March 1, 2018

QUESTION:        We have a family physician who recently applied for colonoscopy clinical privileges at our hospital but is ineligible because he does not meet the threshold eligibility criteria for those privileges.  Our criteria require, among other things, all applicants to demonstrate competence through the performance of 140 colonoscopies in the last two years or during their training.  The physician is requesting that we change this criterion, claiming that it is too high and inconsistent with the American Academy of Family Physicians (“AAFP”) guidance on determining competency for colonoscopies.  What should we do?

ANSWER:            First, check your Medical Staff policies to determine how an applicant for clinical privileges who does not satisfy threshold eligibility criteria should be handled.  Medical Staff policies (typically, your Credentials Policy) should explicitly state that “applicants who fail to meet the threshold eligibility criteria will be notified that their applications will not be processed” and that “a determination of ineligibility does not entitle the individual to a hearing and appeal.” This applies to both applications for Medical Staff appointment and clinical privileges.  Thus, the family physician would be ineligible for a grant of clinical privileges to perform colonoscopies based on the hospital’s current threshold eligibility criteria.

However, in this case, there is a wrinkle since the physician is asking for a change in the criterion.  While you are under no obligation to change the criteria, especially if it is based on a thorough review of the literature, the needs of the community where the hospital is located, and is used in conjunction with other patient-safety-oriented criteria, it may be worth looking into the physician’s claims.  In this case, the physician is correct.  In a colonoscopy position paper, the AAFP states as follows:  “[b]ased upon recent studies, the AAFP has determined that the standard of fifty (50) cases as the primary operator be used as a basis for determination of basic competency in [colonoscopy].”  But, as the AAFP paper observes, the American Society for Gastrointestinal Endoscopy (“ASGE”) recommends that a physician perform 140 colonoscopies as a minimum number before competency can be assessed.  Obviously, this higher number favors specialists who perform colonoscopies as a primary part of their practice.  That doesn’t necessarily mean that the number isn’t legitimate.

The recommendations from the various specialty societies when it comes to the number of procedures needed to assess competency aren’t hard and fast rules.  As the ASGE notes:  “[p]erformance of an arbitrary number of procedures does not guarantee competency.  Whenever possible, competence should be determined by objective criteria and direct observation.  The number of supervised procedures necessary to obtain competency will vary tremendously among trainees.”  Of course, this statement from the ASGE implies that some trainees may need to perform more than 140 colonoscopies to guarantee competency (but the opposite may be true as well).  Whatever number your hospital decides on in setting criteria for clinical privileges should be supported by thorough research and sound reasoning.  At a minimum, you should explore what the relevant specialty societies are recommending, acceptable complication rates (and how to incorporate this into the criteria for the clinical privileges), and the type of training needed to support the request.  Other areas of consideration include what hospitals in similar situations require and the needs of the community.  Most importantly, if there is any doubt, criteria should set thresholds which err on the side of caution to protect patients and to ensure that only competent physicians are performing procedures on patients.