Should an orthopedic surgeon who completed a spinal‑surgery fellowship on schedule be granted privileges to perform complex spinal surgeries, or should his competency be assessed before approval?

Assess Competency Before Granting Privileges (Answer D)

The orthopedic surgeon should undergo competency assessment and proctored observation before being granted unrestricted privileges to perform complex spinal surgeries, regardless of fellowship completion.

Why Competency Assessment is Required

The Joint Commission on Accreditation of Healthcare Organizations mandates that clinical privileges must be based on assessment against professional criteria, not simply credentials or training completion 1. Completion of fellowship training does not automatically guarantee competence to perform complex procedures independently 2, 3.

The Credentialing Process Should Include:

• Comprehensive documentation review: The surgeon must provide a detailed case log showing procedures performed as primary operator, complications encountered during training, and a letter from the fellowship director confirming adequate training and independent capability 2

• Initial proctored cases: Grant temporary privileges for the surgeon to perform initial cases under direct observation by an experienced proctor 1, 2. The Society of Urologic Robotic Surgeons specifically states that proctoring must be a prerequisite for complex surgical procedures 2

• Proctor evaluation before unrestricted privileges: The credentialing committee should withhold unrestricted privileges until the proctor's report is reviewed and competency is confirmed 1, 2

Why Other Options Are Inappropriate

Years of experience alone (Option A) does not guarantee competence in performing specific complex procedures 3. A surgeon may have extensive general orthopedic experience but lack specific technical skills for complex spinal surgery.

Certificate completion alone (Option B) is explicitly insufficient 1, 3. The available guidelines emphasize that credentialing must be a competency-based process where proficiency determines privileges, not simply completion of training 1.

Arbitrary time requirements (Option C) are not evidence-based 3. Requiring 2 years of practice without competency assessment could unnecessarily delay qualified surgeons while failing to identify those who remain incompetent 3.

The Competency-Based Framework

Proficiency should determine credentialing, not arbitrary case numbers or time periods 1. The technical learning curve varies significantly between individual surgeons based on innate skill level, prior experience, case density during training, and presence of collaborative learning 1.

The goal is ensuring surgeons have overcome the technical learning curve to deliver safe and effective care, which varies by individual 2. Some surgeons may demonstrate competence quickly, while others require more extensive observation 1.

Implementation Strategy

1. Review training documentation: Evaluate the fellowship case log, complication experience, and program director attestation 2

2. Grant initial temporary privileges: Allow the surgeon to perform procedures under proctor observation 1, 2

3. Proctor assessment: An experienced spinal surgeon evaluates technical skills, decision-making, and complication management during actual cases 1, 2

4. Committee review: The credentialing committee reviews the proctor's report before granting unrestricted privileges 1, 2

5. Ongoing quality assurance: Implement periodic review of outcomes, complication rates, and random case sampling to ensure maintained competence 3

Critical Safeguards

Hospital trainers and credentialing bodies bear explicit responsibility for patient safety by ensuring surgeons demonstrate competence before independent practice 3. This responsibility cannot be delegated to the fellowship program that provided training 3.

The assessment of competence is complex and multidimensional; isolated credentials may not be sufficient for judging overall competence 1, 3.