When you’re a resident in anesthesiology, your existence is pretty well defined by the training program. You report to the attending on service. You attend required lectures. You show up for graduation dinner. It’s your residency program’s responsibility to guide your practice, from intubation to extubation. What happens when you graduate? Who’s in charge? Early days as an attending can feel disorienting by comparison.
As it turns out, there is still someone in charge — actually, lots of people. Your practice as an attending is monitored by several groups, a few of whom were there during your residency. Understand these groups and the pressures they face. You’ll feel better knowing why you’re filling out paperwork and following policies, even if there’s an intolerable amount of it. In this latest post for Orbit Anesthesia, I’m going to highlight the five most important groups you should know that define how you practice anesthesiology.
1. Practice Group
Your practice group is your team of anesthesiologists. Policies you receive related to your practice group are summarized in the employee handbook. These policies advance both the priorities of the owners and the vitality of the group as a whole.
Ownership. In some cases, an anesthesiologist group is wholly owned by the hospital. In many other cases, the group is actually a company that holds a contract with the hospital, outpatient clinic, or surgery center where you work.
Broadly speaking, practice groups can be corporate-driven or physician-owned. Corporate-driven practice groups are run by business types. Physicians are employees. Stock might be held by private or public investors.
Physician-owned practice groups are partnerships of physicians. These physicians split ownership in the company, represented by stock. Both corporate-driven and physician-owned groups can work well or poorly. There are great success stories in both cases.
Priorities. Practice groups face all sorts of priorities that manifest in their policies. These priorities relate to strengthening all of the various relationships that are important to the group’s survival: with healthcare providers that comprise the group, referring physicians, contracting hospitals, patients, insurance companies, competing groups, and regulatory agencies.
Practical tip: Take some time to read your group’s policy handbook. Give yourself the benefit of situational awareness.
Hospitals are complex businesses. Even the smallest hospital supports many business functions under one roof. The range of hospital policies as they relate to our practice as anesthesiologists are typically decided in various committee meetings and implemented by the medical staff office. The influence an anesthesiology group will have over these decisions varies widely.
Hospital as a holding company. Hotel, restaurant, pharmacy, laundromat, gift shop, IT consultancy, insurance company, and staffing agency. The hospital is all of that in addition to their primary role of being a place where healthcare professionals and patients meet to conquer a spectrum of diagnoses and treatments.
Policy by committee. Hospitals often use policies as rulebooks of undulating strength. To create these policies, there are about as many committees as there are business functions at the hospital. The people that make up these committees also bring their own motives to the policies that follow. The strength and enforceability of a given policy often depends on the political capital of those in favor or disfavor of it.
Consider the decision to grant you certain clinical privileges at a hospital. The decision is made by the credentialing committee. It’s based significantly on your experience, which is why you submit your resume, recommendation letters, case log, and other documentation. But it’s also influenced by turf battles when multiple physician groups at the hospital have overlapping skill sets or service line requirements when hospitals are considering launching new activities.
Practical tip: Every hospital has a medical staff office. They’ll answer hospital-specific policy questions, including those related to credentialing and CME requirements. If it’s important, get your questions answered by email so you have a written record.
3. State Medical Board
There are 70 state medical boards in the US and affiliated territories.
Mission. They keep patients safe by licensing, disciplining and regulating physicians.
Jurisdiction. The jurisdiction of a state medical board is limited to its state. Being licensed by one medical board doesn’t entitle you to practice in another state, except in special cases such as disaster relief.
Paperwork and fees. You’ll need to apply to a new state medical board each time you begin practicing in a new state. Every state medical board has a different application, unique practice requirements, fees, and procedures for disciplinary action. Caveat, the Federation of State Medical Boards has recently launched a Uniform Application to minimize some of the redundancy across states’ applications.
Practical tip: Your state medical board’s website is the authority on your local policies including advertising of services, CME requirements and practice limitations. Start the licensing process early, as it may take over 9 months to complete, and you’ll need to have your unrestricted state license for certain fellowship exams such as Critical Care Medicine.
4. American Board of Anesthesia
The American Board of Anesthesia (ABA) is powerful physician-run organization that isn’t part of the state or federal government.
Where it fits: The ABA is part of a broader consortium of boards called the American Board of Medical Specialties (ABMS). Board-certified physicians are called diplomates of the board.
Utility: The purpose of the ABA is to set a standard of medical knowledge and practice for anesthesiologists through every stage of their career. Part of this purpose is to assure patients, hospitals, and insurance companies that we’re safe in our practice as anesthesiologists. The ABA is responsible for determining the criteria for both initial board certification and its maintenance.
Of late, the policies associated with various ABMS boards have come under increased scrutiny by physicians, led by concerns with the American Board of Internal Medicine (ABIM). The scrutiny relates to annual fees and their usage. There’s also been discontent about maintenance of certification processes. The ABA’s MOCA 2.0 employs one of the more forward-thinking approaches to maintenance of certification, with online questions we can complete from our phones instead of sitting for a test every 10 years. But there are four components to MOCA 2.0, and fulfilling all of them is essential to remain a diplomate of the ABA.
Practical Tip: Visit the MOCA 2.0 site to familiarize yourself with all of your requirements, as some are needed quarterly.
The American Society of Anesthesiologists (ASA) is a research, advocacy and educational organization. Its mission is “advancing the practice and securing the future” of anesthesiology.
Research and Education: The ASA supports anesthesiologists’ research through funding. The ASA also runs an annual meeting that allows us to share both research and clinical skills. This October 2017, the ASA annual meeting returns to Boston, the birthplace of modern anesthesia. Practice management education from the ASA helps anesthesiologists learn the business aspects of our field.
White Papers: White papers released by the ASA are policy statements that define consensus-based or data-driven guidelines on treatment standards or other policy issues related to anesthesia.
Advocacy: The ASA and its political action committee (ASAPAC) lobby for our specialty and its role in safe perioperative care to and legislators at the state and national level.
Practical Tip: Review the ASA Standards and Guidelines related to your practice at least twice a year. These guidelines are the ASA-recommended best practices for our specialty. For those of us with subspecialty certification, make sure to review subspecialty guidelines as well.
6. Drug Enforcement Agency
Located within the Department of Justice, the DEA is tasked with combating drug smuggling and illicit use within the United States.
As anesthesiologists, we register with the DEA for prescribing rights, commonly required for employment. The DEA then tracks our prescriptions. They have the power to investigate us freely when they feel it’s indicated. The DEA can revoke or ask physicians to voluntarily surrender privileges.
Practical Tips: Many states have registries for controlled substance prescriptions, tracking both patients and prescribers.
§ Check where you or patients stand on your state registry if you’re writing prescriptions.
§ Always check your individual hospital’s policy regarding inpatient drug wasting and reporting policies. These policies for drugs such as propofol vary substantially across institutions.
Bottom line: Many organizations govern practice decisions, some more explicitly that others. You’ll need to complete required paperwork and fees for each of these organizations at their designated intervals and due dates.