You Won't Believe who's Asking for What Privileges Now

Dear Colleague,

Traveling around the country and working with many hospitals provides a wealth of opportunities to see what’s happening on the frontlines. It also makes for some amazing stories.  This one comes from a hospital at which an ophthalmologist requested privileges for breast reduction and augmentation after attending a two-week course.

Although perhaps comical, this story is all too real. Similar stories are playing out over and over as physicians, under pressure to find new sources of revenue, cross previously sacrosanct specialty boundaries in search of patients and procedures. In particular, physicians seek to provide elective, high margin, daytime, billable services, and all too often push the envelope of reason and patient safety. That’s exactly what made breast surgery attractive to this particular ophthalmologist.

Minimally invasive surgery and other technological advances lower the bar for the time and intensity of training needed to achieve competence in some of these attractive (read that lucrative) procedures. This trend blurs some of the bright lines of the past regarding training and competence. The question is: How will your medical staff respond to these challenges?

The first step is to adopt the “5 P’s” with which many of you are familiar:  “Our Policy is to follow our Policy. In the absence of a Policy, our Policy is to adopt a Policy.”

Establishing eligibility criteria for requesting privileges is the policy in question. Should an ophthalmologist be eligible to request breast surgery privileges in your institution? If he or she is not eligible, the medical staff will not process the request. The medical staff will also not have to issue a denial or offer a fair hearing. If he or she is eligible, the medical staff must assess the ophthalmologist’s competence. If found to be inadequately competent for the requested privileges, the medical staff must issue a denial and offer a fair hearing, two steps it would rather avoid.

To determine whether the ophthalmologist will be eligible to request breast surgery privileges, the medical staff must wrestle with a key challenge that underlies many credentialing decisions. Where does your medical staff and hospital want to be on the spectrum between “managing loose” and “managing tight”?  I refer to these two management styles as “goods” because there is a value to each, which are two poles on either end of a spectrum. Manage loose allows for flexibility, creativity, customizing care to individual patients, and, in this case, physician entrepreneurialism. Manage tight is how we achieve reliability, high levels of patient satisfaction, cost effectiveness, and patient safety.

Applying this framework to our ophthalmologist’s request for breast surgery privileges, we can recognize the value of supporting physician entrepreneurialism and weigh it against the priority of patient safety and good clinical outcomes. The example of an ophthalmologist requesting breast surgery privileges appears to be outside the bounds of safe and appropriate care, which makes the judgment call of coming down on the manage tight side of this issue quite reasonable. However, numerous current and yet to be imagined requests for privileges outside the usual bounds of a particular specialty lie ahead for your medical staff, especially requests driven by the pursuit of lucrative procedures and evolving technology. Many of these cases will be less black and white and more about managing shades of gray. Applying the 5 P’s and wrestling with where your medical staff and hospital want to be on the spectrum between manage loose and manage tight will be the keys to thoughtfully, safely, and fairly navigating these challenges ahead.

All the best,

Rick Sheff, MD
Principal and CMO
The Greeley Company