Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Sunday, May 27, 2007

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.


"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.


At Sun May 27, 04:07:00 PM, Blogger Dr. K. said...

It's just ridiculous. In other words they are saying "we know that you haven't worked in the hospital for the past two years so please will you let us know how your work in the hospital over the past two years has been going?"

It reminds me of the joke that arose from the movie The Sixth Sense: I see stupid people everywhere. They are all around me.

At Mon May 28, 07:26:00 AM, Blogger Dr. Smak said...

Dr. D,

Sounds like you are following the path of most physicians with a quest for perfection. You can't be at the top of your game for your entire career, and being good enough (to quote an excellent previous post of yours) might have to suffice.

There are some truly horrible physicians out there (not fit to bury the dead dog), but there are also docs out there better than I on their worst day. In physician infancy we all screw up; it is a practice, after all. Chances are that as geriatric physicians (not geriatricians) we are less likely to be up to date, not to mention as quick-witted. How to know? Tough question...

As for the credentialling, it's about as useful as P4P, or it's evil step-cousin Pay For Outcomes. They reflect little more than the ability to complete paperwork (or to hire a competent office manager to do it for you.)

An unrelated note: thank you for your comments about being an outpatient expert. So many FPs look down on that as a career choice, as sellouts or physician extenders. I feel that, for those of us who aren't willing to devote all of our time to our careers, choosing a niche allows us to be better physicians. The day of the FP who manages ICU patients, delivers babies, and manages complex outpatients needs to be over. It can't be done well.

At Mon May 28, 07:57:00 AM, Blogger MedStudentGod (MSG) said...

I wonder if extending yourself into the blog realm and having "friendly" disagreements with other physicians hasn't helped keep you more up to date. You certainly seem to be very knowledgeable and down to earth. However, if you start telling us that vaccines are a waste of time or that penicillin kills everything including viruses (which I've actually heard from an old doc before) then I'd be worried. Till then, keep it up.

At Mon May 28, 08:54:00 AM, Blogger Margaret Polaneczky, MD (aka TBTAM) said...

In this whole re-credentialing process, the onethat I think comes closest to capturing current knowldge is the board recertification. It says at least that youare current on an agreed upon fund of knowledge in a field.

It does nothing, however, to measure how you practice using that knowledge.

At Mon May 28, 09:48:00 AM, Blogger Rita - Supporting Safer Healthcare said...

As a person who until recently worked in the field of Medical Staff Services, I have sympathy for both sides on this issue.

Yes, filling out all the redundant paperwork for hospitals and managed care plans must be painful, I know I'd hate to do it. On the other hand, imagine being the person in the medical staff office who must prepare and mail hundreds of those packets and then carefully review each of them when them come back. I can vouch that that too is a painful process.

Over the past fifteen years or so, federal regulations and accreditation standards pertaining to the medical staff have increased enormously - not to mention the potential for litigation on all sides (thus the two-page tiny-print release form). The goal of course is to weed out those (few) bad doctors you mentioned, and to assure that the physicians on your staff have maintained clinical competence, which is a much more challenging goal to meet.

Everyone agrees with the goals, and nearly everyone agrees that the process has considerable room for improvement.

Perhaps your best course of action would be to request a seat on the Credentials Committee. Learn the system from the inside and then offer suggestions for ways to streamline the process.

Rita Schwab, CPCS, CPMSM

At Tue May 29, 08:50:00 AM, Anonymous Anonymous said...

Ditto to what MSG said. Also, your willingness to question your own abilities/knowledge speaks volumes. If you were closer, you would be my doc. :o)

At Wed May 30, 06:50:00 AM, Anonymous Anonymous said...

Instruction for physicians—as professionals—differs from that for other adults because professions differ from other occupations. First, professionals address more complex problems for their clients than do practitioners of other occupations. Second, the knowledge and skills professionals use in addressing the problems are: Esoteric; require prolonged, supervised training; and can be harmful if used incorrectly. Third and finally, professionals must develop cognitive skills and ethical reasoning abilities not required of other occupations and use those esoteric skills and knowledge in handling complex problems. These differences suggest that the principles of adult learning must be qualified to teach physicians. There is evidence that shows doctors seldom learn solutions to problems they do not have therefore CME should address problems physicians are seeking solutions to.

At Wed May 30, 06:18:00 PM, Anonymous Anonymous said...

YOur comment that some one who needs to be in the hospital doesn't need you, is an example of personal insight that is to be applauded. Good for you!!

The concept that insurance companies require you to have a hospital affiliation in order to take care of their Outpatients is pure BS and needs to be challenged for the following reasons.
1)Any quality review of your hospital work has little if anything to do with your OP work.
2)A hospital affiliation with no admissions attests to what??
3)The insurance company is getting a free ride. You pay to be on the hospital staff, the hospital pays to process your documents and communicate your status to the insurance company. The insurance company pays for nothing and gets to claim that they have a quality process to protect their patients!

Not sure how close you are to retirement, or even if you want to retire....but, tell the hospital and the insurance company to FOAD.

You get no benefit from the hospital so next time the reappointment documents arrive round file them. Better yet, to prevent a second packet from showing up, I suggest that you drop the Administrator (Nice hair and nice suit as I recall) a note-thanks but no thanks.

Advise your patients that you can no longer afford to take insurance as you cannot afford the staff to pursue insurance claims,and you are unwilling to pass these additional costs on to your patients.

I do not know you, but based on your writings, I believe I would like you.

At Wed May 30, 06:42:00 PM, Blogger #1 Dinosaur said...

Tomp: Thanks for the kind words. Ditching all insurances (along with the hospital charade) and going cash-only is, in fact, my ultimate goal. I'll probably take the plunge if/when I lose one of my two staffers.

Rita: Allow me to respectfully disagree. The proliferation of federal requirements has done NOTHING to achieve its stated goals of assuring competence and quality. Witness Kim's rantings about JCAHO regs becoming so ridiculous that they actually impede patient care.

At Sat Jun 02, 09:25:00 PM, Anonymous Anonymous said...

Hi Dino,

Thank you! I've said often (and my patients appreciate) that my job is to keep people out of hospital. Lots of them never thought of it that way before.

I have credentials at two hospitals that don't talk to each other. I have to re-up both of them all the time. Argh.



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