone and to be used either individually or collectively to assist with curriculum development in hospital medicine. However, each chapter should be used in the context of the entire document because a particular issue may only be touched on in one chapter but may be more elaborately detailed in another. For example, all clinical conditions chapters include a competency on the issue of care transitions, but the specific competencies for care transitions are presented in a separate Transitions of Care chapter.

All chapters in each section begin with an introduction that provides brief background information and establishes the relevance of the topic to practicing hospitalists. Each chapter then utilizes the educational theory of learning domains. The learning domains include the cognitive domain (knowledge), the psychomotor domain (skills), and the affective domain (attitudes). The companion article How to Use The Core Competencies in Hospital Medicine: A Framework for Curriculum Development13 describes in detail the educational theory guiding the development of the Core Competencies document and suggested methods for applying it to the development and revision of curricula and other training activities.

The task force further decided that each chapter in the Clinical Conditions and Procedures sections should include a subsection dedicated to system organization and improvement, an added domain that requires integration of knowledge, skills, and attitudes and the involvement of other medical services and disciplines for optimal patient care. The editorial board believed that system organization and improvement was already an intrinsic feature embedded in the chapters of the Healthcare Systems section. Therefore, this subsection was not included in those chapters.

Hospitalists subscribe to a systems organizational approach to clinical management and processes of care within the hospital. This systems approach, more than any level of knowledge or skill, is required to effectively and efficiently practice in the hospital setting. Practicing with a systems approach, with the interest of improving processes of care, is embedded throughout the Core Competencies document and is a practice method that all hospitalists may strive to achieve as they develop and improve their inpatient care. The competencies within the Systems Organization and Improvement section may contain a range of competency expectation (eg, lead, coordinate, or participate in) to acknowledge their uniqueness and variation according to practice settings and locally instituted responsibilities.

Each competency within a chapter details a level of proficiency, providing guidance on learning activities and potential evaluation strategies. Several overarching themes are followed in the chapters that help to define hospitalists as physicians who specialize in the care of hospitalized patients. First, hospitalists strive to support and adhere to a multidisciplinary approach for the patients under their care. Such an approach involves active interaction with and integration of other hospital medical staff (eg, nursing, rehabilitation therapies, social services) and of specialty medical or surgical services when indicated. Recognizing that hospitalists vary in experience and mastery of their field, the task force and editorial board believed that, at minimum, hospitalists would participate in multidisciplinary teams for improvement of the care and process related to the clinical conditions within their organization. However, they might also lead and/or coordinate teams in such efforts. Therefore, most chapters contain competencies that expect hospitalists to lead, coordinate, or participate in multidisciplinary teams or initiatives that will facilitate optimal care within their organization.

Second, because hospital medicine centers around the quality of inpatient care, participation in quality improvement (QI) initiatives, focusing on improving processes or systems of care in a local institution or organization, may be common in hospitalist practices. The level of involvement and role in QI initiatives may vary according to the particular system, the resources available, and a hospitalist's experience. Finally, because hospitalist care intrinsically involves an increase in the number of care transitions and handoffs, hospitalists need to remain sensitive to and focused on the care transitions that occur with their patients. Such transitions may occur as patients enter the hospital, move from one location to another within the hospital, or leave the hospital. This vulnerable time for patients requires hospitalists to be vigilant in their communication effortswith patients, with medical staff, and with outpatient clinicians.

Each competency was crafted to indicate the relevant concept, the level of proficiency expected, and a way to evaluate mastery. The teaching processes and learning experiences that must take place to achieve competency are left for curriculum developers and instructors to design. These core competencies represent an initial step in curriculum development, creating an identity and core set of expectations for hospitalists that we believe will lead to progress and maturity within the field.

SUMMARY AND FUTURE DIRECTIONS

The practice of hospital medicine requires proficiency of interrelated aspects of practiceclinical, procedural, and system‐based competencies. For practicing hospitalists, the Core Competencies document may serve as a resource to refine skills and assist in program development at individual institutions, both regionally and nationally. For residency program directors and clerkship directors, the Core Competencies document can function as a guide for developing the curriculum of inpatient medicine rotations or for meeting the requirements of the Outcomes Project of the Accreditation Council on Graduate Medical Education's. Last, for those developing continuing medical education programs, the Core Competencies document or individual chapters or topics within it may serve as an outline around which specific or broad‐based programs can be developed. Although the development of such curricula and the recipients of them should be evaluated, the actual evaluation is left to the curriculum developers.

Hospitalists are invested in making hospitals run better. They are positioned to take leadership roles in addressing quality, efficiency, and cost interests in both community and academic hospital settings. Their goals include improving care processes, hospital work life, and the setting in which they practice. The key core competencies described in this compendium define hospitalists as agents of change 1) to develop and implement systems to enable best practices to occur from admission through discharge, and 2) to promote the development of a safer culture within the hospital.

Hospital medicine remains an evolving specialty. Although great care was taken to construct these competencies so they would retain their relevance over time, SHM, the Core Curriculum Task Force, and the editorial board recognize the need for their continual reevaluation and modification in the context of advances and changes in the practice of hospital medicine. Our intent is that these competencies be a common reference and foundation for the creation of hospital medicine curricula and serve to standardize and improve training practices.

Identification of the core competencies of a medical specialty provides the necessary framework for that specialty to develop, refine itself, and evolve. It also provides a structure from which training, testing, and curricula can be developed and effectively utilized. For nearly a decade, since the coining of the term hospitalist,1 the field of hospital medicine has been emerging as the next generation of site‐defined specialties, after emergency medicine and critical care medicine. The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (referred to as the Core Competencies from this point on) introduces the expectations of hospitalists, helps to define their role, and suggests how knowledge, skill, and attitude acquisition might be evaluated. Furthermore, this document provides an initial structural framework from which curricula in adult hospital medicine may be developed.

The Core Competencies document, produced by the Society of Hospital Medicine (SHM) and published as a supplement to the first issue of the Journal of Hospital Medicine,2 is meant to serve as a framework for educators at all levels of medical education to develop curricula, training, and evaluations for students, clinicians‐in‐training, and practicing hospitalists. The Core Competencies document is not meant to contain a complete compilation of inpatient clinical topics or to re‐create what many residency training programs in adult inpatient care already provide. It should not limit and does not define every aspect of hospitalist practice. It includes the most common and fundamental elements of inpatient care without exhaustively listing every clinical entity that may be encountered by a hospitalist. Some of the more common clinical topics encountered by inpatient physicians are included, with an emphasis on subject areas that stress a systems‐based approach to health care, which is central to the practice of hospital medicine. This initial version of the Core Competencies document also focuses on potential areas of deficiency in the training of physicians to become hospitalists. It provides developers of curricula and content with a standardized set of measurable learning objectives, while allowing them the flexibility needed to address specific contexts and incorporate advances in medicine.

The SHM, the sole professional organization representing inpatient physicians, defines hospitalists as physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine.3 An estimated 12,000 hospitalists are currently practicing in the United States, with a projected workforce need of an estimated 20,00030,000 practicing hospitalists in the United States in the next 510 years.4 Various factors have contributed to the rapid growth and expansion of hospital medicine, including factors related to care efficiency, care quality, and inpatient teaching.512 The pressures that have contributed to the development of and evolution toward the hospitalist model of care over the past decade are facilitating the transformation from a traditional model of inpatient care to the care of inpatients by hospitalist physicians dedicated primarily to the inpatient setting. As a result of this growth in hospital medicine, the SHM realized that core competencies were needed to help define the field.

The purpose of this article is to describe the developmental process and content structure of the Core Competencies document. It delineates the process from initial needs assessment to topic list development to chapter production to internal and external review and revisions of individual chapters and the complete document. The supplement to this first issue of the Journal of Hospital Medicine contains 1) the Core Competencies,2 2) a reprint of this article, and 3) a reprint of the article by McKean et al. in this issue detailing how to use the Core Competencies,13 with examples and suggestions related to curriculum development. The authors propose that this combined compilation may spur curriculum development in hospital medicine that will help to define the field and set expectations for practice.

PROCESS AND TIMELINE

Education Summit

Early in the growth of hospital medicine, the Society of Hospital Medicine identified a need to better define a common educational and practice framework for hospitalist physicians. Such a framework could help to define hospitalists as a distinct group of practicing physicians with common goals and a common set of competencies. The importance of identifying and delineating the common knowledge, skills, and attitudes of hospitalists was paramount. Figure 1 shows the details of the 4‐year process of developing the Core Competencies.

Figure 1

In 2002, the SHM drew together educational leaders in hospital medicine in its first educational summit. One of the primary charges that the SHM received from this summit was to develop the needed core curriculum in hospital medicine. After the summit, the SHM's Education Committee formed the Core Curriculum Task Force (CCTF), composed of approximately 15 member hospitalists, with representation from university and community hospitals, teaching and nonteaching programs, and for‐profit and not‐for‐profit settings from various geographic regions of the country. The selection process ensured that the task force was representative of practicing hospitalists and SHM membership throughout the United States.

CHAPTER CONTENT DESCRIPTION

As previously delineated, the Core Competencies document has three sections: Clinical Conditions, Procedures, and Healthcare Systems. The chapters in the entire compendium and within each section have been designed to stand alone and to be used either individually or collectively to assist with curriculum development in hospital medicine. However, each chapter should be used in the context of the entire document because a particular issue may only be touched on in one chapter but may be more elaborately detailed in another. For example, all clinical conditions chapters include a competency on the issue of care transitions, but the specific competencies for care transitions are presented in a separate Transitions of Care chapter.

All chapters in each section begin with an introduction that provides brief background information and establishes the relevance of the topic to practicing hospitalists. Each chapter then utilizes the educational theory of learning domains. The learning domains include the cognitive domain (knowledge), the psychomotor domain (skills), and the affective domain (attitudes). The companion article How to Use The Core Competencies in Hospital Medicine: A Framework for Curriculum Development13 describes in detail the educational theory guiding the development of the Core Competencies document and suggested methods for applying it to the development and revision of curricula and other training activities.

The task force further decided that each chapter in the Clinical Conditions and Procedures sections should include a subsection dedicated to system organization and improvement, an added domain that requires integration of knowledge, skills, and attitudes and the involvement of other medical services and disciplines for optimal patient care. The editorial board believed that system organization and improvement was already an intrinsic feature embedded in the chapters of the Healthcare Systems section. Therefore, this subsection was not included in those chapters.

Hospitalists subscribe to a systems organizational approach to clinical management and processes of care within the hospital. This systems approach, more than any level of knowledge or skill, is required to effectively and efficiently practice in the hospital setting. Practicing with a systems approach, with the interest of improving processes of care, is embedded throughout the Core Competencies document and is a practice method that all hospitalists may strive to achieve as they develop and improve their inpatient care. The competencies within the Systems Organization and Improvement section may contain a range of competency expectation (eg, lead, coordinate, or participate in) to acknowledge their uniqueness and variation according to practice settings and locally instituted responsibilities.

Each competency within a chapter details a level of proficiency, providing guidance on learning activities and potential evaluation strategies. Several overarching themes are followed in the chapters that help to define hospitalists as physicians who specialize in the care of hospitalized patients. First, hospitalists strive to support and adhere to a multidisciplinary approach for the patients under their care. Such an approach involves active interaction with and integration of other hospital medical staff (eg, nursing, rehabilitation therapies, social services) and of specialty medical or surgical services when indicated. Recognizing that hospitalists vary in experience and mastery of their field, the task force and editorial board believed that, at minimum, hospitalists would participate in multidisciplinary teams for improvement of the care and process related to the clinical conditions within their organization. However, they might also lead and/or coordinate teams in such efforts. Therefore, most chapters contain competencies that expect hospitalists to lead, coordinate, or participate in multidisciplinary teams or initiatives that will facilitate optimal care within their organization.

Second, because hospital medicine centers around the quality of inpatient care, participation in quality improvement (QI) initiatives, focusing on improving processes or systems of care in a local institution or organization, may be common in hospitalist practices. The level of involvement and role in QI initiatives may vary according to the particular system, the resources available, and a hospitalist's experience. Finally, because hospitalist care intrinsically involves an increase in the number of care transitions and handoffs, hospitalists need to remain sensitive to and focused on the care transitions that occur with their patients. Such transitions may occur as patients enter the hospital, move from one location to another within the hospital, or leave the hospital. This vulnerable time for patients requires hospitalists to be vigilant in their communication effortswith patients, with medical staff, and with outpatient clinicians.

Each competency was crafted to indicate the relevant concept, the level of proficiency expected, and a way to evaluate mastery. The teaching processes and learning experiences that must take place to achieve competency are left for curriculum developers and instructors to design. These core competencies represent an initial step in curriculum development, creating an identity and core set of expectations for hospitalists that we believe will lead to progress and maturity within the field.

SUMMARY AND FUTURE DIRECTIONS

The practice of hospital medicine requires proficiency of interrelated aspects of practiceclinical, procedural, and system‐based competencies. For practicing hospitalists, the Core Competencies document may serve as a resource to refine skills and assist in program development at individual institutions, both regionally and nationally. For residency program directors and clerkship directors, the Core Competencies document can function as a guide for developing the curriculum of inpatient medicine rotations or for meeting the requirements of the Outcomes Project of the Accreditation Council on Graduate Medical Education's. Last, for those developing continuing medical education programs, the Core Competencies document or individual chapters or topics within it may serve as an outline around which specific or broad‐based programs can be developed. Although the development of such curricula and the recipients of them should be evaluated, the actual evaluation is left to the curriculum developers.

Hospitalists are invested in making hospitals run better. They are positioned to take leadership roles in addressing quality, efficiency, and cost interests in both community and academic hospital settings. Their goals include improving care processes, hospital work life, and the setting in which they practice. The key core competencies described in this compendium define hospitalists as agents of change 1) to develop and implement systems to enable best practices to occur from admission through discharge, and 2) to promote the development of a safer culture within the hospital.

Hospital medicine remains an evolving specialty. Although great care was taken to construct these competencies so they would retain their relevance over time, SHM, the Core Curriculum Task Force, and the editorial board recognize the need for their continual reevaluation and modification in the context of advances and changes in the practice of hospital medicine. Our intent is that these competencies be a common reference and foundation for the creation of hospital medicine curricula and serve to standardize and improve training practices.