Medical Society of Virginia Public Comments

Appendix A – Suggested Core Competencies

These are comments from a wide array of physicians who have worked with nurse practitioners and who wished to convey their experience in what skill set affords the ability to provide appropriate patient care.

• Good fund of knowledge, sufficient clinical experience via residency and fellowships, excellent physical exam skills, pharmacology knowledge, managing patients with co-morbidities.

• Differential diagnosis and to be steeped particularly in Internal Medicine which would be helpful as a basic start in any subspecialty.

• In addition to anatomy, pathology, pharmacology, history/physical examination, differential diagnosis, and management of the complex patient, a clinical experience pathway that provides opportunity to distinguish conditions that may rapidly become critical from those conditions that are unlikely to become critical.

• Core knowledge in specialty, knowledge of pharmacotherapy in said specialty, ability to generate a reasonable differential diagnosis and plan of action, the ability to manage several different issues simultaneously, and the ability to know when to refer and who to refer to.

• Experience with diverse patient populations. Background in internal medicine, so a practitioner can make an adequate evaluation and judgment of a condition of a patient.

• Having a broad scope of medicine to handle pharmacology, differential diagnosis, co-morbidities, and how multiple fields of medicine overlap, proper work up, referrals and what their limits are.

• Ability to take comprehensive history and generate differential diagnosis. Understand medication and medication interactions. Also in children understand weight based dosing. Understand community resources and refer appropriately.

• Differential diagnosis referral protocol medical knowledge, including current evidence based medicine. This also will include managing complex patients and their co-morbidities with multiple medications

• The ability to critically think in the areas of history taking, physical examination, diagnostic study and imaging interpretation, pharmacology, differential dx, and having understanding of the patient population and health system/setting that you work in.

• Diagnostic acumen, clinical exam specialty skills, differential diagnosis, managing medications, interpreting lab and radiographic testing, referral sources.

• Diagnostic capabilities with both visual and pathological correlation, ability to prescribe and manage medications in an aging population, appropriate work up and treatment algorithm for both common and rare dermatological conditions.

• Understanding of normal physiology. Understanding pathophysiology of disease states. An ability to compile a comprehensive differential diagnosis list and narrow down this list in an efficient manner. The ability to balance the care of complex patients with a number of comorbid conditions.

• Competent history taking and physical exam. Differential diagnosis; know when to refer and/or ask for consultation.

• Practice-based Learning and Improvement: Show an ability to investigate and evaluate patient care practices, appraise and assimilate scientific evidence, and improve the practice of medicine.

• Patient Care and Procedural Skills: Provide care that is compassionate, appropriate, and effective treatment for health problems and to promote health.

• Systems-based Practice: Demonstrate awareness of and responsibility to the larger context and systems of health care. Be able to call on system resources to provide optimal care (e.g. coordinating care across sites or serving as the primary case manager when care involves multiple specialties, professions or sites).

• Medical Knowledge: Demonstrate knowledge about established and evolving biomedical, clinical, and cognate sciences and their application in patient care.

• Interpersonal and Communication Skills: Demonstrate skills that result in effective information exchange and teaming with patients, their families and professional associates (e.g. fostering a therapeutic relationship that is ethically sound, uses effective listening skills with non-verbal and verbal communication; working as both a team member and at times as a leader). Professionalism: Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to diverse patient populations.

• To be able to practice independently, one must be able to recognize both uncommon as well as common presentations of illness and disease. Must be aware of latest recommendations. Must be able to recognize when course of illness or treatment is not as expected and have knowledgeable base to intervene appropriately

• Pharmacology, differential diagnosis, diagnostic ordering, referral protocol, dual diagnosis co-management

• Emergency management. Safety/adverse effects management, risk assessment (in our field suicide, violence, relapse, etc. prognosis/outcome and disability assessment and opinion, referral for hospice palliative care (example, terminal dementia patients), assessment of testing needs - in our field for EEG, MRI, Psychometry, etc.

• Specialty specific exam, differential diagnosis, proper imaging and lab orders, prescription management, influence of co-morbidities on active problems, proper follow-up.

• Understanding normal physiology and pathophysiology. Being able to create a broad differential diagnosis. Understanding pharmacology and which medications to prescribe. Also to know which medications to prescribe when patients have various organ failures.

• Differential diagnosis Evaluation and management of disease processes. Ability to discuss goals of care with patients and families Ability to know when one does not know - know when to ask for help (appropriate consultation).

• Differential diagnosis, surgical skills, managing immunosuppressive medications and immunosuppressive patients.

• Differential diagnosis, multiple procedures such as intubation, lumbar punctures, central lines, thoracostomy, cricothyroidoyomy, ultrasound, control of nosebleeds, etc., pharmacology, triaging, handling multiple complex patients simultaneously, knowing when to admit vs outpatient treatment, know when need emergent referral vs urgent or outpatient referral.

• Solid knowledge of medication interactions, side effects, pharmacokinetics. Ability to think outside of the box. Experience with disease process. Differential diagnosis and appropriate workup.

• Pharmacology, differential diagnosis, experience with rotations in various core fields (pulmonary, GI, cardiac, endocrine, rheum, ID etc.). In hospital experience is also a necessary requirement.

• Understanding the interplay between disease states and the various treatment options available.
• The ability to take a thorough history with the answers leading to more in depth questions, do a complete physical, and be able to assimilate the information into a diagnosis or differential. Then the ability to do a cost effective workup to confirm or narrow down the diagnosis.

• Ability to develop a robust differential diagnosis, recognizing when patients have problems/require treatment outside one's skill set, ability to critically evaluate evolving medical science and safely incorporate relevant portions into practice, managing patients with comorbidities, mastery of standards of care, stability within a single lane of practice.

• Ability to develop a robust Differential diagnosis, recognizing when patients have problems/require treatment outside one's skill set, ability to critically evaluate evolving medical science and safely incorporate relevant portions into practice, managing patients with comorbidities, mastery of standards of care, stability within a single lane of practice, perspective supervision on testing, such as stress testing.

• Risk stratification, EKG interpretation, recognizes tissue quality that is not normal. Assemble differential diagnoses. Develop treatment; plan to work through the differential. Utilize technology to manage the process of treating patients.

• Working knowledge of medication efficacy, adverse effects, and therapeutic range. Adequate differential diagnosis, for each problem. Knowledge of illnesses with significant co-morbidities.

• History taking, physical examination, differential diagnosis, appropriate ordering of diagnostic tests, pharmacology, and referral protocol.

• Profound knowledge of medication side effects and potential unknown interactions, based on pharmacodynamics of the medication. Ability to formulate a differential diagnosis in a non-linear fashion.

• Prioritizing care for sicker patients as well as the most life threatening aspects of each patient’s condition and taking ownership of the care without unnecessary referrals to multiple other specialists when cases get more challenging Ability to formulate/initiate treatment plans for all the patients who are normally covered within a particular specialty, not only the top 10 diagnosis.

• Full education with complete anatomy and physiology course work, full complement of clinical pharmacology course work, full understanding and competence of managing patients with multiple co-morbidities, evidence of health outcomes that are within the national averages and not below, an established referring access to specialties, backup for caseloads that require additional clinical expertise.

• Understanding of physiology, Understanding of organ systems, tools needed for efficient evaluation of problems. 1. Obtaining a focused, thorough history 2. Understanding of risk factors for various comorbidities 3. Physical exam appropriate for complaint- with the knowledge of what is normal and what you are looking for in each step 4. Understand the underlying pathophysiology of disease so as to link various history and physical exam findings 5. Thorough knowledge of evidence based medicine 6. Ability to develop a reasonable differential diagnosis with the reasoning for and against each differential 7. Understand the risks and benefits of serious work ups, with the knowledge of how to respond to abnormal results of said workups 8. Understand the various treatment modalities, with their risks and benefits. Knowledge of disease, differential diagnosis, treatment options / algorithms, potential side effects, associations with internal disease, diagnostic testing, procedures (biopsies, injections, excisions), managing complex patients, drug interactions.

• Able to take a full history and do a thorough PE including a rectal, filament testing for diabetics, neurologic testing. Fully evaluate lab, x-ray, pathology and the tests. Read EKGs formulate disease hypotheses; know when to follow and when to refer. Discuss diseases with patients and family. Follow-up and be available.

• Understanding of pharmacology, drug interactions, physiology of body systems and pharmacodynamics. 2. Understanding of basic disease processes, complications, prevention and treatment. 3. Recognition of emergency scenarios and ability to manage emergency scenarios to basic lifesaving techniques and triage. 4. Adequacy to ensure follow up of abnormalities and test data etc. 5.Understanding of aseptic technique, sterilization, and disease control, both for procedures and for communicable diseases. 6. Ability to properly hand off and refer problems out of knowledge base or scope of ability, e.g. no dumping or putting referral into patients responsibility when it should be the practitioner's responsibility.

• Understanding of pathophysiology, pharmacology, indications for surgical referrals as well as managing psychiatric and developmental comorbidities Interpretation of medical imaging and neurophysiology results, referral pattern and facilitation of consultations.

• Strong knowledge base, ability to recognize limitations, extensive knowledge of pharmacology, ability to refer to MD quickly, managing multiple health problems with the understanding of why we do things - for ex, not just giving diuretic for swollen legs but recognizing that this maneuver might be life threatening if heart failure symptoms are due to pericardial effusion.

• Differential diagnosis Management of chronic conditions Understanding of management of complications of pregnancy/postpartum care Understanding of when to refer/transfer care

• Pharmacology Procedural skills (IUDs, biopsies, etc.). Adherence to current best clinical practice guidelines.

• A working knowledge of a broad range of medical conditions and interactions as well as the ability to recognize situations or conditions that may be rare, but if unrecognized or not addressed, can lead to significant morbidity or mortality. The ability to formulate a differential diagnosis that is appropriately focused (so as not to promote a shotgun approach to the workup) while recognizing the existence of less likely but critically important conditions/situations. The ability to demonstrate a clear understanding of the limitations of one's training and the need to refer patients to specially trained providers when it is in the patient's best interest WITHOUT needing to rely solely on specialists for conditions typically treated by others within one's field. An appropriate respect for training differences amongst different provider types and the ability to acknowledge that "we don't know what we don't know" and to discuss cases with other providers when patients are atypical or have atypical responses to treatment.

• Knowledge in basic science, pathology, physiology. The training and experience to apply this knowledge to create a differential diagnosis. Appropriate diagnostic testing. Formulating a treatment plan. Ability to carry out the treatment plan. Ability to recognize when a treatment plan is not working. Knowledge of ones limitations.

• Comprehensive background in pathology, physiology, anatomy, pharmacology, co-morbidity disease/injury management, radiology, wound management, methodical diagnostic protocol.

• Exposure to mental health issues, demonstrated communication skills are also important pharmacology, differential diagnosis, knowing when to refer, managing co-morbidities, recognizing and managing common mental health co-morbidities, vaccination schedules/side effects/counseling, developmental assessment and recognition/management of abnormalities; recognizing and addressing social determinants of health; effective care coordination skills; effective community interactions (schools, CSBs, etc.), ability to manage and support those with disabilities (including knowledge of waivers, disability benefits, etc.).

• Adequate clinical patient contact hours under the supervision of an experienced provider, demonstrated knowledge in pharmacology and pharmokenetics, documented core knowledge in illness and disease mechanisms coupled with treatment modalities of the same, established resources for consultation and collaboration with adequate peers for management of difficult/refractory patients.

• Physiology, pharmacology, physical diagnosis, referral protocol, pathology, hematology, laboratory science, management of chronic illness.

• The ability to do a proper examination, understand what testing to order (and not order), and interpretation of results. They will also need to be familiar with the wide range of disease processes and how that's relevant to each other. They will also need to be familiar with various therapeutic options as well as contraindications. They should also need to have a process to keep up to date with changing technology, information, guidelines, etc.

• Core competencies include pathophysiology, anatomy and physiology, pharmacology, the ability to have a wide differential diagnosis but know which are the most critical and relevant tests to order to determine etiology. It is vitally important for clinicians to know what they do not know and when to ask for help through consultation or referral. Knowledge of systems based practice and the barriers to care for different patient populations are also important. Autonomous practice should be limited to those who are able to shoulder the associated liability and consequences.

• Knowledge of oncology drugs and comprehensive treatment of cancer. Hematology knowledge. Pain management. End of life issues.

• Accurate history taking, physical exam, creation and refinement of differential diagnosis, pharmacology, lifesaving procedures, routine procedures, appropriate consultation, admission criteria recognition, discharge and follow up plan creation, EMTALA procedure, documentation, medicolegal concerns.

• Pharmacology, correct visual diagnosis of cancer and concerning lesions (often incredibly subtle), differential diagnosis, referral protocol, appropriate procedural technique AND appropriate decision making for performance of procedures such as biopsies and cryosurgery.

• Pharmacology principles such as pharmacokinetics and pharmacodynamics. Rapid evaluation of critically ill patients and initiation of therapy with continuous reassessment Management of multiple co-mire diseases in the acute setting pharmacology, knowledge of emergent vs. non-emergent complaints, differential diagnosis, managing complex patients, knowledge of vaccinations.

• Critical thinking skills and medical synthesis skills Strong foundation in basic and clinical sciences in order to generate a broad differential diagnosis. Clinical pharmacology skills. Ability to manage patients with multiple co-morbidities. Understanding of the interdependency of the health care system and navigating the complexities. Laboratory ordering and interpretation. Clinical pharmacology and medication prescribing.