Solo Dilemma

The other day I got a big, fat envelope in the mail containing my biennial re-credentialing packet from the hospital. I know I have to go through this whole rigamarole on a regular basis. Most insurance companies require it every two or three years, and so does the hospital. But whoever needs it, it's always a pain.

There's the basic information about name, address(es), phone, fax and contact numbers. Then there's a re-hash of all the educational information; no, my medical school and residency graduation dates haven't changed in the last two years. Fortunately many of the forms have this information "pre-populated" (already filled in for me) but I still have to go through and make sure they have it right. This time around there's a new indignity: my medical school doesn't exist anymore, so I am listed as having graduated from the university that was kind enough to take it over when it was threatened with total oblivion. I sigh and decide I don't care enough to go rocking the boat by trying to change it; I figure not sending them money is revenge enough.

Board certification usually comes next. This, too, hasn't changed in the last two years, but because Family Practice board certification expires, they want to know all the dates of cert and re-cert. It's harder than you might think to put my hand on the piece of paper documenting my second re-cert when I'm a year away from my fourth.

Malpractice insurance doesn't change either, but I always have to write it in, as well as include a copy of my face sheet.

There's the standard list of questions about open malpractice claims (ever since the trial three years ago I can finally say "none" once again, thank FSM), whether I've ever been disciplined or committed of a crime (luckily they specify an exception for "minor traffic violations"; lets me off the hook for that parking ticket downtown eight years ago), and if I'm addicted to any kind of substance, legal or illegal, that could impair my ability to practice my profession. I'm going to assume that because I can do my job without chocolate (even though I don't like to) I'm safe checking off "no" on this one too.

I have to sign the thing. Over the years, the disclaimer/attestation/whatever that precedes the signature (the part that says I've told them everything, haven't lied, that they can contact anyone they want to verify the information, and that I can't sue them) has grown from a sentence or two, to a paragraph or two, to two single-spaced pages in tiny font.

Nowadays there's actually a way to do this online. This outfit collects all the info, verifies it, and then provides it to whatever insurance companies I authorize to receive it. I only just did this thing, even though I've known about it for a couple of years now, and although it was a PITA to go through it the first time, I can see it being a huge time-saver in the future. So I called someone at the hospital, just to see if they can't contact those folks online and not put me through all the nonsense. They said no.

Of course the hospital packet includes more specific stuff on privileges; am I applying for the same set of core privileges I already hold, or am I asking for any changes? And if so, am I qualified to do what I'm asking to, and can I prove it?

Here's my problem: I haven't admitted a patient to the hospital in seven years. I consider myself an expert on outpatient care, and I'm good at it. I can get things done in the community using resources my hospitalist colleagues have no idea exist. My specialty is keeping patients out of the hospital. If someone needs to be in the hospital, it isn't me they need. At this point, no, I don't feel competent to manage an inpatient [and please, whatever you do, don't tell my residency faculty that I've failed them.] But all the insurance companies that I still have to maintain contracts with require that I have hospital privileges. And so the charade goes on.

But this time around there's something new:

If you have had no clinical activity [at the hospital] in the last two years, you must submit the enclosed Clinical Evaluation, to be completed by a peer or associate.

Enclosed is a two-page questionnaire with a list of qualities and two columns for the respondent to check off for each: "Favorable" or "Unfavorable." Here are some of the things they are asking someone else to certify about me:

• Medical knowledge
• Technical skill
• Patient management
• Outcomes
• Quality of charts
• Patient relationships
  
• Involvement in medical staff affairs
• Relationships with nursing staff
• etc.

The second page is a re-hash of the "impairment" questions about restriction of privileges, substance use and so forth.

WTF?

"Solo" means "alone." No other medical professional in the office. No one. How can anyone fill out a form like that meaningfully? Oh, I can probably find a buddy somewhere to sign it and send it in, but this whole episode has got me thinking about several things.

I know I am competent; that I keep up to date; that my charts are wonderful, my patients love me, and my outcomes at least average. At least I think I know this. I believe it, at any rate. But realistically, with no one else in the office (short of an actual observer coming into the office, watching me interact with patients and auditing my charts), how can I prove this? I could be a complete schmuck, and no one would ever know.

I know this because there are other docs I know of who scare me. I've seen their charts when their patients transfer to me; I've talked to them at meetings. They scare the crap out of me and frankly, I wouldn't send my dead dog to them. Yet they somehow manage, year after year, to get re-credentialled by hospitals and insurance plans. Back in the day when HMOs were new in town, they also managed to get themselves into the top "Quality" tier for payments.

(Digression: Dinosaur's Law of HMOs:

The more times the word "Quality" appears in a given document, the more the document is bullshit.)

Then again, I've also known the "good 'ole docs;" the ancient oldsters still using aldomet for hypertension and oral dicloxicillin for impetigo. (Yes, they work, but that's not the point.) The ones who, despite their best efforts to keep up, have held on too long and can't cut it anymore.

How do I know -- in my heart of hearts -- that I'm not one of them?

You might say, "What about CME? If you're doing your 50 hours a year then you're fine." Let me share a dirty little secret: I'm more likely to attend a CME conference about something that interests me than about something that doesn't. (Revelation: yes, there are certain subjects that don't interest certain docs, at least not as much as others.) People -- including me -- tend to stick to the familiar. What this means in the context of continuing medical education is that we tend to be very up to date with some things, without ever realizing how stale our knowledge is in areas we were never very good at to begin with.

So even though I haven't even hit the half-century birthday mark yet, how do I know for sure that my competence hasn't already begun to slip? That the quality of my care isn't really as good as I tell myself it is?

Scarier still: I'll never really know.