Sunday, November 26, 2006

Medical Staff Credentialing --- c'est finis

I'd like to try to wrap this series of posts up by discussing what happens beyond the realm of the training program. If our hypothetical "marginal" resident makes his way into the real world, and if he then does not receive appropriate mentorship, he may fall into bad habits and poor practice patterns, eventually encountering complications. What is to be done?

In an ideal world, he would be given the opportunity to be taken in by a group of more experienced physicians, who would be responsible for monitoring his progress and thought processes, with an eye to ensuring that he could re-emerge from this "apprenticeship" as a more functional doctor.

Let's be honest. That ain't never gonna happen.

Why? Well, there's too much at stake on many levels. First of all, the physicians in his community are (a) not a part of a teaching program; (b) his competitors; and (c) liable for his actions if he is under their wing. Secondly, community hospitals are not set up for this kind of ongoing training, and could similarly be held liable. Finally, there are practical issues that come up --- somebody has to take call with him, see all of his patients, look at his notes, etc., and that takes a lot of time, and generates a lot of expense.

An alternative would be to return this surgeon to his residency program, requesting further training (6 months? a year?) with reevaluation upon completion of such training. Actually, these types of arrangements are (extremely rarely) constructed, but I do not have any information about how successful they are. But, when you think about it, the training program may say "Hey, we just gave you 5 years to get this stuff down pat. What makes you think more time with us would make any difference at all? Sorry, you've gone past the point of no return." And they would probably be right.

And so, it often comes to pass that before this type of surgeon has real troubles, he makes his way to another hospital system, sometimes another state, and may or may not have similar issues in the future (I'd bet a few bucks on the former). And because it is damn near impossible for hospitals or state agencies to communicate even egregious problems, he will likely have no difficulty getting staff privileges.

Right about now the non-medical type who has been patiently reading this just had coffee spew out of his nose --- do you mean to say that a physician can even completely lose his hospital privileges and easily obtain them elsewhere? Even have state medical board problems and get a license to practice in another state? The short answer is --- you bet your booty. The long answer is that state medical boards are all autonomous, and there is no uniformity in how they license physicians, how they report problems, etc. And hospitals are a big fat legal target if they pass along details of a physician's history without careful attorney oversight. And that, in most cases, is a damned shame.

Except, of course, when it's not. Remember that Lady Justice carries something other than her scales -- she packs some old-fashioned heat! There are countless cases of physicians who have had their careers ruined in one facility/town/state by overzealous peer review, false reporting of complications, etc. And that is where a good lawyer can be (OH GOD, I CAN'T BELIEVE I'M GOING TO TYPE THIS) a physician's best friend.

So really, in the end, I don't have a perfect solution for this particular problem. I do believe that there are occasional graduating residents who might be better served with further training, but how that can be accomplished is hard to see. As far as hospitals, state medical boards, and ultimately the public being able to separate the wheat from the chaff, here are a few significant hurdles that need to be overcome, along with some "if I were king" suggestions:
  1. There is a total lack of uniformity for physician licensing among state medical boards. Gee, doesn't it seem that we could establish a pretty solid minimum set of standards?
  2. There is inadequate reporting between state boards when physicians have their licenses restricted. Hey, guys, it's the internet age. Electronic communication of these basic, fairly infrequent issues should be as easy as setting up a blog.
  3. At least in my state, hospitals are required to report to the state medical board when a physician loses his privileges or has them restricted; however, that information is not always readily available to other hospitals in the same state. Once again, if we are in the business of trying to deliver high quality care and protect patients, all hospitals in a given state should be able to at least be informed when this type of restriction arises --- with, of course, notification if and when these restrictions are lifted.
  4. What about physicians who have no hospital privileges? In this era of hospitalists, the numbers of docs who practice in a purely outpatient setting is growing by leaps and bounds. I'm afraid that I have absolutely no idea of what to do here; we have to rely totally on the state boards for these folks.
  5. What responsibility do insurance companies have? Ooh, boy, talk about adding a 64 oz cup of coffee and a pound of salt to my blood pressure. It seems totally incongruous to me that an insurance company would choose to keep a physician on their panel who had lost their privileges at a hospital they do business with --- without doing due diligence at least. They are caught, however, in a legal trap, damned if they do....
  6. What about the current push to ensure hospitals and docs meet a whole raft of quality measurements? This could be the subject for a textbook, much less another post, but the bottom line is that measurement of a whole series of individually complex doctor-patient interactions is a bit harder than it seems.
  7. Shouldn't the peer review process be enough to make sure that "problem" doctors are weeded out? Actually, yes, but the reality is much more difficult. Peer review is a careful process, designed to ensure that the physician being reviewed is not unfairly reprimanded; as a result, it can take some time to remove "problem" physicians from a hospital staff. And that can cause further legal issues -- in fact, some attorneys are working hard to make peer review processes discoverable, which would ensure that no sentient being would ever again serve on a peer review committee.
  8. Who should be in charge of making these changes? That's easy. Me -- we just need to negotiate a bit about my fees.
I apologize to anyone who has taken the time to wade through this morass and feels it was wasted. Medicine is a complex field, with little uniformity in just about every area you look into, but we all understand the need to ensure that quality care is delivered. The definition of quality is, however, hard to put one's finger on --- and in all honesty, it is often defined as Supreme Court justice Potter Stewart defined pornography --- I know it when I see it. It would be prudent for anyone interested in trying to make (needed) changes to work one step at a time, rather than trying to throw a Hail Mary pass.