Tuesday, November 21, 2006

Medical Staff Credentialing - Part the First

There is an interesting, brief post at Rita's place about medical credentialing that has piqued my interest. Actually, given the difficulty I have had with sleeping/thinking/etc. that I described below, it has been a pleasant diversion to think about this topic --- which, by the way, is near and dear to my cold, rock-hard heart. Here it is, in its entirety:

I was recently introduced to a Chief Medical Officer who opened our conversation with, "As far as I'm concerned the medical credentialing system in this country is broken."

My response? "You'll get no argument out of me."

In this age of global communication and technology why must we gather, validate, and store the same information on the same individuals repeatedly, (and often simultaneously to one or more of our colleagues)? Law, interpretive guidelines, and accreditation standards mandate some of the redundancy, but as the healthcare system's credentialing experts, do we allow habit and fear to block our minds to the exploration and development of new concepts?

Something to consider.

Something to consider, indeed. So, without a single moment's pause, I dashed off my typical comment --- rash, unconsidered, and usually including some (well-deserved) attorney bashing:

I agree -- the current system is not one that provides for the best possible care to be delivered at each institution. However, despite the original intent of the privileging process, it has never been one that would be up to that task. Our current system is designed to prevent hospitals, hospital boards, and physicians on peer review committees from being sued (see what happened at Presbyterian Hospital in Dallas recently).

And that, while sad/ridiculous/disingenuous/etc., is a reflection of the tort system we live in.

{While searching for links to the Presbyterian Hospital saga, and the huge award it will have to pay, I discovered that one of my close high school friends is an attorney in the firm representing the plaintiff. Dear God, help me figure out how a Jesuit education produced that!}

Anyways, back to the topic at hand. For argument's sake, let's create the perfect "problem child" physician. He (let's forget sexist issues for the moment) is an average student, who graduates from the average medical school (not in Lake Wobegon) and is accepted to an average residency. Because I have some experience with this arena, let's say he is a resident in general surgery.

Soon, issues arise. He's late for rounds. He doesn't always answer his pager. He's not the prototypical "stellar" resident, and fumbles enough for answers while being pimped by senior residents and faculty that everyone suspects he's just not quite cut out for life as a surgeon. But, at other times, he shines like a 16-year-old boy's first car.

The years roll on, and he is promoted; he may be shuffled off into a lab year, just so the folks in charge of his education can watch him a bit more closely. Upon returning to clinical rotations, he starts to have a series of blunders --- operative, at times, but mostly errors in judgement. By this time, however, he's a senior resident and the errors really aren't felt to be that bad, and it's really, really hard to not graduate someone from residency......so off he goes, to the real world.

The real world, mind you, is unsuspecting. Just as we expect that a new car will always perform up to its advertising, we expect that a newly minted and trained physician will be a widget that we can plug into a system and expect him to function --- flawlessly. Depending upon his situation, it must be made clear that the new-to-practice surgeon I described above may eventually become a very capable practitioner, a dependable and clinically proficient surgeon ---- Depending. Upon. The. Situation. Not every surgeon is fortunate enough to land in a position that provides him with the support and mentoring necessary to ensure his eventual success. The surgeon described above may opt for a position that will allow his shortcomings to blossom like a field of tulips in Holland, and multiply like the weeds in my lawn ---- he may choose, out of an inner sense of inadequacy, to practice at a "small" hospital, out of the way, where the likelihood of really sick patients, and really difficult surgery, is minimized.

That becomes his biggest mistake, and eventually initiates a chain of events that leads, ultimately, back to the beginning --- leaving folks like Rita wondering why in the H-E-Double-Hockey-Sticks did "they" let this guy out of residency?

OK, so now you may be wondering why --- on many levels:
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?
If I can solve the housing issues I described in my last post --- let's just say I've sold my damn house but don't have one to move into yet! --- I'll go on to the next phase of this problem in my next post!