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May 1998
Volume 62 |
Number 5
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| Credentialing
of New Pain Procedures or Physicians Performing New Procedures |
Douglas G. Merrill, M.D., Chair
Committee on Pain Management
Author's Note: The ASA Committee on Pain Management has
received a great number of requests from members of ASA regarding
guidance in the areas of credentialing new physicians and new procedures
in pain management. It is the opinion of the Committee on Pain Management
that the best way for a department, hospital or physician group
to accomplish this goal is to monitor outcomes. Until a cohesive,
specialty-wide approach to outcomes measurements is in place, however,
we consider the following recommendations our best advice in this
area.
This document has been developed by the ASA Committee on Pain
Management but has not been reviewed or approved as a practice
parameter or policy statement by the ASA House of Delegates. Variances
from the recommendations contained in this document may be acceptable
based on the judgment of the responsible physician. The recommendations
are designed to encourage quality patient care but cannot guarantee
a specific outcome. These recommendations are subject to revision
from time to time as warranted by the evolution of technology
and practice.
I. Introduction
Very often physicians wish to expand their technical capabilities
by learning and performing new procedures. As well, new procedures
are developed and promulgated from time to time. As a result,
program directors, department chairs, medical directors of institutions
and organizations often request advice from the ASA Committee
on Pain Management for management of such situations.
This document is the recommendation of the members of
that committee and is intended only as information to be considered
by members encountering such situations. It is not a guideline
and certainly should not be construed as a standard of care.
II. Credentialing of New Procedures
When a physician wishes to engage in the performance of
a new procedure* or when a new procedure
is to be performed at an institution for the first time, the following
steps should be considered:
- A review of literature should be undertaken to ascertain
any scientific basis which may or may not exist for the procedure.
Specifically, the published accounts of the procedure should
be reviewed to be certain of any strictures which were placed
on patient selection and treatment. As much as possible, these
restrictions should be used in the employment of the new procedure.
- If available, a protocol should be created and submitted
to an Institutional Review Board (IRB) for approval. The absence
of an IRB at the hospital or outpatient center involved is not
necessarily a real hurdle. Often IRBs are available to monitor
protocols used outside their parent institution.
- Consents should be individually crafted which include risks
specifically attendant to this new procedure. The consent should
make it clear that this procedure is new and that the experience
with it at this institution is not substantive.
- The procedure should be approved for use only as a portion
of a treatment algorithm which portrays specific indications
and alternatives to the use of the procedure. The protocol should
be submitted and formally approved by the institution or department,
and it should be used when the outcomes of the procedure are
periodically reviewed by the department or institution.
- All new procedures should be used in the setting of a multidisciplinary
approach to pain management. Decisions with regard to use of
the procedure should be made after evaluation of other potential
(noninvasive) alternatives and consideration of the patient's
response to evaluations and therapies proffered by physical,
occupational and behavioral therapists where appropriate.
- The outcomes of each patient who undergoes the procedure
must be followed and reported to the institution or department
responsible for its oversight. It is recommended that the evaluation
of the patient's status be made using such tools as the SF-36
or other such health surveys. These evaluations should be conducted
at specified intervals (e.g., one, three, six and 12 months),
to allow a full understanding of any true value of the procedure.
- After a period of review of the safety and outcomes (cost,
efficacy) of the procedure, the department or institution may
choose to terminate the oversight process, continue it or stay
the use of the procedure altogether.
- If the new procedure has any attendant risk of airway or
hemodynamic compromise, then it must be performed only by physicians
specifically trained in the management of such events.
III. Credentialing of Physicians Performing
Procedures New to Them
- All of the above recommendations regarding the credentialing
of procedures are appropriate to the credentialing of physicians
who are new to the institution or who have no substantive experience
in a particular procedure's use.
- Additionally, it is recommended that whenever possible mentoring
should be used as a primary means of credentialing a physician.
This mentoring could (if necessary) include off-site apprenticeship
of the physician to a practitioner who is experienced and active
in the use of the technique. That practitioner should be chosen
by the department or institution and have no vested interest
in the practice of the apprentice. If possible, the physician
being credentialed should perform the procedure several times
under the tutelage of such a practitioner. The physician's apprenticeship
should include a written report from the experienced practitioner
to the department or institution which reviews the performance
of the apprentice.
- The consents for this procedure should include a specific
statement of the physician's inexperience.
- As noted above, the physician must provide evidence of capability
in the management of any resuscitative measures which might
be required in the event of a complication resulting from the
performance of the new procedure.
*New procedure is defined as any
procedure not included in the ASA Guidelines for the Management
of Chronic Pain.
Douglas G. Merrill, M.D., is Director
of Valley Analgesia Services, Valley Anesthesiology Consultants,
Phoenix, Arizona.
E-mail the author.
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