To the core

Medicine has disciplines, and Thrombosis and Hemostasis is one of them. Unlike other disciplines, Thrombosis and Hemostasis has many houses. In many institutions, Thrombosis and Hemostasis was traditionally part of Hematology, whereas in other centers, the thrombosis side would have been dealt with by cardiologists, within the subspecialty of Angiology. In some places, the more recently created subspecialty of Vascular Medicine deals exclusively with the thrombotic aspect, whereas hereditary and acquired bleeding disorders have remained in Hematology. In other places still, Vascular Medicine includes both thrombotic and bleeding disorders, which, if anything, matches the idea of the thrombohemorrhagic balance, where too little of a clotting factor makes a patient bleed, and too much leads to pathologic thrombus formation. Whereas few centers have independent departments of Thrombosis and Hemostasis, sections or subdivisions are often found, sometimes as part of Hematology and sometimes as part of Internal Medicine. And of course, in clinical practice, many aspects of thrombosis and hemostasis are dealt with by other specialists, such as bleeding by surgeons, thrombosis prophylaxis by orthopedic specialists, and recurrent miscarriage by gynecologists. So, we are everywhere and nowhere. Our discipline has sprouted from laboratory medicine, with the identification and characterization of coagulation factors, and the subsequent standardization of their measurement. Over the last few decades, a thrombosis and hemostasis expert has come out of the mist, and a clinical discipline is emerging with consensus as to what the field is and as to what competencies belong there. Recently, the ISTH has taken the initiative to develop a listing of what a specialist in Thrombosis and Hemostasis should know and should be able to do. The core competencies of this clinician are neatly summarized in the Core Curriculum article published in this issue of the Journal of Thrombosis and Haemostasis. A form of crowd intelligence was used to produce this Core Curriculum; that is, members of the ISTH were asked to rate the importance of a large list of competencies. These refer to what an individual should know or is able to do, rather than learning aims, which one usually sees in academic curricula or courses as organized by the ISTH. The rationale for using competencies is that these refer only to the result of education, not the process, and hence can be applied across regions and countries, which may differ widely in how individuals reach these competencies. In essence, the process came down to a working group from across the globe that compiled a list of potential competencies, and a subsequent survey of ISTH members and others in the field known to the ISTH (e.g. recent meeting attendants). They were asked to rate each item on a scale that distinguished between the competencies that one did not even need to be familiar with, those that one should be familiar with or be able to teach, and those that one should be able to actively carry out. After a long process of reviewing, and obtaining views from experts and pilot studies, 143 items were included in the final survey. This survey was sent to approximately 15 000 individuals, of whom 644 sent it back. This response rate is low, but not for these types of study, and in contrast to surveys aimed at medical research questions, it does not seem likely to have biased the results. Perhaps the most remarkable finding of the survey is that respondents, be they clinicians or non-clinicians, senior or junior, or from Europe or elsewhere, agreed, to a high extent, on the ranking of the competencies that were relevant and those that were not. So, although we may dwell in different houses under different names, we generally agree on what we should know and do. The detailed description of the competencies can be read in the article, which concludes that the Core Curriculum consists of 60 competencies that a specialist in thrombosis and hemostasis should be able to do, 55 that they should be able to teach, and 28 that they should know how to do. How to go further with this Core Curriculum? First, the ISTH will tie its educational programs to it. Second, those responsible for national and regional training programs may choose to make it part of the portfolio for specialists in training or postgraduate programs. Finally, the ISTH could decide to offer examinations and award certificates that could be incorporated in the licensing procedures in various places, be a valuable part of a curriculum vitae, or improve a vanity wall in a doctor’s office.