How then should we define who is a capable provider in the hospital setting? According to the Dreyfus Model of Skills Acquisition, as learners develop along the continuum from novice to beginner to competent to proficient to expert, their skills become more developed, letting them tackle more complex issues and tasks more efficiently.
For example, the novice knows that a patient with dyspnea might have pneumonia and orders a chest X-ray but little more. The competent provider realizes many other disease states can cause dyspnea and would assess for those as well, often getting bogged down in extraneous details. The proficient provider immediately focuses on the important details and determines pneumonia as the cause of the dyspnea, applying the proper treatment algorithms with a level of efficiency beyond that of the competent peer.
The expert intuitively diagnoses the pneumonia and prescribes the proper diagnostic and therapeutic evaluation. He does so while considering the patient’s immune status, the impact of the hospital’s antimicrobial resistance patterns, and the potential risks and benefits of short-course antimicrobial therapy—all through the prism of quality core measures, cost, and throughput.
In a healthcare system at best strained and by most evidence severely fractured, we can no longer accept competence as the determinant of a capable provider. Rather, we should use proficiency moving toward expertise as the measuring stick for caring for increasingly more complex patients.
The designation “hospitalist” or even RFP-HM should not determine if one is proficient to practice hospital medicine, just as the designation of primary care provider should not exclude one from practicing in the hospital. Certainly, there are practitioners able to seamlessly cross the inpatient/outpatient boundary without losing a step. However, I suspect the more likely scenario is expertise in one and at best proficiency in the other.
Levitin’s 10,000-hour threshold supports this assumption, as it would take at least 10 years to amass 10,000 hours in each practice setting. Most likely, development of expertise in one arena means mere competence in another. As exhibit A, I tremble at the thought of the mischief I would cause if I took my stethoscope to the primary care clinic.
Instead, the ethical standards of our profession should dictate that each provider determines if they meet this pursuit-of-expertise standard. Employers and credentialing boards need to raise the bar toward expertise, ensuring these thresholds are met.
In the end, hospital or clinic sites should be the domain of capable providers, regardless of their primary practice site. However, we need to recalibrate how we define a capable provider who is moving away from competence toward proficiency verging on expertise. Experience as a surrogate for expertise, more than primary practice setting or RFP-HM status, should be the major determinant for who cares for hospitalized patients. TH
Dr. Glasheen is associate professor of medicine at the University of Colorado at Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.