Medical Privileges
Who Owns the Vascular Tree?

Competition among physicians of different specialties has escalated in the past several years as new technology expands. Healthcare boards, responsible for credentialing physicians to perform these procedures, are finding their decisions are becoming increasingly complex and often have an economic twist. Today, the issue is heating up over "who owns the vascular tree?" Physicians can perform specialized procedures at a hospital only if granted privileges by the organization's board of directors. Several specialties are involved in performing vascular procedures—cardiologists doing angioplasties, neurosurgeons performing aneurysms of the brain, vascular surgeons taking care of aneurysms of, for example, the kidney interventional radiologists doing both diagnostic and therapeutic vascular procedures. For these physicians, the economic implications of these procedures often dominate the discussion. "The need to credential physicians of different specialties to perform vascular procedures arises in every question and answer session of my presentations at The Governance Institutesaid Barry C.Dorn, M.D. One Physician may have obtained additional training to perform a specific procedure, while the same procedure has been done by other physicians without that specialized training. Should only the trained physician be granted privileges to perform the procedure? Should the other physicians have their privileges for that procedure revoked? How does an organization establish objective criteria to use in the process of credentialing physicians to perform new procedures involving new or expanded use of technology?

A hospital must ensure that physicians have the education, training, and clinical skills required to perform complex new procedures. Hospitals and physicians involved in the credentialing process must remember their obligation to protect the public. These procedures often carry high price tags and can contribute significantly to a physician's income. Mike Griffith, M.D., also emphasized the focus on the patient. "If you start with the patient, it makes it easier for the board, the hospital, and the physician," he said. Griffith, a neurosurgeon, practices at St. Mary's Hospital in Grand Junction, Colorado. "Every credentialing issue should .begin with the patient at the top of the list —what is best for the patient," he said. Dorn has a solution to handle the segmentation and increasing professiona1 competition with- in this field. "It's very straightforward to me,” he said. Hospitals can solve the problem by establishing an "Invasive Vascular Division" that includes credentialed specialists with privileges to perform specific procedures in cardiolo- gy, radiology, neurosurgery, and vascular surgery. Vascular procedures would be performed only by specialists who meet the criteria for privileges within this division. Establishing a new division requires a comprehensive plan that ultimately must be presented to the board of directors by the medical staff. When an organization’s medical leadership embark on this course, they typically look to the Medical Executive Committee and the Credentiahng Committee of the medical staff to define the new criteria. Dorn's formula for credentialing criteria has five components:

1. Physician specialized training
2. Years of Experience
3. Medical judgment
4. Ability to handle complications
5. Ability to follow the patient

through to the conclusion of the episode Griffith added that handling complications and follow-through can be accomplished when the specialist has a working relationship with another physician specialist who is willing to assume care of the patient if a procedure goes awry. Specialized training does not always supersede experience, Dorn said. Those with many years’ experience performing a certain procedure may serve patients as well as those with the specialized training. Griffith noted that boards must examine the experienced physician’s track record in performing specific procedures. With a good track record, it may be reasonable to “grandfather” in physicians who have extensive experience with a procedure, but these physicians "must demonstrate ongoing competence,' Griffith said. "Physicians are only as good as their last procedure,” he added.

According to Dorn, directors must understand the basis of the specialist segmentation controversy, and get the right information from medical-staff leadership. "Physicians tend to be a little argumentative and will say trustees don't under- stand the practice of medicine," Dorn said. It's up to medicalstaff leadership to educate the board and offer advice and counsel about these prickly issues. “The more knowledge you have as a board member, the more likely the medical staff will take you in the right direction,” said Dorn.