Assess Competency After Certification (Option C)
The most ethically suitable approach is to assess the competency of the orthopedic fellow's performance after certification before granting privileges for complex spinal surgery. 1
Why Competency Assessment is the Ethical Standard
The Joint Commission on Accreditation of Healthcare Organizations explicitly requires that granting clinical staff privileges must be based on assessment of applicants against professional criteria specified in medical staff bylaws, not simply on completion of training. 2
Physicians are charged with identifying the criteria that constitute professional competence and evaluating their peers accordingly—the process cannot rely solely on credentials or experience alone. 2
Key Principle from Guidelines
The British Journal of Neurosurgery guidelines make clear that a fellow cannot perform spinal surgeries independently until the neurosurgical trainers at that hospital formally assess his competence and grant him appropriate clinical privileges based on demonstrated technical skills and outcomes. 1
Why the Other Options Are Inadequate
Option A (Grant Based on Experience Alone)
- 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
- The assessment of competence is complex and multidimensional; therefore, isolated recommendations or credentials alone may not be sufficient for judging overall competence. 2
Option D (Arbitrary 2-Year Waiting Period)
- 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
- Assessment should be based on actual cognitive knowledge and technical skills rather than solely on the structure of training or arbitrary time periods. 1
How to Properly Assess Competency
The neurosurgical trainers at the hospital have explicit responsibility to ensure patient safety by ensuring that fully trained neurosurgeons are responsible for patient care and that all surgeons have access to help and advice. 1
The assessment should include:
- Evaluation 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
Critical Safeguard
The neurosurgical trainers must make decisions about whether surgeons can operate independently, with direct supervision, or with assistance based on demonstrated competence. 1 The responsibility for determining surgical competence rests with the trainers and credentialing bodies at the hospital where privileges are being requested, not with the fellow's previous training program. 1
Important Caveat
The trainers must answer truthfully if patients ask about the experience of those who will perform their surgery. 1 This transparency requirement underscores why formal competency assessment—rather than automatic privilege granting—is the ethical standard for patient safety.