Competency decisions after a leave of absence

Dear colleague,

Dealing with a leave of absence used to be a rare event for medical staff leaders. Today, changes in physician demographics combined with societal forces make leaves of absence more frequent.

The dramatic rise in the number of female physicians has resulted in many women physicians taking a leave of absence to raise children. Some return to work in a matter of months, but many do not return for years. Physicians in the military reserves are often called into service, sometimes for long tours of duty overseas. As more physicians actively practice well into their seventies and eighties, some will be forced to take a leave of absence due to illness.

Each of these scenarios poses different competency challenges for credentials committees, but they have one important element in common: The medical staff and board should only grant the returning physician privileges for which the physician is currently competent and physically capable to perform. The two most important factors to consider before making this determination are:

·         How long the leave lasted

·         What the physician did during the leave

For a medical leave, the nature of the medical condition and any residual deficits will be critical. Let’s tackle these scenarios one at a time.

A vacation of only a few weeks does not raise concerns about the physician’s competence upon returning, but a leave of a few years does. Somewhere between a few weeks and a few years lies a gray zone that makes competency decisions unclear. The longer the leave, the greater the likelihood the physician’s competency will decline to an extent that could impact patient care. Gone are the days when practicing medicine could be compared to riding a bicycle. Today, we recognize that competency declines with time away from active practice, hence the emphasis on “current” competency. This calls for a “5 P’s moment.” For those unfamiliar with the 5 P’s, it states, “Our Policy is to follow our Policy. In the absence of a Policy, our Policy is to create a Policy.” In this case, the medical staff should establish a policy regarding return from leaves of absence. The policy should establish the length of leave that triggers the need to reassess the provider’s competence.

What that reassessment looks like has to do with what the provider did during the leave. If he or she was on active duty as a trauma surgeon in the military, his or her competence as a trauma surgeon upon return will not be in question; however it could be regarding his or her competence in elective breast surgery. For a physician taking time off to raise children (male as well as female physicians), some will return to practice in the office and some will not. The scope of services provided in the office may not translate into competency in the clinical conditions and procedures for which the provider is requesting hospital privileges.

Some hospitals have taken the “manage tight” approach of requiring a mini-residency or re-immersion experience for physicians returning from a prolonged leave of absence of multiple years. Others have taken a “manage loose” approach of granting the same privileges the physician held before the leave. A middle of the road approach could grant the returning provider privileges to provide patient care and perform procedures under the supervision of another provider with the same privileges until he or she re-establishes his or her skills and demonstrates current competence. The devil is in the details of what constitutes supervision, but these are details to work out in the policy.

For physicians returning from a medical leave, whether in their 50s or 80s, before making a decision about their privileges, the medical staff must obtain information about the provider’s medical condition, especially any residual deficits. This may be obtained by requesting a letter from the provider’s treating physician(s). Your policy should also allow for requiring the provider to undergo a medical evaluation by a different physician mutually agreed to by the hospital and provider. In either case, the evaluating physician should be provided a list of the requested privileges and be asked to perform a medical evaluation specifically targeted on fitness for safely carrying out the requested privileges.

When it comes to physicians returning from a leave of absence, the goals are to be supportive of physicians seeking to return to practice while also protecting patients. Keeping these goals in focus and in balance will lead to good credentialing decisions.

All the best,

Rick Sheff, MD

Principal and Chief Medical Officer

The Greeley Company