“You are not privileged to perform an appendectomy” the operation theatre sister told me when she checked the consent form.
I was infuriated by this remark. The patient was planned for a laparoscopic cystectomy (removal of an ovarian cyst) for severe endometriosis. This patient requested that I remove her appendix, if was affected by endometriosis. I wrote a letter to the CEO of the hospital demanding an explanation on how the sister can prevent me from performing this surgery when I had been doing this for the last 20 years. The management did not budge. They told me that I was not privileged to do this procedure and I needed to get a general surgeon to take the consent for the appendectomy.
I have no problems with a general surgeon performing this procedure. However, the problem is with the insurance providers. They will question me as to why an appendectomy was done when the patient has an endometriotic cyst and more importantly why there is a charge for the appendectomy. If I perform the appendectomy, I do not issue a charge code for this procedure but when it is performed by a general surgeon, he will charge for the procedure. Insurance companies will not pay for this procedure. How should I navigate this situation? Fortunately, my friendly general surgeon, who observed me perform the laparoscopic appendectomy, agreed with me not to charge any fee for this additional procedure.
When I started practice in Mahkota Medical Centre in 1994, there were 20 of us and all of us were young and fresh out of government hospitals. We did not have anyone or any committee guiding or telling us what we could or couldn’t do. We did everything in good faith. Our main interest was the well being of the patient. If we thought we were not good enough for a procedure, we got help from others. For example, our new cardiologists called senior cardiologists from Kuala Lumpur to help them while performing angiograms and angioplasties. Only after they felt comfortable enough to perform the procedures by themselves, did they stop getting assistance. Similarly, our surgeons would bring in other surgeons to perform complicated cases. I myself got assistance from surgeons and urologists when I performed complicated cases. No one was credentialing or privileging us at that time.
However, as more doctors joined the hospital, with increasing trend for litigation, and especially when the Private Health Care Act was enforced, Credentialing and privileging became more and more important. Quality assessment societies such as the Malaysian Society of Quality Health (MSQH) and Joint Commission International (JCI) require that everyone working in a hospital is credentialed and privileged. Moreover, with more and more subspecialisation, generalists have to prove that they can perform a certain procedure now allocated to a subspecialist.
What is credentialing and privileging anyway? Credentialing is a “practitioner’s appraisal process”. It is a primary evaluation process that involves the verification of the practitioner’s right to participate in the medical staff membership and of his/her competency to provide patient care in the appropriate setting in the hospital. It is usually done once in every two years. If the hospital carries the credentialing process by itself, the medical director usually bears ultimate responsibility for credentialing along with the Credentialing Committee. Sometimes the credentialing is delegated to a third-party called “Credentialing Verification Organization (CVO) who will report the results to the hospital. The reason for the credentialing is that without it, the hospital will have no knowledge of the competency of the physicians who are about to join the clinical team and thus jeopardizing the quality of clinical service/care provided within the facility. In the event of a legal action against any one of its physicians, the hospital may expose itself to some liability by having failed to carry out proper credentialing.
Privileging, on the other hand is granting permission to provide specific medical or other patient care services in the organization. Within well-defined limits, based on the individual’s professional license, competence and experience, ability and judgment, and on the organization’s ability to provide and support the service.
Who forms the Credentialing and Privileging Committee? The Private Health Care act is silent on this issue. It is the prerogative of the Medical Director to choose who will sit in this committee. It is not an elected committee.
So when a new specialist joins a hospital, this committee will first look at all his/her credentials. This will include the medical degree/licence, speciality certification, the training that he/she has undergone, other hospital privileges, malpractice history and so on. Once the committee is satisfied with the credentialing process, then comes the privileging part. There is usually a general acceptance of the scope of work within a speciality and these privileges are given to them but when it comes to special privileges, then this will be a point of contention. For example, in the field of OBGYN, can the specialist be privileged to perform IVF, laparoscopic surgery, handle gynaecological oncology cases or urogynaecology procedures? This can be a difficult decision for the Credentialing and Privileging committee. Sometimes the Credentialing and Privileging committee may consult the resident specialists for their input.
Another issue will be how the Credentialing and Privileging committee should continue issuing these privileges every 2 years. Should they ask the specialists to provide a log book of how many of each procedure they have been performing? If they have not been performing enough of a certain procedure, are they going to withdraw the privilege? In my experience, this is rarely done. The situation becomes more complicated when the privilege crosses speciality like the case of the appendectomy I described earlier.
What about new procedures? Who will credential and privilege them? What about experimental procedures or certain procedures performed for the first time in Malaysia or in a certain hospital? Does the Credentialing and Privileging committee have the right to give such privileges?
I had this experience recently when I started providing High Intensity Focused Ultrasound (HIFU) service for fibroid and adenomyosis at Mahkota Medical Centre. Although I went to China to undergo training in January 2020, the installation of the machine was delayed because of the pandemic. I could only start providing the service in July 2021. A HIFU specialist came from China to do the cases with me for 3 months as a refresher. She taught me to become competent in HIFU. The HIFU society then certified me and then with that certificate I was privileged by my hospital to perform the procedure. As I am the first in Malaysia to perform ultrasound based HIFU this was a tricky process.
So what advice can I give young doctors.
1 Keep a log book. Write down everything that you do when you are training and even after you have become a specialist. This log book will be useful to show the administration of any private hospital that you intend to work for, in the future. Without a log book it is difficult to justify what you can or cannot do in a private hospital.
2. Collect certificates whenever you attend a meeting or a workshop to gain new skills. This can also be shown to get accreditation.
3. Try to get as wide an experience as possible before moving to private practice so that you can be privileged to perform a wide variety of procedures. The more you can do the better the chances of getting such privileging.
4. Be systematic in your training in whatever field you are pursuing. When training in a speciality, one’s focus is usually to pass the final exam but think beyond that and the possibility of working in a private practice where your seniors will ask you what you can and cannot perform competently.
5. If you feel unfairly unprivileged, have a process to appeal.
I would like to thank my wife Sarojini for editing this article
I would also like to thank Dr Gunasegaran for editing and providing his input on this article.