What is the most ethical approach for granting clinical privileges to an orthopedic fellowship graduate to perform complex spinal surgery?

Ethical Approach to Granting Clinical Privileges for Complex Spinal Surgery

The most ethical approach for granting clinical privileges to an orthopedic fellowship graduate to perform complex spinal surgery is to assess the competency of their performance after certification (option C). 1

Rationale for Competency Assessment After Certification

• The Joint Commission on Accreditation of Healthcare Organizations mandates that granting clinical staff privileges must be based on assessment against professional criteria specified in medical staff bylaws 1
• Physicians themselves are charged with identifying the criteria that constitute professional competence and evaluating their peers accordingly 1
• The assessment of competence is complex and multidimensional; therefore, isolated recommendations or credentials alone may not be sufficient for judging overall competence 1

Why Other Options Are Less Appropriate

Option A: Grant privilege based on experience

• Experience alone does not guarantee competence in performing complex procedures like spinal surgery 1
• Simply completing a certain number of procedures without proper assessment of outcomes and technique may not ensure patient safety 1

Option B: Grant privilege since he completed fellowship

• Completion of a fellowship or residency does not automatically guarantee competence 1
• Some training programs may not include structured teaching of all necessary skills for complex spinal procedures 1
• The field of spinal surgery has evolved to include minimally invasive techniques, specialized approaches, and multidisciplinary collaboration that may not be uniformly taught in all fellowship programs 2, 3

Option D: Cannot until at least 2 years post clinical

• Imposing an arbitrary time requirement without assessment of actual competence is not evidence-based 1
• This approach could unnecessarily delay qualified surgeons from practicing within their competence 1

Best Practices for Competency Assessment

• Assessment should be based on actual cognitive knowledge and technical skills rather than solely on the structure of training 1
• Evaluation should include review of the surgeon's performance on procedures similar to those for which privileges are requested 1
• When the competence of a physician requesting privileges is not clear, monitoring the candidate's interpretations or administration of a test may be appropriate 1
• Quality assurance programs should include periodic review of a random sample of procedures by independent experts to confirm continued competence 1

Important Considerations for Complex Spinal Surgery

• Complex spinal surgery requires specialized skills and knowledge, particularly with the advancement of minimally invasive techniques and technology 2, 3
• The field increasingly involves multidisciplinary collaboration between orthopedic surgeons, neurosurgeons, and other specialists 4
• Patient outcomes in terms of morbidity, mortality, and quality of life should be the primary metrics for assessing competence 4, 5

By assessing competency after certification, institutions can ensure that surgeons have the necessary skills to perform complex spinal procedures safely while maintaining high standards of patient care and outcomes.