The senior obstetrician requesting obstetric privileges.

As the American physician workforce matures in age, senior physicians on the active clinical staff may become vulnerable to diminished professional performance. Many physicians compensate by using experiential rather than analytic methods to effectively solve clinical problems. Surgical expertise also may be at risk in these circumstances. Organized medical staffs must confront these realities before adverse events are reported as patient safety is their primary responsibility. The appropriate credentialing process will enable talented and experienced senior clinicians to continue to provide high quality medical care.

[Mitigating the moral risks of private medicine in public hospitals (SHARAP) through regulation and accountability].

BACKGROUND: SHARAP (the Hebrew acronym for private medical service) is an arrangement that allows patients in certain Israeli hospitals to choose their physicians in return for a fee paid, either privately or through some form of parallel insurance. At present, SHARAP is legally precluded from government hospitals but the issue is a source of public debate and the introduction of SHARAP into public hospitals owned by the government and health funds is supported by the Israel Medical Association and MK Yakov Litzman. While advantages to patients, hospitals and medical practitioners are acknowledged, these arrangements carry moral risks related to justice and fair allocation of resources, problems relating to conflicts of interests, the potential for exploitation of patients by physicians with private privileges and the potential for corrupt behaviors. AIM: To address the questions: Do the advantages of these arrangements justify the moral risks involved in the introduction of private medicine into public hospitals? Secondly, can these moral risks be mitigated through regulation without undermining the advantages accrued? METHOD: Ethical and public health policy evaluation based on empiric data and international experience. RESULTS: The potential advantages to patients, providers, hospitals and government of a SHARAP program in public hospitals may be undermined if the implementation does not incorporate regulatory structures. Appropriate regulatory precautions may mitigate most of these concerns adequately to allow all parties to enjoy benefits whilst diminishing actual harm incurred though injustice, conflicts of interest and exploitation.

O uso do termo de consentimento livre e esclarecido na prática médica / The use of the free and clarified consent term in medical practice

Este artigo analisa a aplicação do termo de consentimento livre e esclarecido (TCLE) na prática dos médicos que trabalham no Hospital Universitário (HU) da Universidade Federal de Sergipe, localizado na cidade de Aracaju. A pesquisa que originou o trabalho verificou aatribuição de importância à aplicação do TCLE na prática médica. Foram entrevistados cinco médicos do HU, bem como analisados 72 prontuários de pacientes internos, de acordo com a bioética, a legislação e a doutrina brasileiras. Concluiu-se que apesar de visto como importante, o TCLE só é utilizado em dois serviços naquela unidade, apesar dos avanços da responsabilidade civil médica no Brasil.

Conflict of credentialing: accolade or unfair trade.

The newly appointed chief of surgery at an open-staff hospital received an application for vascular privileges from a senior general surgeon who took a period of additional fellowship in vascular surgery at a nonacademic regional medical center. The fellowship does not make him board eligible in vascular surgery, but he has maintained his general surgery board certification and the pertinent bylaws do not specifically state which certification is required, only that the surgeon must be board certified and have additional training in vascular surgery. He is a member of a large politically powerful group practice that apparently wants to refer their substantial number of vascular cases internally. The chief of surgery finished vascular surgery training locally 3 years ago. The applicant has a checkered past, with multiple lawsuits and in-house investigations of cases with poor outcomes. The credentialing procedure is that the chief of service makes a recommendation to the chief of staff who makes a recommendation to the board of directors for approval. The chief of staff, who will make the final recommendation to the hospital board of directors, is a member of the applicant's group practice. What recommendation should the chief of vascular surgery make to the chief of staff?

The ethics of administrative credentialing.

A vascular surgeon has practiced in the same community for more than 20 years, holding privileges at the two largest local general hospitals. She is widely respected and admired by patients and fellow physicians in all specialties, and her results are consistently good. Recently, the board of directors at the hospital that has been the source of 80% of her case referrals hired a notorious slash-and-burn management firm to improve the balance sheet. The new chief executive officer (CEO) installed an information technology system that can provide management with physician-specific figures on costs and reimbursements. The management consultants identified the 10% of physicians with the worst cost/reimbursement ratios over the preceding 5 years and persuaded the board of directors to order their clinical privileges withdrawn. Our seasoned surgeon learns that she is among the targeted group. Is there an ethical issue here, and, if so, how should she respond?