Got Credentials?

  • Zakowski, Mark, MD
| Jul 11, 2011

No, not just a college or medical school diploma, and not just Board Certification—I mean EVERYTHING. What am I talking about here? Today, more than ever, physicians need to be sensitive to, and informed about current practice affairs issues and their impact on future careers in anesthesiology.

Medical Staff Credentialing is the process by which physicians are measured, debated, and judged. Want to work at a hospital or surgery center? Accrediting agencies, both state and national organizations (e.g. The Joint Commission), have been placing increasing emphasis on the Medical Staff Credentialing process. New regulations force ongoing evaluation of a physician’s skill and ability to practice. For this blog, I’ll focus on the initial entry barrier to working in a health care facility: approval by the Medical Staff Credentials Committee.

Events that are long forgotten in the average practitioner’s mind can cause a 15-minute debate in the Credentials Committee, which recommends admitting an applicant “on staff” or keeping someone out in the cold. Are you in Academia and filling out forms for a current or former resident? Or ar you in Private Practice and helping a colleague who moved? Don’t be in such a rush. Checking the wrong box, or indeed simply being truthful about some of the individual’s personal habits will cause further inquiry and potentially lead to denial of credential or months of delay. What’s going on?

In the old days (okay, only about ten years or so ago), credentialing was an afterthought, a bother, and a mere form to be filled out. Physicians thought, “They could never refuse to grant ME medical staff privileges,” and “I am the doctor and they NEED me.” Minor offenses were overlooked or automatically forgiven. Major offenses were perhaps discussed, but rarely an absolute block for admission. Worse, sub-standard doctors simply moved from hospital to hospital to avoid being caught or having their license revoked. In 1999 James Stewart wrote the New York Times Bestseller, Blind Eye about just this topic. In 2011, however, the road to privileges is now strewn with potholes, bumps, and some would even say IEDs. The concern is about quality, yes, but at least equally so, the ever increasing burden of corporate compliances with regulatory agencies.

So, what is really involved in applying for Medical Staff Privileges? Typically, the physician signs a stack of forms authorizing the hospital/surgery center to check out the information supplied by the applicant, including background, employment history and reference verification, as well as a criminal background check and waiver pertaining to the right to sue people involved in the process. Sounds simple, so far. The credentialing process should be smooth sailing for an individual with excellent evaluations in all areas, including technical procedure performance, cognitive skills, professionalism, working with others, ethics and yes, even computer skills and charting!

So, what are some of the unexpected problems (to the under-informed) an application might have?

Criminal Record

Timeframe: forever
Details: drunk driving, college arrests, etc.
Relates to: professionalism, ability to perform, possible substance abuse, and treatment

Malpractice Suits

Malpractice lawsuits can happen to anybody, even in the absence of negligence, but credentials committees examine if there is a trend, and how severe is the alleged lapse in judgment.

Timeframe: usually last seven years
Details: brief summary and details required as supplement, quantity and quality of the allegations/settlements are considered
Relates to: any/all areas of qualification

Employment History

Multiple job changes can give the impression of poor performance with evasion of disciplinary actions. Even medical leave of absences can raise questions about ones ability to perform in the future.

Timeframe: forever
Details: applicant must provide plausible explanations for gaps and job changes
Relates to: professionalism, performance


Pick your references carefully. Make sure they are willing to write good things about you. Most people are no longer willing to write bad things – for fear of retribution. Thus, even “average” evaluations can cause further follow-up. Typically the Credentials Committee will make phone call follow-ups to references to elicit more information – does “average” mean good or not willing to check “below average” or perhaps “unsatisfactory” even?

Timeframe: recent references are required, if applicant is not more than several years from graduation, a letter from the residency program director or chairperson
Details: huge flag when a candidate can’t find people willing to say great things about them
Relates to:  Professional performance, quality of care, ethics, character and personality

Dr. Google/Social Media

In today’s world information about you, personally and professionally, both positive and negative can be found with ease on the internet. Once the committee begins to question something on an application, the applicant will probably be “Googled” and checked out on Facebook, so be careful what you have posted. Don’t forget to tell the young and active to be careful about what they post on social networking sites. As a practicing physician, it behooves you to be careful about what information you personally disseminate.

Timeframe: forever– the Internet has a long memory!
Details: whatever is available to the public will be seen and considered
Relates to:  professionalism, personality and character

Having spent a great deal of time, money and energy to become a physician, it is imperative that doctors be aware of the factors that can interfere with a professional career. There are many items examined in the credentialing process. Provide the best available and most accurate information to credentialing bodies, and explain any inconsistencies up front, to ensure a timely medical staff appointment.

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