Tuesday, October 19, 2010

A (Bizarre) Window Into an Important Process

I have mentioned before that I participate in the process in my hospital of overseeing the credentialing of physicians.  That is, I’m part of a committee that looks over the shoulders (in our case, literally in the same room to watch the work) of the physicians who decide whether physicians have the training, licensure, certification, and practice history to qualify for privileges at my hospital.  It can be an interesting process, and I’m quite appreciative at how hard the physicians on the credentialing committee work and how seriously they take this.

So, it certainly caught my attention that the California Board of Medical Examiners has begun hearings before and administrative law judge on the practice of Dr. Michael Kamrava, the fertility specialist who implanted and cared for Nadya Suleman, mother of fourteen including the octuplets for which she was labeled “Octomom.”  The Board is raising the questions of whether this was in Ms. Suleman’s best interests, in the best interest of children, and in accord with the standards of care of physicians providing this specialized care.

That phrase, “standard of care,” is important in medical practice.  It carries connotations of professional standards, clinical competence, and benefit to the patient.  In any given specialty establishing the “standard of care” involves knowledge of current research, often expressed by statements from professional societies.

And there are standards of care in fertility medicine.  As a result of his practice, exemplified perhaps in his care of Ms. Suleman, Dr. Kamrava has been expelled by the American Society for Reproductive Medicine.  That does not affect his medical license, but it is a damaging critique of his practice.  By itself, his expulsion doesn’t affect his ability to maintain his practice, but it may well affect his privileges with hospitals around him.

There are certainly many issues around fertility medicine, and especially around the production of numbers of embryos to be maintained in frozen storage until – and unless – desired.  At the poles, there are those who consider them “products of conception” that can be discarded unless offered for some use, such as development of human stem cell lines for research and/or therapy; and those who, committed to the belief that these are persons held in abeyance, want to see them offered for adoption by implantation.  It raises issues of whether children are blessings and miracles of God, that for medical reasons some may never receive; or objects (even if of affection) to which we have “a right.”

However, those issues will not be at the forefront in this review.  They won’t necessarily be irrelevant, but they won’t be primary to the discussion of “standard of care.”  This review will not question premises underlying this medical specialty, but will focus on practice within it.

It is worth noting that this is a process that rarely gets this level of attention.  That is, physicians are challenged all the time, whether in court or before a state board, but it is rarely of more than local interest.  It gets into local papers, and goes into state registries, but doesn’t get national attention, or even hold the local attention for long.  There is a National Provider Data Bank maintained by the Department of Health and Human Services to which states can submit adverse actions against physicians.  The purpose of the Data Bank is

intended to improve the quality of health care by encouraging State licensing boards, hospitals, professional societies, and other health care organizations to identify and discipline those who engage in unprofessional behavior; to report medical malpractice payments; and to restrict the ability of incompetent physicians, dentists, and other health care practitioners to move from State to State without disclosure or discovery of previous medical malpractice payment and adverse action history. Adverse actions can involve licensure, clinical privileges, professional society membership, and exclusions from Medicare and Medicaid.

But, the information is really intended for hospitals and other institutions, and not the general public.  That is in its own way problematic.  It’s not unheard of for a physician to move enough so as to change jurisdictions ahead of consequences, and the public hears little about it.  This will give an opportunity for most of us to observe a review that is commonly out of sight.

Testimony has begun, and even after testimony a decision may take the California Board a while to issue a decision.  One way or another, it will be interesting to watch, and hopefully enlightening. 

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