Many hospitalists don't perform individual ‘core competencies' in a given year

Though hospitalists perform more of the nine inpatient procedures designated as “core competencies” by the Society of Hospital Medicine (SHM) than non-hospitalists, only 11% perform all these procedures in a given year, a survey found.

Researchers analyzed data from a national survey mailed to internal medicine members of the American College of Physicians in 2004; 1,059 were eligible respondents. The survey asked whether respondents had performed any of 40 different bedside procedures in the last year, and the individual volume of those they had performed. Of the 40 procedures, researchers evaluated nine that have been designated as core competencies by SHM: electrocardiogram interpretation, chest X-ray interpretation, arthrocentesis, thoracocentesis, abdominal paracentesis, lumbar puncture, central line placement, endotracheal intubation and ventilator management. They defined hospitalists as respondents who spent more than 10 hours per week in clinical activity, and more than 40% of clinical time in hospital-based activity. The study was published online March 2 in the Journal of General Internal Medicine.

Nearly 17% of eligible respondents were classified as hospitalists (n=175). Eleven percent of hospitalists performed all nine SHM core procedures, compared with 3% of non-hospitalists (P<0.001). Hospitalists were significantly more likely than non-hospitalists to have performed each of the individual core procedures except electrocardiogram interpretation, arthrocentesis and chest X-ray interpretation. The hospitalists performed a median of four of the nine SHM core procedures in the previous year (interquartile range [IQR], two to six). They performed less than a median of six central line placements, thoracenteses, paracenteses, or lumbar punctures in the previous year.

Hospitalists who worked more than 45 hours per week performed more core procedures than those who worked fewer hours (P<0.001). Hospitalists spent a median of 40 hours per week in hospital-based patient care versus five hours per week for non-hospitalists (P<0.001); both types of physicians worked a median of 50 hours per week (IQR, 36 to 60 hours per week; P=0.32). There was no significant difference between hospitalists and non-hospitalists in terms of year of medical school graduation, hospital size or population of practice location.

There are several possible reasons why hospitalists don't perform more of the SHM core procedures, the authors said. Invasive diagnostic procedures may be less necessary than other procedures, given advances in diagnostic imaging techniques and clinical decision-making tools. Hospitalists also may opt to focus on cognitive and relational tasks, and refer certain patients to subspecialists, surgeons or radiologists, they said.

Also, reimbursement for some procedures may not match up with the time needed to perform them—a hypothesis partially supported by a non-significant trend showing that hospitalists whose incomes were less tied to productivity (e.g., salaried hospitalists) performed a wider variety of core procedures than those whose incomes were more contingent on productivity, the authors said. Study limitations include that data were self-reported and that respondents were ACP members, which may limit generalizability of results. The survey was also undertaken in 2004; practice patterns may have changed since then, the authors noted.