Despite the greater importance of other factors, many staffing decisions are made solely on the basis of references. This is particularly troublesome in facilities that require that the references come from members of their own medical staff, or even from members of the specialty section where privileges are sought. This tends to limit membership in the medical staff to friends of existing members, since new physicians in the community (or physicians from other hospitals) will not be professionally acquainted when the members of the medical staff. From a risk management perspective, it is more important that an applicant have a reference from a physician acquainted with the applicant's professional competence than that the applicant be friends with members of the medical staff. The governing body must be alert to the tendency of medical staffs to become clannish. Physicians who are socially close or whose practice are intertwined will be much less likely to be effective at monitoring their colleagues. The ideal situation would be to have most of the medical staff members be independent practitioners without personal ties to other members of the staff. As noted earlier, a very precarious legal position exists when members of the medical staff are aware of physician misconduct but for personal reasons do not take action.
There is a growing tendency to limit hospital medical staff membership to board-certified or board-eligible physicians. While this seems like a useful mechanism to guarantee a quality staff, there is no evidence to support the premise that board certification has any bearing on the quality of medical care delivered. A recent study by the Harvard University Department of Surgery established that many of the negligent errors made by surgeons were related to doing too much or to using fashionable but dangerous therapies. The study concluded that "the data indicates that board certification, not surprisingly, did not protect against these misadventures." In fields such as surgery, which are very dependent on technical skills, board certification is good evidence of adequate experience, but it is not an indicator of judgment. In fields such as family practice, where training programs are highly variable and many practitioners "grandfathered" into board eligibility, board certification is much less useful as a measure of ability.
The governing body should not let the fact that a practitioner is board-certified reduce the scrutiny of other admission criteria. The governing body should allow applicants who are not board-certified to demonstrate training or experience that is equivalent to board certification. Many valuable applicants may be turned away if board certification is used as an inflexible requirement for medical staff membership. For instance, such a requirement may prevent physicians who have expertise in public health or occupational medicine from being admitted to the staff. These physicians are often not board-certified in conventional hospital fields, but they have skills that can be invaluable in the management of contagious diseases or intoxications.
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