To reference or not to reference, that is the question

Many medical staffs struggle with the issue of reference letters – some request them too often and some don’t request them often enough. When deciding whether to request a reference letter from another organization, medical staffs should first determine what The Joint Commission mandates and whether they want to go above and beyond that requirement. Even organizations that are not Joint Commission-accredited will find this a helpful place to start because it outlines a best practice.

Basically, medical staffs request reference letters when they do not have sufficient internal data to prove that a physician is competent to exercise the privileges that he or she is requesting. Medical staffs often lack internal competency data on new applicants and low-volume physicians, which is why The Joint Commission mandates that medical staffs request reference letters for these types of practitioners. The reference letters serve as surrogate measures of competence when medical staffs don’t have their own competency data.

Some organizations argue that if they are required to request reference letters for low-volume practitioners and new applicants, shouldn’t they request reference letters for everyone – even applicants for reappointment with sufficient competency data? These organizations mandate in their bylaws that the medical staff request reference letters for all reappointment applicants, which is an acceptable practice as long as the reference letters provide useful information and do not significantly slow down the reappointment process. 

Other organizations don’t feel that the external reference letters offer any more information than internally-collected competency data does. These organizations feel that requesting reference letters puts a large burden on the medical staff services department and delays the reappointment process, far outweighing any potential benefit. If your organization doesn’t find reference letters clinically useful and difficult to handle administratively, then don’t request them if you have adequate internal competency data.

Once a medical staff decides to request reference letters, then it must ask, “Who should serve as the references?” The answer to this question will differ between initial applicants and reappointment applicants. For initial applicants who are new graduates, a medical staff needs to reference the residency program director at the teaching hospital where the applicant completed his or her residency. But after that, who should the medical staff ask? In the past, medical staffs allowed the new applicant to choose their references—usually the three individuals most likely to give them a favorable reference. This is called the non-directed approach. But how useful are good references from the three people who hold the applicant in a favorable light? On the flip side of the coin, if an applicant’s three best references still cannot offer a favorable recommendation, then you have a major red flag.  

In today’s environment, many medical staffs are choosing the directed approach, particularly for initial applicants. Directed references are those that the medical staff chooses, rather than those the applicant chooses. For a surgeon, the medical staff might ask for a reference letter from the chair of the surgery department, the chair of the anesthesia department, and the nurse manager of the OR at the facility where the applicant previously worked. The medical staff should ask each of those individuals only for information that he or she is competent to provide. The medical staff should not ask the nurse manager to assess the applicant’s surgical skills, but he or she could offer useful information regarding the applicant’s professionalism and communication skills. 

For reappointment applicants, particularly low-volume physicians, the medical staff should request information from current staff members who can attest to the quality of the care that the applicant provides to patients. For primary care physicians, medical staffs should gather information from some of the specialists that they refer to. Particularly, the medical staff should ask the specialist whether the care that the primary care physician provides is commensurate with his or her level of expertise and whether the physician referred appropriately. For specialists, medical staffs should request information from primary care providers to assess how well their patients were taken care of by the specialists. 

In summary, medical staffs should always request reference letters for new applicants and low-volume physicians and only request reference letters when for other reappointment applicants when the information gained outweighs the hassle factors of gathering it. Finally, medical staffs need to carefully design who the references should come from to get the most useful information.

Mary Hoppa, MD, MBA, CMSL, is a senior consultant with The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.