Is practicing medicine really like riding a bicycle?

Dear Colleague,

Last month in Medical Staff Leader Connection, we discussed the challenge of whether to use minimum volumes as threshold criteria for privilege eligibility. As a stepping off point for tackling this issue, we began with the Competency Equation which states: 

Current competence = Evidence you did it recently + Evidence that when you did it, you did it well

The assumption behind this approach to competency is that recent data is required to establish current competence. The corollary of this assumption is that if a practitioner has not performed a privilege recently, the practitioner cannot be deemed currently competent to carry out that privilege. Yet all of us have heard physicians claim that much of practicing medicine is like riding a bicycle. However, this is not the case.

The debate over how much of medicine is truly like riding a bicycle and how much requires demonstrating current competence arises from three key issues that speak to the transition that is occurring in the field of credentialing and privileging and the profession of medicine itself. The first of these key issues is the field’s shift from the perspective that privileges, once granted, were somehow “owned” by physicians and couldn’t be “taken away” unless the medical staff could prove incompetence. Instead, it is now understood that the requirement for reappointment that exists in both the Centers for Medicare & Medicaid Services’ Conditions of Participation and The Joint Commission’s standards means that privileges automatically lapse at the end of the period of appointment. They must be granted anew at that time, which means the provider’s competency at that time must be reassessed and matched with the privileges he or she requests.

The second key issue is a growing awareness that providers’ knowledge and skills decline over time when they are not actively used in practice. Let us consider the case of a general surgeon who, when he completed his residency training, had applied for and been granted privileges to perform hysterectomies on the basis of having completed more than a dozen hysterectomies during training. However, once in practice, he found that in his hospital, all the hysterectomies were performed by gynecologists. At the end of his first two-year appointment, he applied for and was granted hysterectomy privileges, an option available to him because the medical staff still used laundry lists for delineating privileges. The same occurred at the next reappointment, even though the surgeon hadn’t completed a single hysterectomy in the previous two years. At the next reappointment cycle, the credentials committee expressed discomfort in re-granting hysterectomy privileges without evidence of current competence. The surgeon’s response was an angry retort, “Are you telling me the anatomy has changed since I last did a hysterectomy?” This type of comment misses the point. It’s not the anatomy that has changed, but the surgeon’s automaticity, memory for steps in the procedure, and judgment to handle unexpected complications that may arise. If the surgeon considered doing a hysterectomy using minimally invasive technology, that technology is evolving so rapidly that what he had been trained to use might not be the equipment used today. As an added concern, patient safety and human factors research is showing that procedures performed after a break as short as a weekend can produce higher error rates. The airline industry uses flight simulators to help pilots returning from a leave to ramp back up in current competence. Simulation training is an option for some practitioners, as well.

The third issue is that the bar has been raised in our field. As noted in the October 21, Medical Staff Leader Connection, the new standard is to make privileging an objective, evidence-based process. This means credentialing and privileging decisions today should be based on evidence of current competence and conduct, not simply the absence of bad news.

Together, these issues highlight a sea change in the medical profession. I have stated previously that we are in the midst of a transition in the medical profession. We are moving from a period characterized by too much loose management regarding physician competence and performance to a new period that will increasingly be characterized tighter management.  As valuable as this transition is, we must maintain vigilance because there is such a thing as management that is too tight. As we move towards more evidence-based privileging, I expect we will find increasing data showing that some aspects of medicine are like riding a bicycle, but it will prove to be a far smaller portion of what physicians do than most physicians would claim today.

All the best,

Richard A. Sheff, MD, CMSL, chair and executive director of The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.