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As a health care consumer, it is important to understand who is guiding you, the patient, how to consume or utilize health care resources.

It all begins with post-graduate training or medical school. Medical School in where the student receives his/her medical degree, either medical doctor (MD) doctor of osteopathic medicine (DO). The current graduation rate from medical school MD-only is 82.5%, a decline of almost 10% over the past 40 years. Each student receives a grade point average (GPA) which ranks each student each year. Students with high class rank and high GPAs typically apply to competitive residency training programs: the next step after medical school.

After receiving a medical degree (MD or DO), the new graduated physician applies for residency in the discipline of choice. Prior to entering residency, all graduates must complete a year of internship or the first year of post-graduate training (PG1). The residency disciplines are broadly divided into medical specialties (internal medicine, family medicine, etc) and surgical specialties (general, orthopedic, ENT, ophthalmology, urology, etc.). During residency training, each resident receives a yearly evaluation and is required to complete an in-training examination. The in-training examination is ranked nationally allowing each resident to compare his/her knowledge with physicians in similar specialties. Certain specialties in each group are very competitive such as orthopedic surgery, increasing the significance of the yearly evaluation and in-training examination scores.

Upon completing a residency, a newly trained residency graduate may elect to perform a fellowship. Fellowship training is designed to advance the skills (academic and technical) or expertise of graduate of a resident training program.

At this point, training is over. The new residency graduate must demonstrate knowledge and experience.  Initially, knowledge and experience are verified by a letter of support from the residency director and fellowship director. It is the responsibility of the medical staff and credentialing body (health system) to review, in detail the letters of support and the case log demonstrating exposure and hopefully experience. A physician credentialed and privileged to perform procedures at a health system does not guarantee board certification or core competency.

In order to provide patient care, the graduate physician applies for hospital privileges. At this phase, the physician is board eligible. He/she must produce a letter from his/her residency director in support of the application and produce a log book to demonstrate experience in caring for patients. The graduate physician will be credentialed at the health system (membership) and privileged (expertise) to provide care for requested procedures.  At this stage, determination and verification of competency is an obligation of the facility permitting the physician to practice medicine.  This obligation is termed core competency and is often insufficiently evaluated by the credentialing committee at most health systems. The ability to perform specific procedures is internally determined by each individual physician. Performing a procedure without adequate training and experience often results in injury.  These poor outcomes are often hidden inside an internal health system called peer review or with the excuse from the treating physician- “that was a severe injury and I did the best I could”. The question is “Is there another local provider who has more expertise and proficiency?”

Board Certification in surgical specialties is a two-step process: a written examination at the completion of residency (part 1 orthopedic pass rate 2016 – all 86%, first time 96%) and an oral examination two year later (orthopedic pass rate 2016 – 96%).  The written test assesses knowledge and the oral exam is an attempt to determine competence. The examinee selects the cases for oral presentation for part 2.

As you can see board certification is almost guaranteed if the applicant has the knowledge. Knowledge, however, does not determine experience and competence. Although knowledge is a start, it does not in any way guide the health care consumer about competence. The privileging process at most health systems fails to evaluate case logs and most core competencies are never verified. Minimal standards are in development by the American College of Graduate Medical Education (ACGME). Unfortunately, competency is self-determined by the physician provider creating an inherent gap in proficiency and expertise between physician performing similar procedures.

Pitfalls for any consumer of health care to understand:

  • Board certification does not guarantee proficiency or core competency
  • Certificate of added qualification does not guarantee proficiency or core competency
  • Physician performing similar procedures may have very different expertise, skill and competency
  • Advertising a skill or service does not guarantee proficiency or competency

Questions to ask

  • Have you ever had to a case reviewed at “peer review”?
  • How many times have you performed this procedure?
  • Where did you train and was this training focused upon this type of disorder?
  • How long have you been in practice?
  • Is your group focused on this type of care?
  • Are you or your group recognized nationally?
  • Do you have any partners in your practice that are able to help you should you need help?
  • If I have an emergency complication following your treatment, who will treat my problem?
  • Verify that non-operative and operative treatment option are available for your condition-surgery is only one treatment option
  • Understand the complications associated with the proposed treatment options

How to protect yourself

  • Physician must have completed a residency and possess a supporting letter of recommendation from his residency director
  • Physician must demonstrate knowledge by having passing scores on in-training examinations
  • Physician must attain board certification and maintenance
  • Physician must not limitation of privileges at any facility
  • Physician must be able to perform all aspects of specialty discipline from elective procedures to emergent procedures including management of complications. For example, hand surgeon must be able to perform replantation/revascularization and care of the mangled hand as recommended by the American Society for Surgery of the Hand (ASSH).

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