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European Journal of Internal Medicine 23 (2012) 338341

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European Journal of Internal Medicine


journal homepage: www.elsevier.com/locate/ejim

Reections in Internal Medicine

Core competencies in Internal Medicine


Jos Manuel Porcel a, 1, 2, Jordi Casademont b,, 1, 2, Pedro Conthe c, 2, Blanca Pinilla c, 2, Ramn Pujol d, 2, Javier Garca-Alegra e, 2
a

Department of Internal Medicine, Hospital Universitario Arnau de Vilanova, Lleida, Spain Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain Department of Internal Medicine, Hospital Gregorio Maran, Madrid, Spain d Department of Internal Medicine, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain e Department of Internal Medicine, Hospital Costa del Sol, Marbella, Mlaga, Spain
b c

a r t i c l e

i n f o

a b s t r a c t
The working group on Competencies of Internal Medicine from the Spanish Society of Internal Medicine (SEMI) proposes a series of core competencies that we consider should be common to all European internal medicine specialists. The competencies include aspects related to patient care, clinical knowledge, technical skills, communication skills, professionalism, cost-awareness in medical care and academic activities. The proposal could be used as a working document for the Internal Medicine core curriculum in the context of the educational framework of medical specialties in Europe. 2012 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

Article history: Received 23 December 2011 Received in revised form 29 February 2012 Accepted 5 March 2012 Available online 28 March 2012 Keywords: Internal Medicine Medical education, continuing Medical education, graduate Clinical competence Medical specialization

1. Introduction For some time, the European Federation of Internal Medicine (EFIM) and the Section of Internal Medicine of the European Union of Medical Specialists (UEMS) have been trying to dene the core competencies which should be acquired by all internists in Europe, irrespective of the model of each national health system, years and form of training in each country [1]. The role of internal medicine is heterogeneous and the activity of the internists also varies in different areas. For example, the patient care provided by an internist in a local hospital or in a referral hospital is often different. In some circumstances internists act as true subspecialists in their specic areas of interest. In others, they play an important role outside the hospital setting. In addition, the medical problems that an internist faces cannot easily be distinguished from those of other medical specialties. Certainly, the internists have to deal with older adults, in whom comorbidities and drug side effects and interactions are common while evidence based treatments are often lacking.

Corresponding author. Tel.: + 34 935565609; fax: + 34 935565938. E-mail address: jcasademont@santpau.cat (J. Casademont). 1 These authors have contributed equally to the composition of the manuscript. 2 On behalf of the working group named Competencies of the Internist from the Spanish Society of Internal Medicine (SEMI).

This highlights the importance of dening the basic knowledge and skills that any European internist must possess, regardless of workplace or personal interests. However, it is difcult to distinguish between essential and advanced competencies. Moreover, there is a tendency to misinterpret what should be acquired during specialised training with professional skills acquired later. These concerns are not unique for Europe. In the U.S. there have been several initiatives to establish what skills should be acquired by competent internists. However, the results in general have been dissimilar and are not very operative [24]. Internal medicine in southern European countries is essentially considered as an independent specialty and has a great inuence within their respective national health care systems, while in other European countries general internists are less common. In Spain, Internal Medicine Departments are responsible for more than 16% of all hospital discharges [5]. The Spanish Society of Internal Medicine (SEMI) has also an important role within the European Federation of Internal Medicine (EFIM) and, therefore, its position has a signicant impact at the European level. According to the strategy of SEMI [6], the development of a handbook of the competencies of the internist has been established as a priority, which must be complementary to the Internal Medicine training programme revised in depth in 2007 [7]. In this spirit, the SEMI Board of Directors established a working group whose initial conclusions are reected in this document and presented as a working document possibly useful to open a debate in this journal

0953-6205/$ see front matter 2012 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ejim.2012.03.003

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among the different Internal Medicine national societies of the European community. 2. Methodology and limitations SEMI selected a group of experts in medical education and members of the Training Group of the Spanish Foundation of Internal Medicine (FEMI) in order to establish the working methodology and the development of an initial document (see acknowledgements). This document was subsequently modied by several parallel groups which were instituted during a meeting of different Heads of Departments and Units, held in Cordoba in October 2010. Their contributions constituted the background to draft this nal document. A limitation of this proposal is that it does not include those competencies that internists may acquire to full the needs of their regions, hospitals or departments or even personal preferences which make them specialists in a disease or a group of diseases. At the same time, the degree of knowledge or training for various competencies may differ greatly depending on the setting of each individual. Therefore, the aim of this article is not to write a detailed description of the content of all knowledge, competencies and attitudes. Rather, it is to make available a list of core competencies for internists which will help guide the development of future training programmes, trainee evaluations and continuous medical education. We are aware that such a list has the risk of being incomplete and, at the same time, laden with unnecessary details. Conscious that the approach may be insufcient and probably includes inconsistencies and redundancies, we present it as a background document to start a discussion by European Societies of Internal Medicine. 3. Classication of the competencies Internists must know and be able to apply in clinical practice the principles of evidence-based medicine and scientic reasoning. Slightly modifying the scheme proposed by the EFIM [1] and the American Accreditation Council for Graduate Medical Education [4], the competencies that all internal medicine specialists should have can be divided into seven sections (Table 1): 1) patient care, 2) clinical knowledge, 3) technical skills, 4) communication skills, 5) professionalism, 6) cost awareness in medical care, and 7) academic activities. 3.1. Patient care Internists should be able to do qualied clinical examinations including: Write a complete medical history. The clinical interview includes an assessment of functional status using different scales, as well as occupational, family and psychosocial history. Perform a physical examination based on the patient's history. Interpret the data obtained from the clinical history and physical examination, establish a differential diagnosis and develop a plan to conrm the diagnosis. Indicate the proper tests (laboratory, imaging and functional) to refute the tentative diagnosis.
Table 1 Competencies that all internists should possess. 1. 2. 3. 4. 5. 6. 7. Patient care. Clinical knowledge. Technical skills. Communication skills. Professionalism. Cost-awareness in medical care. Academic activities.

Design a cost-effective therapeutic plan which should be individualised to the patient's condition. Avoid unnecessary diagnostic and therapeutic efforts in patients with a poor prognosis, terminal situations or severe comorbidities. Write a hospital discharge report. Ensure a comprehensive diagnostic and therapeutic plan for patients with co-morbidities, multiple diseases, systemic diseases or non-specic health problems. Provide clinical care in various healthcare settings: specialised centres (with direct responsibility on patients or as consultants in surgical services), intensive care and emergency departments, primary care and home care. Articles, which develop these competencies, have been recently published in Revista Clnica Espaola (the Ofcial Journal of the Spanish Society of Internal Medicine) [811]. 3.2. Clinical knowledge The wealth of knowledge contained in Internal Medicine is extraordinarily broad, as reected in the traditional textbooks on the specialty [12,13]. Given the difculty of establishing a consensus on what should be considered basic knowledge, far from being a comprehensive account, internists must, just as examples: 1. Establish the differential diagnoses of common disease presentations, such as: unintentional weight loss, fever of unknown origin, traveller's fever, chest pain, dyspnoea, coughing, haemoptysis, syncope, dyspepsia, vomiting, abdominal pain, diarrhoea, jaundice, ascites, delirium, cephalalgia, acute neurological decit, seizures, acute loss of vision, dizziness and vertigo, altered level of consciousness, falls in elderly people, arthralgia, regional musculoskeletal pain, muscle weakness, rash, purpura and pruritus. 2. Know how to manage prevalent diseases in the hospital setting: Cardiovascular diseases: hypertension, heart failure, acute coronary syndrome, atrial brillation, endocarditis, surgical indications for valvular heart disease, acute pericarditis, aneurysm and aortic dissection, peripheral arteriopathy and venous thrombosis. Respiratory diseases: chronic obstructive pulmonary disease, asthma, respiratory failure, pneumonia, pleural effusion, tuberculosis, pulmonary embolism, solitary pulmonary nodule, pulmonary hypertension, interstitial diseases and obstructive sleep apnoea. Diseases of the nervous system: meningitis and encephalitis, stroke, dementia, brain focal lesions, migraine, parkinsonism, multiple sclerosis, peripheral neuropathies and radiculopathies and myasthenia gravis. Renal diseases: urinary tract infections, acute and chronic renal failure, nephrotic syndrome, water-electrolyte and acidbase imbalances, and nephrolithiasis. Diseases of the endocrinemetabolic system and of nutrition: diabetes mellitus and its complications, dyslipidemia, thyroid dysfunction, adrenal dysfunction, suprarenal focal lesion, alterations of calcium, alterations of uric acid, basis of diet and nutrition (enteral and parenteral). Diseases of the digestive system: gastroesophageal reux disease, peptic ulcer, gastrointestinal bleeding, acute gastroenteritis, irritable bowel syndrome, malabsorption syndromes, inammatory bowel disease, acute and chronic pancreatitis, acute and chronic hepatitis, cirrhosis and its complications and biliary diseases. Tumour diseases: lung cancer, breast cancer, colon cancer, prostate cancer, hepatocellular carcinoma, cancer of unknown origin, oncological emergencies, febrile neutropenia, paraneoplastic syndromes and cancer screening. Diseases of the blood: anaemia, thrombocytopenia and thrombocytopathy, hypercoagulable state, plasma cell dyscrasias,

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lymphomas, leukemias, myelodysplasia, myeloproliferative disease and transfusion therapy. Rheumatic and systemic autoimmune diseases: osteoporosis, septic arthritis, gout, osteoarthritis, bromyalgia, clinical signicance of autoantibodies, rheumatoid arthritis, systemic lupus erythematosus, scleroderma, idiopathic inammatory myopathy, Sjgren's syndrome, vasculitis, polymialgia rheumatica, sarcoidosis and amyloidosis. Diseases of the skin: infections of skin and soft tissue, urticaria and angioedema, skin ulcers and cutaneous manifestations of internal diseases. Infectious diseases not included in previous sections: infection with human immunodeciency virus, sexually transmitted diseases, osteomyelitis, nosocomial infections (catheter-associated infections, Clostridium difcile diarrhoea), infections in immunocompromised patients, malaria, rational use of antibiotics, adult vaccinations. Intensive and Emergency Medicine not included in previous sections: Advanced cardiopulmonary resuscitation, sepsis, shock, anaphylaxis, coma, acute respiratory distress syndrome, indications for invasive and non-invasive mechanical ventilation, malignant arrhythmia, hypertensive urgencies and emergencies, subarachnoid haemorrhage, acute liver failure and acute poisoning. Perioperative and consultation medicine: evaluation of cardiac and preoperative pulmonary risks, medication in the perioperative period, blood glucose control, prophylaxis of venous thromboembolism, infectious and non-infectious complications in the postoperative period, medical problems in pregnant women. Age-related diseases and miscellaneous diseases: scales of functional and cognitive assessment, urinary incontinence, benign prostatic hypertrophy, polypharmacy, palliative care (pain, dyspnoea, insomnia, constipation), substance abuse, depression, anxiety and drug allergy. 3. Know the indications, contraindications, dosage and interactions of the major drug groups: analgesics and anti-inammatory drugs, corticosteroids, anticoagulants and antiplatelets, antibiotics, antivirals, antifungals, antisecretory, insulin, oral antidiabetics, hypotensives, lipid-lowering drugs, diuretics, bronchodilators and inhaled corticosteroids, common antiarrhythmics, sedatives, antidepressants and psychotropics, antiepileptics, laxatives, antihistamines, immunosuppressives, antimalarials, bisphosphonates and biological therapies. Needless to say, the internist should also be able to identify uncommon symptoms and rare diseases. Some of these forms of clinical knowledge can be obtained in more detail by reading recent articles [1416]. 3.3. Technical skills Internists must be procient in the interpretation of laboratory, functional and imaging tests obtained as part of the diagnostic evaluation of the diseases mentioned above. Possessing these skills and interpretation techniques are inherent in the daily work of internists [17,18]. Some examples are: Complete blood count, basic biochemistry, coagulation tests and urinalysis. Electrocardiogram. Plain chest X-ray. Arterial blood gas and respiratory function tests. Also, internists should be able to perform and interpret the results of a series of technical procedures for diagnostic or therapeutic purposes, which include, for instance: Measurement of blood pressure and assessment of paradoxical pulse, direct fundoscopy, pulse oximetry and oxygen therapy, diagnostic and therapeutic thoracentesis, diagnostic and therapeutic paracentesis, lumbar puncture and arthrocentesis of the knee.

3.4. Communication skills Internists must demonstrate interpersonal skills that lead to effective communication with patients, their families and other professionals [19,20]. They must be able to: Provide clear and concise information to patients about their health and encourage them to participate in treatment decisions. Provide effective communication according to different background and culture. Inform the patient's relatives, having respect for the patient's directives. Tactfully inform about the nature of diseases with grim prognosis. Deal with end-of-life situations. Be able to evaluate the patient's ability to make decisions. Request informed consent and autopsy. Know how to ll out a death certicate and medical reports. Interact appropriately with colleagues from different specialties in order to maintain continuity of care. Establish consensus and decisions shared with other professionals. 3.5. Professionalism Internists must demonstrate commitment in carrying out their professional responsibilities with excellence [2124], which implies: Respecting the principles of ethics and condentiality. Having the ability to work in a multidisciplinary team and consulting with other specialists when needed (be aware of the self-limitations). Having knowledge of legislation relating to the practice of the medical profession. Knowing about the healthcare organisation where they work and having a commitment to their goals. Participating in the development and implementation of protocols, clinical practice guidelines and informed consent. Understanding the principles of clinical management and quality of care. Knowing how to organise their own curriculum. Keeping up-to-date with current medical knowledge. 3.6. Cost-awareness in medical care This point refers to the ethics of efciency, namely the rationale use of health resources [25]. In particular, the internist should know: The cost of the medical care provided. The importance of avoiding unnecessary diagnostic tests. The economic implications of the use of emergency services and of hospital admissions and readmissions. The real benet of using new therapeutic procedures or drugs over the existing ones. The need for stewardship of resources. 3.7. Academic activities Teaching and clinical research are essential tasks of internists [2629], irrespective of where they work [3035]. Internists must: Actively participate in teaching undergraduate and postgraduate students and residents, considering teaching based on learners. Know how to perform an advanced literature search in the MEDLINE database and know the major sources of scientic evidence. Be procient in English to the point of reading medical literature without difculty. Have adequate knowledge of biostatistics to be able to interpret and produce a research paper. Be able to write a scientic paper for publication in a biomedical journal.

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Conduct a critical reading of diagnostic, prognostic and intervention studies. Be able to give presentations at scientic meetings. 4. Conclusions

[4] [5]

[6]

This document aims at identifying the competencies that European internists should gather regardless of the place, tradition and health care organisation in which they work. This is an initial proposal from a country where general Internal Medicine is thoroughly established, particularly in hospital-based care. The document is not exhaustive, and may undoubtedly be improved in conjunction with other National Societies and under the EFIM support. The aim is to provide a discussion framework that helps to improve educational, assessment and continuous personal development programmes [36]. The competencies described here also represent the core of the specialty of Internal Medicine in the future setting of the core curriculum in the specialties of health sciences. Learning points All European internists should gather similar core competencies irrespective of the country, workplace or personal interests. Competencies are more than just the knowledge that has to be acquired during specialised training. Competencies are characteristic of fully developed professionals and involve the ability to meet complex demands by mobilising psychosocial resources to deal with medical problems in a particular context. Competencies encompass aspects of patient care, clinical knowledge, technical skills, communication skills, professionalism, cost-awareness in medical care and academic activities. Identifying and agreeing on core competencies for European internists may help improve educational and continuous personal development programmes. Conict of interest The authors state that they have no conicts of interest. Acknowledgements We thank all participants in the meeting of the Heads of Departments and Units in the SEMI held on the 8th of October 2010 in Cordoba for their work, discussion and ideas provided. The SEMI's Group on Internal Medicine Competencies included the following people: Jos Manuel Porcel (coordinator), Jordi Casademont, Melchor lvarez de Mon, Pedro Conthe, Javier Garca-Alegra, Gonzalo Garca de Casasola, Jaime Merino, Blanca Pinilla, Ramn Pujol, Emilio Pujol and Ana Torres. References
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