Friday, November 24, 2006

Medical Staff Credentialing -- II

Now that I've had time to digest a little turkey, it's time to dive back into the medical staff credentialing issue introduced in my last post. If you were reading, I ended with a few questions about a hypothetical surgeon who is having "problems" in practice:

Why would this be his biggest mistake?
Why in the H-E-Double-Hockey-Sticks did "they" let this guy out of residency?
Why does this really matter?
Why can't we "fix" this problem?
One among many difficulties in training a physician is how to appropriately mentor him or her --- and identifying those physicians that need more than your average dose of mentoring. Actually, I don't really care for the word "mentoring," as I think it implies a greater responsibility for the trainer, rather than putting the onus on the trainee where it more properly lies. I prefer to think more in terms of apprenticeship, which residency more closely approximates.

In any event, we have over the years established fairly rigid time frames for producing practicing doctors --- in the case of general surgeons, almost all training programs are 5 years in length. It is anticipated that upon completion of 5 years of training that all of the general surgeons who graduate are reasonably similarly educated, and can be assumed to have a similar skill level in caring for patients. But ask any parent of a college-aged child and they will regale you with stories of kids who take 4, 5, 6, etc. years to get a degree ---- not always out of laziness. So it may be reasonable to assume that for some training physicians, the "standard" residency term is not long enough (I shudder at the thought of longer residencies!).

If we make that assumption, then training programs are charged with deciding who either needs more time in residency or who should be forced to find an alternate career path --- and that, as the saying goes, is easier said than done. Just try telling a 3rd year surgical resident that he is not cut out for the job --- and then call your lawyer as soon as that discussion is over. Long gone are the days that allowed program directors great latitude in these matters --- and extending residency training time involves not only legal issues, but monetary ones, as CMS only funds a certain amount of training. And this is how in the H-E-Double-Hockey-Sticks "they" let this guy out of residency.

With these difficulties, it is then easy to see that the occasional (and I emphasize occasional) less qualified resident makes his way into the real world. The best possible place for him to land, then, would be in a group practice surrounded by physicians who have several years of practice under their belt ---- from whom he could continue to learn. There is no question that I learned a tremendous amount from my senior partners over the years, and that has allowed me the self-assurance to ask for help when needed. If the less-than-fully-qualified resident lands in another situation, he very well may flounder, and end up digging a rather deep hole completely unintentionally.

So, this hypothetical surgeon gets what by all objective measurements is good training, but not quite enough for him. He then takes a position that does not provide him with what he needs most, the steady hand of one or many experienced mentors. And then he has what every other surgeon who has ever picked up a scalpel has ---- complications. Because we all have complications, unless they are so grievous and unusual as to generate scrutiny quickly, it takes a while before they reach a "critical mass" that causes a group of his peers to point out that, hey, there's a problem here, and initiate a closer look at his practice.

Is this now someone who should continue to practice? If not, is he a candidate for "salvage?" This is (part of) what Rita had to say:
I've met the somewhat bumbling average resident you describe - more than once. And you're absolutely correct - many average Joes can become stellar performers with a bit of mentoring and guidance. Unfortunately, established physicians who do not work with formal programs in teaching hospitals are often afraid to put their own practices at potential legal risk in order to mentor the new kid. I suspect that this is a case of "fear making the wolf bigger than he is," but the "wolf" of potential litigation does indeed prowl just outside the door.
I do believe that there are some potential areas that we could improve to ensure that we protect patients and ensure appropriate training, but they would not be easy. So, if I were king, here are a few things I would enact:
  1. Allow residency program directors more latitude in deciding who should [a] continue their chosen specialty training and/or [b] who needs more training. Perhaps the various Residency Review Committees could establish guidelines for making those decisions at certain times during training; unfortunately, they have a tendency to focus a bit too much on testing data (such as the), and I would prefer allowing program directors to make these decisions based purely on clinical performance.
  2. Establish formal cooperative arrangements between training programs, so that the resident who needs longer training has the opportunity to get at least a part of that training in an alternate, unbiased arena.
  3. Establish a uniform appeals process, so that residents who are asked to leave a training program or undergo further training cannot run to the nearest sympathetic lawyer and make the whole thing into a circus.
  4. Encourage graduating residents to look primarily for established practices to join --- perhaps the ultimate impossible dream (and I am the prime example, given my original practice).
These suggestions are, of course, as impossible to enact as they are impractical in many respects. However, they represent an acknowledgement that there are areas for improvement.

Now, what do we do with our hypothetical surgeon, who has not been able to train under the rules of my kingdom? On to the next post, a look at credentialing for hospitals and insurance companies, as well as peer review.