Friday, February 19, 2010

Medical Staff: Active but Inactive

A few weeks ago the hospital where I hold "active" privileges sent me the usual form where I must fill in the names of other physicians who can vouch for my competence. Did I say active? I have not admitted, managed, or consulted on a case there in years (decades?).

What better way to determine the quality of a doctor’s work could there be than the repeated and collective observations of other doctors, nurses, and even administrators, in the hospital where he or she works day in and day out. Little wonder that many health insurance companies require doctors to declare their active hospital medical staff status contracted as providers in order to contract a preferred providers.
But doctors in private offices (like myself) practice almost in secret. Even their colleagues in the same office may have scant opportunity to observe the quality of their work. Only their patients may really know how they work, but patients often appreciate doctors doing the wrong thing or shun doctors who do the right thing, to obtain drugs for example.

So active membership on the medical staff of a hospital would seem to almost guarantee quality. When most doctors followed their patients from office to hospital and back again, you could rely on that system. But today hospitals hire “hospitalists” who work only in the hospital and only for the hospital, usually for a salary, and doctors who work in their offices rarely if ever care for hospital patients. How does the hospital determine that these doctors still deserve “active” privileges without the opportunity to observe their work directly? They require the doctors to provide references from their colleagues. Doctor A says Doctor B does great work. Doctor B says Doctor A does great work. And neither has more than a vague idea of the quality of the work of either. You scratch my back, etc.

Most of those doctors probably justify our faith in the quality of their work, but why do we allow this sham conspiracy of insurance companies, doctors and hospitals to continue? Health insurers need panels of doctors willing to reduce their fees in exchange for access to larger numbers of patients, and hospitals want those office based doctors to refer their sick patients to them.

I do not mean to suggest that hospitals should not allow doctors who do not admit patients some kind of affiliation. For myself I am grateful for the opportunity for continuing education and (almost) free lunches with colleagues as well as an opportunity to serve the community by my activity on committees. And the medical staff lounge provides opportunity for discussing specific cases as well as medicine in general, sometimes enhancing collaboration on cases or referrals back and forth.

Historically hospitals have classified staff privileges as active, courtesy, and consulting. Usually hospitals grant courtesy designation to physicians who can prove active status at another hospital. Physicians with consultant status are allowed to provide consultation only; they are not allowed to admit patients or manage their care.

When hospitals allow insurers to exploit there reappointment process it only serves to weaken the house of cards of our health care system by creating an illusion of quality where it may not exist. It should be abandoned in favor of a valid method of determining how well doctors care for their patients when they cannot be observed directly. Instead the insurers should find ways to assess physician competence, and I hope hospitals will find a way to encourage physician affiliation that benefits all. JCAHO should give its blessing.

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