Wednesday, October 12, 2005

Letters to the Editor......
From yesterday's Wall Street Journal two letters in response to the story I discussed in yesterday's post. The first:
Your page-one article "A Doctor's Tale Shows Weaknesses in Medical Vetting" (Sept. 21) reminds all physicians of the two simple words describing the obstacle we face when disciplining a peer: hospital bylaws. These step-by-step rules on how things are to be done are ostensibly physician-written, but are in reality edited by hospital boards and their attorneys. They detail the committee meetings, the documentation, the practice and chart reviews, hearings, rebuttals and official notifications required in managing poor doctors. When followed to the letter, these rules hamstring the medical staff and delay suspension of the troublemaker while more patients suffer. If not precisely followed, which can easily happen in the emotional rush to protect patients, the accused physician's attorney charges the medical staff with violating its own bylaws. Then the bad apple cuts a deal and moves to another state, safe in knowing that it is illegal for the old hospital to tell the new hospital what happened. Then the malpractice begins anew.

So, which is better: the current system, or a different one where maybe overzealous doctors too quickly judge a colleague? I bet Dr. John Anderson King's patients know the answer.

Brantley Burns, M.D.
Tennessee Orthopedic Clinics
Knoxville, Tenn.

Now there is a fine balance between efficiency and due process. Examining the Dr. Poliner situation Dr. Rangel points out, quite rightly that peer review may be used as a blunt too against competitors. Ideally peer review would be fair and impartial, but not drawn out. Discipline should be meted out without fear of litigation. As I have posted before, outside of large cities peer review may be best served by outsourcing it.

The second:
As a board-certified orthopedic surgeon who chairs a large metropolitan hospital's clinical risk committee that supervises the clinical performance of its medical staff, I must say that the issues you raise aren't uncommon.

Dr. King's basic biographical information -- multiple practice locations crossing interstate lines, gaps in residency training and lack of board certification or eligibility -- are all red flags that should have prompted careful scrutiny of his practice qualification and credentials. Too often, hospital peer-review committees are left to deal with physicians practicing outside accepted standards whose initial credentialing process was "shepherded" by an overzealous administrator wanting to add new medical "product lines" or an established medical group eager to take on a new partner.

That willingness to expedite the due diligence process, rather than placing the burden of proof of clinical competence on the practitioner at the time of application to a hospital staff, sets the stage for the messy, and invariably litigious, denouement of suspension and expulsion from a medical staff, not to mention the harm done to a hospital's reputation or the community it serves.

In the case of Putnam County, W.Va., HCA Inc. didn't serve the interests of its patients well. Better no specialist in a community than a bad one.

Michael M. Katz, M.D.

This is the "ounce of prevention is worth a pound of cure" letter. In a peer review situation the burden of proof is more equally divided between the committee and the physician. In a credentialing situation, even under "fair hearing" rules that most medical staff bylaws must follow, the burden of proof lies much more on the applicant. When I was on the credentials committee there were several situations where an applicant was asked to appear before the committee and explain litigation, gaps in training, or frequent moves. Sometimes the committee would be satisfied, other times we would not be and ask for additional documentation. A few times the applicant would "get the message" and either not provide the documentation, or withdraw the application.
Re-credentialing often times can fall into the same trap as peer review, depending on who sits on the committee. In fairness, I never felt pressured to pass along an applicant due to economic concerns of the hospital.
Additional views from Red State Moron and the Aggravated Doc Surg.
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