Gastrointestinal bleeding occurring in hospitalized patients admitted for nongastrointestinal disorders has been extensively studied in intensive care unit patients. However, a systematic study in noncritically ill medical patients has not yet been done. In critically ill patients the incidence of hospital‐acquired gastrointestinal bleeding (GIB) varies from 0.17% to 5%, depending on its definition.16 These bleeding events significantly increase the morbidity and duration of hospitalization.1, 5, 79

Risk factors for bleeding in the intensive care unit include mechanical ventilation, coagulopathy, burns, chronic renal failure, and neurological insults.15 Several studies have found that stress ulcer prophylaxis with histamine‐2 (H2) receptor antagonists, sucralfate, or proton pump inhibitors (PPIs) decreases bleeding in this group of patients, with a relative risk reduction of 29%61%.10, 11 However, use of these drugs outside this high‐risk group has been questioned because of the low overall risk of bleeding.1, 11, 12 Despite their being an unproven benefit in the noncritically ill population, prophylactic H2 antagonists or PPIs are prescribed in an indiscriminant fashion to up to 30%50% of patients admitted to the hospital,13, 14 suggesting that physician preference dictates this practice. To shed light on this issue in noncritically ill patients, we conducted a retrospective casecontrol study in order to identify risk factors that predict hospital‐acquired gastrointestinal bleeding in this group of patients and to assess whether treatment with prophylactic acid suppression was associated with fewer bleeding events. We also sought to characterize the endoscopic lesions in these patients.

MATERIALS AND METHODS

Study Patients

The institutional review board of the Cleveland Clinic Foundation (Cleveland, OH) approved this study. All patients admitted to the General Internal Medicine service between January 1, 1999, and December 31, 2002, were eligible for inclusion. Two types of cases were included: 1) patients admitted for nongastrointestinal illnesses who developed bleeding at least 24 hours after admission and required esophagogastroduodenoscopy (EGD) during hospitalization (designated in‐hospital bleeding), and 2) patients admitted with gastrointestinal bleeding (requiring EGD) who had been hospitalized on the General Medical service during the preceding 4 weeks for a nongastrointestinal illness (designated out‐of‐hospital bleeding). This second group was included to identify risk factors for delayed bleeding that might not be obvious during hospitalization.

Medical records of all General Medicine patients who underwent EGD were reviewed in a standardized fashion (Fig. 1). We excluded patients with documented gastrointestinal complaints (including bleeding) at the time of the index admission or within 24 hours of admission, bleeding in the intensive care unit (ICU) or in another hospital prior to transfer to the General Medicine service, or a history of gastrointestinal bleeding during the month prior to admission. ICU stay prior to General Medicine admission, if not associated with GI bleeding, was not an exclusion criterion for our study.

Figure 1

Controls, also without any acute gastrointestinal symptoms at admission, were randomly matched to cases in a 1:1 ratio by date of admission. We used this liberal matching strategy because any factors matched for would no longer be eligible to be risk factors for bleeding. If more than one control was admitted on the same day as a case, then a random number was used to select the control.

DISCUSSION

Our data suggest that the incidence of hospital‐acquired gastrointestinal bleeding in noncritically ill medical patients is low (approximately 0.4%) and that treatment with anticoagulants or clopidogrel predisposes to this complication. Anticoagulation is a well‐known risk factor for gastrointestinal bleeding, with an estimated odds ratio of 2416; our study confirmed this risk.

Although some studies have questioned the utility of prophylactic acid blockade in the intensive care unit,15 the weight of current evidence supports prophylaxis in selected critically ill patients. In a randomized double‐blind study of 1200 mechanically ventilated patients, the relative risk of gastrointestinal bleeding in patients treated with ranitidine was 0.44 (95% CI 0.210.92 P = .02).11 Many experts discourage indiscriminant use of prophylaxes, even by patients in intensive care units, recommending that it be used only in patients with established risk factors for bleeding.1, 12

Despite the absence of evidence of any benefit of the use of prophylactic acid blockade outside the intensive care unit, this practice is common. In our study, 27.5% of patients who were not on outpatient acid suppression medications (PPIs or H2 antagonists) were started on them on admission to the hospital, presumably as prophylaxes, as we excluded patients admitted for acute gastrointestinal complaints. Other studies have reported prophylaxis rates of 30%50%.13, 14 Many patients started on this prophylaxis during hospitalization go on to take these drugs following discharge, creating an unnecessary economic burden.13, 14 In our study, GI prophylaxis did not appear to prevent hospital‐acquired gastrointestinal bleeding. However, the odds ratio associating the use of prophylactic acid suppression with gastrointestinal bleeding (1.0) was associated with a wide 95% confidence interval (0.42.4), so we cannot exclude the possibility that these medications might provide a relative risk reduction that we were unable to detect. Finally, although gastrointestinal bleeding in the intensive care unit is associated with significant morbidity and mortality,8, 9 we found no evidence to suggest that gastrointestinal bleeding in our patients was associated with poor outcomes.

In interpreting the data from this study, it is important to note that the definition of hospital‐acquired gastrointestinal bleeding in the literature has been inconsistent. Some studies have required that bleeding be hemodynamically significant1, 2, 5, 11a stringent criterion that may be present in only 10%15% of patients with bleeding16whereas other studies defined gastrointestinal bleeding on the basis of occult‐blood‐positive nasogastric aspirates or positive endoscopic findings.7, 15 Because the definition used in the present study required a hard clinical event (EGD), it excluded bleeding events that were considered clinically insignificant by treating physicians. We justified this definition on our belief that any bleeding that warrants invasive evaluation is clinically relevant because it is expensive and puts the patient at some physical risk. Even though some of our patients were diagnosed with GIB without obvious melena or hematemesis (ie, based on stool positivity for occult blood), many of these patients had significant drops in hemoglobin during hospitalization, which, accompanied by occult blood positivity, justified inpatient EGD. We do not believe our definition of GI bleeding was too restrictive, at least for our institution, as physicians at the Cleveland Clinic generally pursue inpatient EGD with clinically apparent gastrointestinal bleeding; we maintain that bleeding that is minor enough not to change management is of limited clinical relevance. Nevertheless, the threshold for EGD at a given institution could affect the rate of EGD for soft indications and the overall prevalence of nosocomial GI bleeding based on our definition.

It also is worth noting that our definition of nosocomial bleeding encompassed some patients with recent hospitalization on the medical service who bled following discharge (15% of cases in this study). This inclusion criterion was chosen because of our concern that the stress of hospitalization might lead to complications even after discharge. We chose an arbitrary postdischarge cutoff of 4 weeks. When we excluded these patients from analysis, the results were similar (data not shown). Although it is possible that we missed some patient who presented to other institutions with GI bleeding following discharge from the Cleveland Clinic, we suspect that the number of such patients was very small based on current referral patterns.

We do not have complete information to determine exactly why patients were on acid‐suppressive therapy prior to admission, but the available data suggest that many had gastroesophageal reflux disease (GERD), PUD, or prior GI bleeding. For this reason, we focused the investigation of the potential efficacy of prophylactic initiation of acid blockade among patients who at presentation were not taking these medications, as prior GERD (or undocumented GIB) leading to chronic use of acid blockade may predispose to subsequent GIB. Although we analyzed only those patients who had newly started taking acid‐suppressive medications, we acknowledge that a few of them may have been started on these medications for other reasons, like chest pain or GERD. However, the evidence suggests that an overwhelming number are started on these medications for the sole purpose of GI prophylaxis.13, 14

Our study was limited by its retrospective casecontrol design. However, because of the low prevalence of hospital‐acquired gastrointestinal bleeding outside the critical care unit, a prospective study would have to enroll thousands of patients in order to generate statistically meaningful results.

In summary, hospital‐acquired gastrointestinal bleeding outside the intensive care unit is uncommon, with an incidence of about 0.4% according to our definition of bleeding. We found no evidence that these bleeding episodes are associated with increased mortality or with occult malignancy. Furthermore, we found no evidence that prophylactic gastric acid suppression prevents these events, and only 41 patients (0.2% of the total cohort) had lesions that might be preventable with gastric acid blockade. We discourage the indiscriminant use of prophylactic acid suppressants in general medical patients.

Gastrointestinal bleeding occurring in hospitalized patients admitted for nongastrointestinal disorders has been extensively studied in intensive care unit patients. However, a systematic study in noncritically ill medical patients has not yet been done. In critically ill patients the incidence of hospital‐acquired gastrointestinal bleeding (GIB) varies from 0.17% to 5%, depending on its definition.16 These bleeding events significantly increase the morbidity and duration of hospitalization.1, 5, 79

Risk factors for bleeding in the intensive care unit include mechanical ventilation, coagulopathy, burns, chronic renal failure, and neurological insults.15 Several studies have found that stress ulcer prophylaxis with histamine‐2 (H2) receptor antagonists, sucralfate, or proton pump inhibitors (PPIs) decreases bleeding in this group of patients, with a relative risk reduction of 29%61%.10, 11 However, use of these drugs outside this high‐risk group has been questioned because of the low overall risk of bleeding.1, 11, 12 Despite their being an unproven benefit in the noncritically ill population, prophylactic H2 antagonists or PPIs are prescribed in an indiscriminant fashion to up to 30%50% of patients admitted to the hospital,13, 14 suggesting that physician preference dictates this practice. To shed light on this issue in noncritically ill patients, we conducted a retrospective casecontrol study in order to identify risk factors that predict hospital‐acquired gastrointestinal bleeding in this group of patients and to assess whether treatment with prophylactic acid suppression was associated with fewer bleeding events. We also sought to characterize the endoscopic lesions in these patients.

MATERIALS AND METHODS

Study Patients

The institutional review board of the Cleveland Clinic Foundation (Cleveland, OH) approved this study. All patients admitted to the General Internal Medicine service between January 1, 1999, and December 31, 2002, were eligible for inclusion. Two types of cases were included: 1) patients admitted for nongastrointestinal illnesses who developed bleeding at least 24 hours after admission and required esophagogastroduodenoscopy (EGD) during hospitalization (designated in‐hospital bleeding), and 2) patients admitted with gastrointestinal bleeding (requiring EGD) who had been hospitalized on the General Medical service during the preceding 4 weeks for a nongastrointestinal illness (designated out‐of‐hospital bleeding). This second group was included to identify risk factors for delayed bleeding that might not be obvious during hospitalization.

Medical records of all General Medicine patients who underwent EGD were reviewed in a standardized fashion (Fig. 1). We excluded patients with documented gastrointestinal complaints (including bleeding) at the time of the index admission or within 24 hours of admission, bleeding in the intensive care unit (ICU) or in another hospital prior to transfer to the General Medicine service, or a history of gastrointestinal bleeding during the month prior to admission. ICU stay prior to General Medicine admission, if not associated with GI bleeding, was not an exclusion criterion for our study.

Figure 1

Controls, also without any acute gastrointestinal symptoms at admission, were randomly matched to cases in a 1:1 ratio by date of admission. We used this liberal matching strategy because any factors matched for would no longer be eligible to be risk factors for bleeding. If more than one control was admitted on the same day as a case, then a random number was used to select the control.

DISCUSSION

Our data suggest that the incidence of hospital‐acquired gastrointestinal bleeding in noncritically ill medical patients is low (approximately 0.4%) and that treatment with anticoagulants or clopidogrel predisposes to this complication. Anticoagulation is a well‐known risk factor for gastrointestinal bleeding, with an estimated odds ratio of 2416; our study confirmed this risk.

Although some studies have questioned the utility of prophylactic acid blockade in the intensive care unit,15 the weight of current evidence supports prophylaxis in selected critically ill patients. In a randomized double‐blind study of 1200 mechanically ventilated patients, the relative risk of gastrointestinal bleeding in patients treated with ranitidine was 0.44 (95% CI 0.210.92 P = .02).11 Many experts discourage indiscriminant use of prophylaxes, even by patients in intensive care units, recommending that it be used only in patients with established risk factors for bleeding.1, 12

Despite the absence of evidence of any benefit of the use of prophylactic acid blockade outside the intensive care unit, this practice is common. In our study, 27.5% of patients who were not on outpatient acid suppression medications (PPIs or H2 antagonists) were started on them on admission to the hospital, presumably as prophylaxes, as we excluded patients admitted for acute gastrointestinal complaints. Other studies have reported prophylaxis rates of 30%50%.13, 14 Many patients started on this prophylaxis during hospitalization go on to take these drugs following discharge, creating an unnecessary economic burden.13, 14 In our study, GI prophylaxis did not appear to prevent hospital‐acquired gastrointestinal bleeding. However, the odds ratio associating the use of prophylactic acid suppression with gastrointestinal bleeding (1.0) was associated with a wide 95% confidence interval (0.42.4), so we cannot exclude the possibility that these medications might provide a relative risk reduction that we were unable to detect. Finally, although gastrointestinal bleeding in the intensive care unit is associated with significant morbidity and mortality,8, 9 we found no evidence to suggest that gastrointestinal bleeding in our patients was associated with poor outcomes.

In interpreting the data from this study, it is important to note that the definition of hospital‐acquired gastrointestinal bleeding in the literature has been inconsistent. Some studies have required that bleeding be hemodynamically significant1, 2, 5, 11a stringent criterion that may be present in only 10%15% of patients with bleeding16whereas other studies defined gastrointestinal bleeding on the basis of occult‐blood‐positive nasogastric aspirates or positive endoscopic findings.7, 15 Because the definition used in the present study required a hard clinical event (EGD), it excluded bleeding events that were considered clinically insignificant by treating physicians. We justified this definition on our belief that any bleeding that warrants invasive evaluation is clinically relevant because it is expensive and puts the patient at some physical risk. Even though some of our patients were diagnosed with GIB without obvious melena or hematemesis (ie, based on stool positivity for occult blood), many of these patients had significant drops in hemoglobin during hospitalization, which, accompanied by occult blood positivity, justified inpatient EGD. We do not believe our definition of GI bleeding was too restrictive, at least for our institution, as physicians at the Cleveland Clinic generally pursue inpatient EGD with clinically apparent gastrointestinal bleeding; we maintain that bleeding that is minor enough not to change management is of limited clinical relevance. Nevertheless, the threshold for EGD at a given institution could affect the rate of EGD for soft indications and the overall prevalence of nosocomial GI bleeding based on our definition.

It also is worth noting that our definition of nosocomial bleeding encompassed some patients with recent hospitalization on the medical service who bled following discharge (15% of cases in this study). This inclusion criterion was chosen because of our concern that the stress of hospitalization might lead to complications even after discharge. We chose an arbitrary postdischarge cutoff of 4 weeks. When we excluded these patients from analysis, the results were similar (data not shown). Although it is possible that we missed some patient who presented to other institutions with GI bleeding following discharge from the Cleveland Clinic, we suspect that the number of such patients was very small based on current referral patterns.

We do not have complete information to determine exactly why patients were on acid‐suppressive therapy prior to admission, but the available data suggest that many had gastroesophageal reflux disease (GERD), PUD, or prior GI bleeding. For this reason, we focused the investigation of the potential efficacy of prophylactic initiation of acid blockade among patients who at presentation were not taking these medications, as prior GERD (or undocumented GIB) leading to chronic use of acid blockade may predispose to subsequent GIB. Although we analyzed only those patients who had newly started taking acid‐suppressive medications, we acknowledge that a few of them may have been started on these medications for other reasons, like chest pain or GERD. However, the evidence suggests that an overwhelming number are started on these medications for the sole purpose of GI prophylaxis.13, 14

Our study was limited by its retrospective casecontrol design. However, because of the low prevalence of hospital‐acquired gastrointestinal bleeding outside the critical care unit, a prospective study would have to enroll thousands of patients in order to generate statistically meaningful results.

In summary, hospital‐acquired gastrointestinal bleeding outside the intensive care unit is uncommon, with an incidence of about 0.4% according to our definition of bleeding. We found no evidence that these bleeding episodes are associated with increased mortality or with occult malignancy. Furthermore, we found no evidence that prophylactic gastric acid suppression prevents these events, and only 41 patients (0.2% of the total cohort) had lesions that might be preventable with gastric acid blockade. We discourage the indiscriminant use of prophylactic acid suppressants in general medical patients.

Gastrointestinal bleeding occurring in hospitalized patients admitted for nongastrointestinal disorders has been extensively studied in intensive care unit patients. However, a systematic study in noncritically ill medical patients has not yet been done. In critically ill patients the incidence of hospital‐acquired gastrointestinal bleeding (GIB) varies from 0.17% to 5%, depending on its definition.16 These bleeding events significantly increase the morbidity and duration of hospitalization.1, 5, 79

Risk factors for bleeding in the intensive care unit include mechanical ventilation, coagulopathy, burns, chronic renal failure, and neurological insults.15 Several studies have found that stress ulcer prophylaxis with histamine‐2 (H2) receptor antagonists, sucralfate, or proton pump inhibitors (PPIs) decreases bleeding in this group of patients, with a relative risk reduction of 29%61%.10, 11 However, use of these drugs outside this high‐risk group has been questioned because of the low overall risk of bleeding.1, 11, 12 Despite their being an unproven benefit in the noncritically ill population, prophylactic H2 antagonists or PPIs are prescribed in an indiscriminant fashion to up to 30%50% of patients admitted to the hospital,13, 14 suggesting that physician preference dictates this practice. To shed light on this issue in noncritically ill patients, we conducted a retrospective casecontrol study in order to identify risk factors that predict hospital‐acquired gastrointestinal bleeding in this group of patients and to assess whether treatment with prophylactic acid suppression was associated with fewer bleeding events. We also sought to characterize the endoscopic lesions in these patients.

MATERIALS AND METHODS

Study Patients

The institutional review board of the Cleveland Clinic Foundation (Cleveland, OH) approved this study. All patients admitted to the General Internal Medicine service between January 1, 1999, and December 31, 2002, were eligible for inclusion. Two types of cases were included: 1) patients admitted for nongastrointestinal illnesses who developed bleeding at least 24 hours after admission and required esophagogastroduodenoscopy (EGD) during hospitalization (designated in‐hospital bleeding), and 2) patients admitted with gastrointestinal bleeding (requiring EGD) who had been hospitalized on the General Medical service during the preceding 4 weeks for a nongastrointestinal illness (designated out‐of‐hospital bleeding). This second group was included to identify risk factors for delayed bleeding that might not be obvious during hospitalization.

Medical records of all General Medicine patients who underwent EGD were reviewed in a standardized fashion (Fig. 1). We excluded patients with documented gastrointestinal complaints (including bleeding) at the time of the index admission or within 24 hours of admission, bleeding in the intensive care unit (ICU) or in another hospital prior to transfer to the General Medicine service, or a history of gastrointestinal bleeding during the month prior to admission. ICU stay prior to General Medicine admission, if not associated with GI bleeding, was not an exclusion criterion for our study.

Figure 1

Controls, also without any acute gastrointestinal symptoms at admission, were randomly matched to cases in a 1:1 ratio by date of admission. We used this liberal matching strategy because any factors matched for would no longer be eligible to be risk factors for bleeding. If more than one control was admitted on the same day as a case, then a random number was used to select the control.

DISCUSSION

Our data suggest that the incidence of hospital‐acquired gastrointestinal bleeding in noncritically ill medical patients is low (approximately 0.4%) and that treatment with anticoagulants or clopidogrel predisposes to this complication. Anticoagulation is a well‐known risk factor for gastrointestinal bleeding, with an estimated odds ratio of 2416; our study confirmed this risk.

Although some studies have questioned the utility of prophylactic acid blockade in the intensive care unit,15 the weight of current evidence supports prophylaxis in selected critically ill patients. In a randomized double‐blind study of 1200 mechanically ventilated patients, the relative risk of gastrointestinal bleeding in patients treated with ranitidine was 0.44 (95% CI 0.210.92 P = .02).11 Many experts discourage indiscriminant use of prophylaxes, even by patients in intensive care units, recommending that it be used only in patients with established risk factors for bleeding.1, 12

Despite the absence of evidence of any benefit of the use of prophylactic acid blockade outside the intensive care unit, this practice is common. In our study, 27.5% of patients who were not on outpatient acid suppression medications (PPIs or H2 antagonists) were started on them on admission to the hospital, presumably as prophylaxes, as we excluded patients admitted for acute gastrointestinal complaints. Other studies have reported prophylaxis rates of 30%50%.13, 14 Many patients started on this prophylaxis during hospitalization go on to take these drugs following discharge, creating an unnecessary economic burden.13, 14 In our study, GI prophylaxis did not appear to prevent hospital‐acquired gastrointestinal bleeding. However, the odds ratio associating the use of prophylactic acid suppression with gastrointestinal bleeding (1.0) was associated with a wide 95% confidence interval (0.42.4), so we cannot exclude the possibility that these medications might provide a relative risk reduction that we were unable to detect. Finally, although gastrointestinal bleeding in the intensive care unit is associated with significant morbidity and mortality,8, 9 we found no evidence to suggest that gastrointestinal bleeding in our patients was associated with poor outcomes.

In interpreting the data from this study, it is important to note that the definition of hospital‐acquired gastrointestinal bleeding in the literature has been inconsistent. Some studies have required that bleeding be hemodynamically significant1, 2, 5, 11a stringent criterion that may be present in only 10%15% of patients with bleeding16whereas other studies defined gastrointestinal bleeding on the basis of occult‐blood‐positive nasogastric aspirates or positive endoscopic findings.7, 15 Because the definition used in the present study required a hard clinical event (EGD), it excluded bleeding events that were considered clinically insignificant by treating physicians. We justified this definition on our belief that any bleeding that warrants invasive evaluation is clinically relevant because it is expensive and puts the patient at some physical risk. Even though some of our patients were diagnosed with GIB without obvious melena or hematemesis (ie, based on stool positivity for occult blood), many of these patients had significant drops in hemoglobin during hospitalization, which, accompanied by occult blood positivity, justified inpatient EGD. We do not believe our definition of GI bleeding was too restrictive, at least for our institution, as physicians at the Cleveland Clinic generally pursue inpatient EGD with clinically apparent gastrointestinal bleeding; we maintain that bleeding that is minor enough not to change management is of limited clinical relevance. Nevertheless, the threshold for EGD at a given institution could affect the rate of EGD for soft indications and the overall prevalence of nosocomial GI bleeding based on our definition.

It also is worth noting that our definition of nosocomial bleeding encompassed some patients with recent hospitalization on the medical service who bled following discharge (15% of cases in this study). This inclusion criterion was chosen because of our concern that the stress of hospitalization might lead to complications even after discharge. We chose an arbitrary postdischarge cutoff of 4 weeks. When we excluded these patients from analysis, the results were similar (data not shown). Although it is possible that we missed some patient who presented to other institutions with GI bleeding following discharge from the Cleveland Clinic, we suspect that the number of such patients was very small based on current referral patterns.

We do not have complete information to determine exactly why patients were on acid‐suppressive therapy prior to admission, but the available data suggest that many had gastroesophageal reflux disease (GERD), PUD, or prior GI bleeding. For this reason, we focused the investigation of the potential efficacy of prophylactic initiation of acid blockade among patients who at presentation were not taking these medications, as prior GERD (or undocumented GIB) leading to chronic use of acid blockade may predispose to subsequent GIB. Although we analyzed only those patients who had newly started taking acid‐suppressive medications, we acknowledge that a few of them may have been started on these medications for other reasons, like chest pain or GERD. However, the evidence suggests that an overwhelming number are started on these medications for the sole purpose of GI prophylaxis.13, 14

Our study was limited by its retrospective casecontrol design. However, because of the low prevalence of hospital‐acquired gastrointestinal bleeding outside the critical care unit, a prospective study would have to enroll thousands of patients in order to generate statistically meaningful results.

In summary, hospital‐acquired gastrointestinal bleeding outside the intensive care unit is uncommon, with an incidence of about 0.4% according to our definition of bleeding. We found no evidence that these bleeding episodes are associated with increased mortality or with occult malignancy. Furthermore, we found no evidence that prophylactic gastric acid suppression prevents these events, and only 41 patients (0.2% of the total cohort) had lesions that might be preventable with gastric acid blockade. We discourage the indiscriminant use of prophylactic acid suppressants in general medical patients.

It is right and fitting that an article focused on palliative care appears in the inaugural issue of the Journal of Hospital Medicine (JHM).1 Both hospital medicine and palliative care are rapidly growing fields expanding in response to quality and economic imperatives. Both fields recognize the need to develop systems to care for seriously ill patients and to work within interdisciplinary teams. In fact, a natural and mutually beneficial relationship should exist between these two fields. For palliative care, hospital medicine and hospitalists offer the physicians and systems approach to care that could guarantee access to high‐quality palliative care for all hospitalized patients. In addition, hospitalists offer the promise of increasing the number of hospital‐based palliative care programs as the presence of a hospitalist program is strongly associated with having or starting such a program.2, 3 For hospital medicine and hospitalists, palliative care offers a compassionate and high‐quality response to the challenge of caring for seriously and terminally ill patients and their families. By each embracing the other, both fields could find willing and eager partners in the quest to provide the highest possible quality of care for hospitalized patients.

In this first issue of JHM, Dr. Meier offers hospitalists an intriguing and attractive picture of palliative care. She describes how the growth of palliative care is driven by the needs of an ever‐larger group of patients living with chronic and life‐threatening illness and evidence of high quality and satisfaction for these patients who have many physical, emotional, psychological, and spiritual concerns. Dr. Meier also demonstrates how hospital‐based palliative care can coordinate with hospices to provide the continuity of care for terminally ill patients that is often elusive at hospital discharge. Finally, Dr. Meier provides a practical list of resources for clinicians seeking further training in the field. No doubt hospitalists will appreciate this list as the core competencies in hospital medicine, published as a supplement to this issue of JHM, include palliative care, pain management, communication, and discharge planning.

As Dr. Meier states in her article Palliative Care in Hospitals, many types of clinicians can provide palliative care in hospitals, including general internists, nurses, geriatricians, oncologists, hospitalists, and others, yet hospitalists are likely to emerge as the predominant providers of palliative care to hospitalized patients.4 That 75% of Americans die in institutionalized settings, where hospitalists are becoming the dominant providers of care, will drive this prediction.5 In addition, hospitalists are increasingly leading efforts in quality improvement, patient satisfaction, and patient safety.6 Of necessity these initiatives will involve the sickest hospitalized patients and will look to palliative care as a proven response for improving quality and increasing satisfaction.

Hospital medicine and palliative care have other aspects in common that make a melding of the two fields beneficial. Both fields recognize and emphasize the need for interdisciplinary care; good communication between members of the health care team and between health care providers and patients; and timely, effective, and responsible discharge planning. Finally, both fields often rely on multiple sources of funding including professional fee billing and support from the hospital for the added value that programs provide. Sharing so many issues in common should help hospital medicine and palliative care form strong links.

For these links to take hold and for the benefits of this partnership to bear fruit, members of both fields, and especially those with a foot in each, need to reach out. For hospitalists this means getting educated in palliative care, an area for which hospitalists recognize they are underprepared.7 Each hospitalist must be able to provide primary, basic palliative care to each patient.8 Some hospitalists will discover the rewards of palliative care and seek further training and even board certification. These hospitalists can start or join palliative care teams in their institutions. Finally, some hospitalists will become experts in palliative care and join or lead palliative care programs at tertiary care centers. In turn, palliative care providers must reach out to hospitalists. Palliative care clinicians should seek out hospitalists at their institutions and hospices should contact hospitalists at their local hospitals. These programs need to invite hospitalists to participate in the palliative care team and suggest how their services can help the patients of hospitalists. This natural alliance can come about only if both sides reach out.

A partnership between palliative care and hospital medicine will be good for patients and their families as well as for each field, as hospitalists enable realization of the goal of providing palliative care to every patient in the United States. In addition, this partnership will be good for hospitalists who embrace this work. Palliative care can connect us to the humanism and compassion that brought so many of us to medicine and can serve as an antidote to burnout. Furthermore, by caring for patients with life‐threatening illnesses we remember that our time is limited and that each day is a gift. We recognize the importance of making the most of our time regardless of how long we have and of choosing carefully how and with whom we spend our time.

In this first issue of JHM, Dr. Meier makes a strong argument for the need and continued growth of palliative care in hospitals, lays out a strategy for achieving this growth through education and program development, and in doing so, opens the door to hope for the future. Through palliative care we can offer patients hope for healing when cure is not possible, for comfort in the face of suffering, and for what can still be despite all that cannot. The possibility that hospitalists could provide all patients access to palliative care is cause enough for hope. The knowledge that hospitalists will play a major role in making this possibility a reality and may become the predominant providers of palliative care can make that hope a reality.

It is right and fitting that an article focused on palliative care appears in the inaugural issue of the Journal of Hospital Medicine (JHM).1 Both hospital medicine and palliative care are rapidly growing fields expanding in response to quality and economic imperatives. Both fields recognize the need to develop systems to care for seriously ill patients and to work within interdisciplinary teams. In fact, a natural and mutually beneficial relationship should exist between these two fields. For palliative care, hospital medicine and hospitalists offer the physicians and systems approach to care that could guarantee access to high‐quality palliative care for all hospitalized patients. In addition, hospitalists offer the promise of increasing the number of hospital‐based palliative care programs as the presence of a hospitalist program is strongly associated with having or starting such a program.2, 3 For hospital medicine and hospitalists, palliative care offers a compassionate and high‐quality response to the challenge of caring for seriously and terminally ill patients and their families. By each embracing the other, both fields could find willing and eager partners in the quest to provide the highest possible quality of care for hospitalized patients.

In this first issue of JHM, Dr. Meier offers hospitalists an intriguing and attractive picture of palliative care. She describes how the growth of palliative care is driven by the needs of an ever‐larger group of patients living with chronic and life‐threatening illness and evidence of high quality and satisfaction for these patients who have many physical, emotional, psychological, and spiritual concerns. Dr. Meier also demonstrates how hospital‐based palliative care can coordinate with hospices to provide the continuity of care for terminally ill patients that is often elusive at hospital discharge. Finally, Dr. Meier provides a practical list of resources for clinicians seeking further training in the field. No doubt hospitalists will appreciate this list as the core competencies in hospital medicine, published as a supplement to this issue of JHM, include palliative care, pain management, communication, and discharge planning.

As Dr. Meier states in her article Palliative Care in Hospitals, many types of clinicians can provide palliative care in hospitals, including general internists, nurses, geriatricians, oncologists, hospitalists, and others, yet hospitalists are likely to emerge as the predominant providers of palliative care to hospitalized patients.4 That 75% of Americans die in institutionalized settings, where hospitalists are becoming the dominant providers of care, will drive this prediction.5 In addition, hospitalists are increasingly leading efforts in quality improvement, patient satisfaction, and patient safety.6 Of necessity these initiatives will involve the sickest hospitalized patients and will look to palliative care as a proven response for improving quality and increasing satisfaction.

Hospital medicine and palliative care have other aspects in common that make a melding of the two fields beneficial. Both fields recognize and emphasize the need for interdisciplinary care; good communication between members of the health care team and between health care providers and patients; and timely, effective, and responsible discharge planning. Finally, both fields often rely on multiple sources of funding including professional fee billing and support from the hospital for the added value that programs provide. Sharing so many issues in common should help hospital medicine and palliative care form strong links.

For these links to take hold and for the benefits of this partnership to bear fruit, members of both fields, and especially those with a foot in each, need to reach out. For hospitalists this means getting educated in palliative care, an area for which hospitalists recognize they are underprepared.7 Each hospitalist must be able to provide primary, basic palliative care to each patient.8 Some hospitalists will discover the rewards of palliative care and seek further training and even board certification. These hospitalists can start or join palliative care teams in their institutions. Finally, some hospitalists will become experts in palliative care and join or lead palliative care programs at tertiary care centers. In turn, palliative care providers must reach out to hospitalists. Palliative care clinicians should seek out hospitalists at their institutions and hospices should contact hospitalists at their local hospitals. These programs need to invite hospitalists to participate in the palliative care team and suggest how their services can help the patients of hospitalists. This natural alliance can come about only if both sides reach out.

A partnership between palliative care and hospital medicine will be good for patients and their families as well as for each field, as hospitalists enable realization of the goal of providing palliative care to every patient in the United States. In addition, this partnership will be good for hospitalists who embrace this work. Palliative care can connect us to the humanism and compassion that brought so many of us to medicine and can serve as an antidote to burnout. Furthermore, by caring for patients with life‐threatening illnesses we remember that our time is limited and that each day is a gift. We recognize the importance of making the most of our time regardless of how long we have and of choosing carefully how and with whom we spend our time.

In this first issue of JHM, Dr. Meier makes a strong argument for the need and continued growth of palliative care in hospitals, lays out a strategy for achieving this growth through education and program development, and in doing so, opens the door to hope for the future. Through palliative care we can offer patients hope for healing when cure is not possible, for comfort in the face of suffering, and for what can still be despite all that cannot. The possibility that hospitalists could provide all patients access to palliative care is cause enough for hope. The knowledge that hospitalists will play a major role in making this possibility a reality and may become the predominant providers of palliative care can make that hope a reality.

It is right and fitting that an article focused on palliative care appears in the inaugural issue of the Journal of Hospital Medicine (JHM).1 Both hospital medicine and palliative care are rapidly growing fields expanding in response to quality and economic imperatives. Both fields recognize the need to develop systems to care for seriously ill patients and to work within interdisciplinary teams. In fact, a natural and mutually beneficial relationship should exist between these two fields. For palliative care, hospital medicine and hospitalists offer the physicians and systems approach to care that could guarantee access to high‐quality palliative care for all hospitalized patients. In addition, hospitalists offer the promise of increasing the number of hospital‐based palliative care programs as the presence of a hospitalist program is strongly associated with having or starting such a program.2, 3 For hospital medicine and hospitalists, palliative care offers a compassionate and high‐quality response to the challenge of caring for seriously and terminally ill patients and their families. By each embracing the other, both fields could find willing and eager partners in the quest to provide the highest possible quality of care for hospitalized patients.

In this first issue of JHM, Dr. Meier offers hospitalists an intriguing and attractive picture of palliative care. She describes how the growth of palliative care is driven by the needs of an ever‐larger group of patients living with chronic and life‐threatening illness and evidence of high quality and satisfaction for these patients who have many physical, emotional, psychological, and spiritual concerns. Dr. Meier also demonstrates how hospital‐based palliative care can coordinate with hospices to provide the continuity of care for terminally ill patients that is often elusive at hospital discharge. Finally, Dr. Meier provides a practical list of resources for clinicians seeking further training in the field. No doubt hospitalists will appreciate this list as the core competencies in hospital medicine, published as a supplement to this issue of JHM, include palliative care, pain management, communication, and discharge planning.

As Dr. Meier states in her article Palliative Care in Hospitals, many types of clinicians can provide palliative care in hospitals, including general internists, nurses, geriatricians, oncologists, hospitalists, and others, yet hospitalists are likely to emerge as the predominant providers of palliative care to hospitalized patients.4 That 75% of Americans die in institutionalized settings, where hospitalists are becoming the dominant providers of care, will drive this prediction.5 In addition, hospitalists are increasingly leading efforts in quality improvement, patient satisfaction, and patient safety.6 Of necessity these initiatives will involve the sickest hospitalized patients and will look to palliative care as a proven response for improving quality and increasing satisfaction.

Hospital medicine and palliative care have other aspects in common that make a melding of the two fields beneficial. Both fields recognize and emphasize the need for interdisciplinary care; good communication between members of the health care team and between health care providers and patients; and timely, effective, and responsible discharge planning. Finally, both fields often rely on multiple sources of funding including professional fee billing and support from the hospital for the added value that programs provide. Sharing so many issues in common should help hospital medicine and palliative care form strong links.

For these links to take hold and for the benefits of this partnership to bear fruit, members of both fields, and especially those with a foot in each, need to reach out. For hospitalists this means getting educated in palliative care, an area for which hospitalists recognize they are underprepared.7 Each hospitalist must be able to provide primary, basic palliative care to each patient.8 Some hospitalists will discover the rewards of palliative care and seek further training and even board certification. These hospitalists can start or join palliative care teams in their institutions. Finally, some hospitalists will become experts in palliative care and join or lead palliative care programs at tertiary care centers. In turn, palliative care providers must reach out to hospitalists. Palliative care clinicians should seek out hospitalists at their institutions and hospices should contact hospitalists at their local hospitals. These programs need to invite hospitalists to participate in the palliative care team and suggest how their services can help the patients of hospitalists. This natural alliance can come about only if both sides reach out.

A partnership between palliative care and hospital medicine will be good for patients and their families as well as for each field, as hospitalists enable realization of the goal of providing palliative care to every patient in the United States. In addition, this partnership will be good for hospitalists who embrace this work. Palliative care can connect us to the humanism and compassion that brought so many of us to medicine and can serve as an antidote to burnout. Furthermore, by caring for patients with life‐threatening illnesses we remember that our time is limited and that each day is a gift. We recognize the importance of making the most of our time regardless of how long we have and of choosing carefully how and with whom we spend our time.

In this first issue of JHM, Dr. Meier makes a strong argument for the need and continued growth of palliative care in hospitals, lays out a strategy for achieving this growth through education and program development, and in doing so, opens the door to hope for the future. Through palliative care we can offer patients hope for healing when cure is not possible, for comfort in the face of suffering, and for what can still be despite all that cannot. The possibility that hospitalists could provide all patients access to palliative care is cause enough for hope. The knowledge that hospitalists will play a major role in making this possibility a reality and may become the predominant providers of palliative care can make that hope a reality.

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.

Congratulations to the Society of Hospital Medicine (SHM) for launching this important new journal. Congratulations as well to the SHM members, who have identified an important patient care need and moved to meet that need by defining the special competencies of the hospitalist. The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (the Core Competencies), by the Society of Hospital Medicine, accompanies this inaugural issue of the Journal of Hospital Medicine.

As a geriatrician, I can personally attest to the need to have skilled physicians on‐site in the hospital to care for elderly patients. Older people with complex illnesses are susceptible to multiple hospital complications, which often present subtly but can quickly turn into life‐threateningbut potentially reversibleillnesses. Given the demography of hospitalized patients in the 21st century in the United States, every good hospitalist also has to be a good geriatrician.

As evidenced in the Core Competencies, the hospitalist community recognizes as well the importance of developing expertise in caring for both the medical and surgical conditions of patients. Providing attentive diagnostic and management skills to pre‐ and postoperative patients, especially those with preexisting chronic conditions, will surely improve outcomes.

Continuity and coordination within a single hospital episode and across multiple hospitalizations are major challenges for our fragmented and often chaotic health care system. The Core Competencies recognizes the centrality of systems‐based practice to the foundation of hospitalist skills. We at the American Board of Internal Medicine (ABIM) share the belief that every physician must understand the principles of quality improvement; accordingly, this competency is now demanded of every resident and is assessed in the maintenance of certification (MOC) of every internal medicine specialist. That hospitalists have grabbed the quality‐improvement mantle is a welcome development and shows that hospitalists are likely to become key teachers of systems‐based care and quality‐improvement competencies in teaching hospitals.

The growth of hospital medicine in the United States has raised many important issues concerning quality of care that cannot be totally solved by the creation of a hospital‐based practice discipline. The vexing issues of continuity of care, continuing relationships, and efficient management of resources over the entire trajectory of a patient's illness (not just during a hospitalization) are not fundamentally addressed by the existence of hospital medicine as a discipline. However, hospitalists can partner with others in the health care system to create a clinically meaningful continuum that truly would serve patients, especially those with the greatest need such as the elderly and the chronically ill. The ABIM has been in discussions with the Society of Hospital Medicine, the Society of General Internal Medicine, the American College of Physicians, and the Alliance of Academic Internal Medicine to develop a response to the important and evolving arenas of specific expertise in hospital and outpatient medicine. The Core Competencies in Hospital Medicine will significantly help to further these discussions.

Let me raise two concerns whose resolution will need the input of hospitalists as the discipline of hospital medicine becomes more mature. First, hospitalist models are quite variable. Many academic physicians who call themselves hospitalists attend on an inpatient service 2, 3, or 5 months a year and still see outpatients. Many physicians who consider themselves general internists (and not hospitalists) have a weekly half‐day clinic and attend on the wards 3 months a year. Which is a hospitalist? Does it matter? Will the definition of a hospitalist be based on achievement of the competencies described here, or will it be based primarily on the amount of time in hospital‐based practice? This will be an important question to resolve, especially as we embark on a path toward offering a hospitalist credential.

Second, general internal medicine is becoming an increasingly vital part of the continuum of care for patients with multiple complex chronic illnesses, at the same time that poor reimbursement has undermined its vitality and threatens its existence. (Family medicine is also suffering from reduced interest among medical students.) Because most institutions function on an each tub on its own bottom model, it is unrealistic to expect the practice of ambulatory general internal medicine to support itself. Generalist practices thrive in integrated group models. These practices recognize the importance of the physician who provides a coordinating function for all the specialists who care for a complex patient. Such an outpatient generalist thus reduces excess and unnecessary care while identifying gaps where relevant specialties could improve function or quality of life. Ambulatory practice also requires skill in systems and improvement, but few of the 80% of generalists who practice in small groups have sufficient infrastructure and resources to support practice redesign. Indeed, a new report from Mercer consultants coined the phrase ambulatory intensivists to identify practices with Medicare patients and recognizes that these practices are every bit as intense and complex and in need of systems management as an inpatient practice. What the complex patient needs is a seamless interface between the two.

The authors of the Core Competencies in Hospital Medicine hope that this document will stand the test of time as it evolves. I would urge that the document remain flexiblea living documentbecause the one thing about which we can be sure is that hospital practice will change. More and more critical care will be delivered throughout the hospital, more and more of all kinds of care will be performed outside the hospital, and the nature of hospitals will surely change with shifts in reimbursement that we cannot yet imagine but that might be right around the corner. If able to provide hands‐on care less expensively, physician assistants and nurse‐practitioners functioning according to protocols developed by systems thinkers, only some of whom will be physicians, may replace the physician in some settings. What will become of hospitalists as these systems change? I hope that hospitalists, together with other general internists, will be at the forefront of ensuring that the changes in practice that result from the combination of new technologies and financing structures will ultimately also serve the needs of patients. The patient is at the center of our discipline and, as articulated so clearly in the Core Competencies, should always be the focus of our future thinking.

Congratulations to the Society of Hospital Medicine (SHM) for launching this important new journal. Congratulations as well to the SHM members, who have identified an important patient care need and moved to meet that need by defining the special competencies of the hospitalist. The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (the Core Competencies), by the Society of Hospital Medicine, accompanies this inaugural issue of the Journal of Hospital Medicine.

As a geriatrician, I can personally attest to the need to have skilled physicians on‐site in the hospital to care for elderly patients. Older people with complex illnesses are susceptible to multiple hospital complications, which often present subtly but can quickly turn into life‐threateningbut potentially reversibleillnesses. Given the demography of hospitalized patients in the 21st century in the United States, every good hospitalist also has to be a good geriatrician.

As evidenced in the Core Competencies, the hospitalist community recognizes as well the importance of developing expertise in caring for both the medical and surgical conditions of patients. Providing attentive diagnostic and management skills to pre‐ and postoperative patients, especially those with preexisting chronic conditions, will surely improve outcomes.

Continuity and coordination within a single hospital episode and across multiple hospitalizations are major challenges for our fragmented and often chaotic health care system. The Core Competencies recognizes the centrality of systems‐based practice to the foundation of hospitalist skills. We at the American Board of Internal Medicine (ABIM) share the belief that every physician must understand the principles of quality improvement; accordingly, this competency is now demanded of every resident and is assessed in the maintenance of certification (MOC) of every internal medicine specialist. That hospitalists have grabbed the quality‐improvement mantle is a welcome development and shows that hospitalists are likely to become key teachers of systems‐based care and quality‐improvement competencies in teaching hospitals.

The growth of hospital medicine in the United States has raised many important issues concerning quality of care that cannot be totally solved by the creation of a hospital‐based practice discipline. The vexing issues of continuity of care, continuing relationships, and efficient management of resources over the entire trajectory of a patient's illness (not just during a hospitalization) are not fundamentally addressed by the existence of hospital medicine as a discipline. However, hospitalists can partner with others in the health care system to create a clinically meaningful continuum that truly would serve patients, especially those with the greatest need such as the elderly and the chronically ill. The ABIM has been in discussions with the Society of Hospital Medicine, the Society of General Internal Medicine, the American College of Physicians, and the Alliance of Academic Internal Medicine to develop a response to the important and evolving arenas of specific expertise in hospital and outpatient medicine. The Core Competencies in Hospital Medicine will significantly help to further these discussions.

Let me raise two concerns whose resolution will need the input of hospitalists as the discipline of hospital medicine becomes more mature. First, hospitalist models are quite variable. Many academic physicians who call themselves hospitalists attend on an inpatient service 2, 3, or 5 months a year and still see outpatients. Many physicians who consider themselves general internists (and not hospitalists) have a weekly half‐day clinic and attend on the wards 3 months a year. Which is a hospitalist? Does it matter? Will the definition of a hospitalist be based on achievement of the competencies described here, or will it be based primarily on the amount of time in hospital‐based practice? This will be an important question to resolve, especially as we embark on a path toward offering a hospitalist credential.

Second, general internal medicine is becoming an increasingly vital part of the continuum of care for patients with multiple complex chronic illnesses, at the same time that poor reimbursement has undermined its vitality and threatens its existence. (Family medicine is also suffering from reduced interest among medical students.) Because most institutions function on an each tub on its own bottom model, it is unrealistic to expect the practice of ambulatory general internal medicine to support itself. Generalist practices thrive in integrated group models. These practices recognize the importance of the physician who provides a coordinating function for all the specialists who care for a complex patient. Such an outpatient generalist thus reduces excess and unnecessary care while identifying gaps where relevant specialties could improve function or quality of life. Ambulatory practice also requires skill in systems and improvement, but few of the 80% of generalists who practice in small groups have sufficient infrastructure and resources to support practice redesign. Indeed, a new report from Mercer consultants coined the phrase ambulatory intensivists to identify practices with Medicare patients and recognizes that these practices are every bit as intense and complex and in need of systems management as an inpatient practice. What the complex patient needs is a seamless interface between the two.

The authors of the Core Competencies in Hospital Medicine hope that this document will stand the test of time as it evolves. I would urge that the document remain flexiblea living documentbecause the one thing about which we can be sure is that hospital practice will change. More and more critical care will be delivered throughout the hospital, more and more of all kinds of care will be performed outside the hospital, and the nature of hospitals will surely change with shifts in reimbursement that we cannot yet imagine but that might be right around the corner. If able to provide hands‐on care less expensively, physician assistants and nurse‐practitioners functioning according to protocols developed by systems thinkers, only some of whom will be physicians, may replace the physician in some settings. What will become of hospitalists as these systems change? I hope that hospitalists, together with other general internists, will be at the forefront of ensuring that the changes in practice that result from the combination of new technologies and financing structures will ultimately also serve the needs of patients. The patient is at the center of our discipline and, as articulated so clearly in the Core Competencies, should always be the focus of our future thinking.

Congratulations to the Society of Hospital Medicine (SHM) for launching this important new journal. Congratulations as well to the SHM members, who have identified an important patient care need and moved to meet that need by defining the special competencies of the hospitalist. The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (the Core Competencies), by the Society of Hospital Medicine, accompanies this inaugural issue of the Journal of Hospital Medicine.

As a geriatrician, I can personally attest to the need to have skilled physicians on‐site in the hospital to care for elderly patients. Older people with complex illnesses are susceptible to multiple hospital complications, which often present subtly but can quickly turn into life‐threateningbut potentially reversibleillnesses. Given the demography of hospitalized patients in the 21st century in the United States, every good hospitalist also has to be a good geriatrician.

As evidenced in the Core Competencies, the hospitalist community recognizes as well the importance of developing expertise in caring for both the medical and surgical conditions of patients. Providing attentive diagnostic and management skills to pre‐ and postoperative patients, especially those with preexisting chronic conditions, will surely improve outcomes.

Continuity and coordination within a single hospital episode and across multiple hospitalizations are major challenges for our fragmented and often chaotic health care system. The Core Competencies recognizes the centrality of systems‐based practice to the foundation of hospitalist skills. We at the American Board of Internal Medicine (ABIM) share the belief that every physician must understand the principles of quality improvement; accordingly, this competency is now demanded of every resident and is assessed in the maintenance of certification (MOC) of every internal medicine specialist. That hospitalists have grabbed the quality‐improvement mantle is a welcome development and shows that hospitalists are likely to become key teachers of systems‐based care and quality‐improvement competencies in teaching hospitals.

The growth of hospital medicine in the United States has raised many important issues concerning quality of care that cannot be totally solved by the creation of a hospital‐based practice discipline. The vexing issues of continuity of care, continuing relationships, and efficient management of resources over the entire trajectory of a patient's illness (not just during a hospitalization) are not fundamentally addressed by the existence of hospital medicine as a discipline. However, hospitalists can partner with others in the health care system to create a clinically meaningful continuum that truly would serve patients, especially those with the greatest need such as the elderly and the chronically ill. The ABIM has been in discussions with the Society of Hospital Medicine, the Society of General Internal Medicine, the American College of Physicians, and the Alliance of Academic Internal Medicine to develop a response to the important and evolving arenas of specific expertise in hospital and outpatient medicine. The Core Competencies in Hospital Medicine will significantly help to further these discussions.

Let me raise two concerns whose resolution will need the input of hospitalists as the discipline of hospital medicine becomes more mature. First, hospitalist models are quite variable. Many academic physicians who call themselves hospitalists attend on an inpatient service 2, 3, or 5 months a year and still see outpatients. Many physicians who consider themselves general internists (and not hospitalists) have a weekly half‐day clinic and attend on the wards 3 months a year. Which is a hospitalist? Does it matter? Will the definition of a hospitalist be based on achievement of the competencies described here, or will it be based primarily on the amount of time in hospital‐based practice? This will be an important question to resolve, especially as we embark on a path toward offering a hospitalist credential.

Second, general internal medicine is becoming an increasingly vital part of the continuum of care for patients with multiple complex chronic illnesses, at the same time that poor reimbursement has undermined its vitality and threatens its existence. (Family medicine is also suffering from reduced interest among medical students.) Because most institutions function on an each tub on its own bottom model, it is unrealistic to expect the practice of ambulatory general internal medicine to support itself. Generalist practices thrive in integrated group models. These practices recognize the importance of the physician who provides a coordinating function for all the specialists who care for a complex patient. Such an outpatient generalist thus reduces excess and unnecessary care while identifying gaps where relevant specialties could improve function or quality of life. Ambulatory practice also requires skill in systems and improvement, but few of the 80% of generalists who practice in small groups have sufficient infrastructure and resources to support practice redesign. Indeed, a new report from Mercer consultants coined the phrase ambulatory intensivists to identify practices with Medicare patients and recognizes that these practices are every bit as intense and complex and in need of systems management as an inpatient practice. What the complex patient needs is a seamless interface between the two.

The authors of the Core Competencies in Hospital Medicine hope that this document will stand the test of time as it evolves. I would urge that the document remain flexiblea living documentbecause the one thing about which we can be sure is that hospital practice will change. More and more critical care will be delivered throughout the hospital, more and more of all kinds of care will be performed outside the hospital, and the nature of hospitals will surely change with shifts in reimbursement that we cannot yet imagine but that might be right around the corner. If able to provide hands‐on care less expensively, physician assistants and nurse‐practitioners functioning according to protocols developed by systems thinkers, only some of whom will be physicians, may replace the physician in some settings. What will become of hospitalists as these systems change? I hope that hospitalists, together with other general internists, will be at the forefront of ensuring that the changes in practice that result from the combination of new technologies and financing structures will ultimately also serve the needs of patients. The patient is at the center of our discipline and, as articulated so clearly in the Core Competencies, should always be the focus of our future thinking.