Dear Director,
I was contacted by a doc I used to work with about a job. We have an opening, and he used to be a great doc, but he’s been out of clinical medicine for about three years and I’m wondering about credentialing, what his skill set will be like, and how much clinical decline he’s had. How can I give him a “tryout?”
There are a variety of reasons physicians may take an extended leave from clinical work. This can range from health-related absences to pursuing non-clinical jobs to even returning to clinical medicine from retirement. Every year, thousands of physicians also return to the clinical world after a prolonged absence.
The process is officially termed reentry, and the AMA defines physician reentry as “a return to clinical practice in the discipline in which one has been trained or certified following an extended period of clinical inactivity not resulting from discipline or impairment.”
We all know people who have taken leaves of absence related to maternity, paternity, medical care such as cancer treatment, and even sabbaticals. I’ve never had an issue with someone coming back to work with even a 6-month absence. States generally have specific reentry rules as to who needs a reentry plan based on the duration of the absence. These tend to range from 2-5 years and some states may even require additional testing.
Two years away from clinical medicine is a general rule of thumb where your hospital bylaws (if not your state) will require a reentry plan. Physicians who have maintained their license and board certification who have been out of clinical medicine for less than two years are typically able to return to clinical practice through routine credentialing. Some physicians may go out on a planned, extended leave (sabbatical, health, caring for family), and will have pre-arranged the credentialing process to make a return seamless based on the hospital bylaws. The absence duration for a smooth reentry plan after a planned leave of absence (LOA) will be based on your hospital bylaws and may require the LOA to be under 12 months.
Getting Started
It’s likely that your hospital will have established credentialing criteria in their bylaws. Your hospital bylaws typically include “threshold criteria” for credentialing which likely includes having an active license, being in continuous practice, and having active malpractice insurance. For those who haven’t been in continuous practice that exceed your hospital’s or state’s threshold, let’s use two years as an example, the clinician will likely need to define how they maintained clinical competence during the absence.
Prior to going down this pathway, it’s important for you as the medical director to appropriately vet the candidate. Be sure to get as much information as necessary as to why they left medicine and why they want to return. Sometimes too much information can be a bad thing. For instance, the “whole story,” may contain health information, including a substance use disorder, as to why they left practice. Potentially, having this information and then not credentialing the physician can open you as the employer and/or the hospital to an ADA claim, i.e. you didn’t credential me because of my disability.
If that checks out, then a discussion about how they maintained clinical competency during their absence can ensue. Maintaining clinical competence may be defined as having completed continuing medical education or maintaining board certification status by completing annual LLSA or MyEMCert Modules. Depending on where the candidate sits at this point, their length of absence from clinical practice, and the hospital bylaws, then a request for a waiver should be made to the credentialing committee with the plan to participate in a reentry program.
If the candidate cannot get to the waiver status, they should look to get clinical experience elsewhere and then return to the hospital. Getting credentialed as an emergency physician at a hospital may be more challenging than getting a job at an urgent care.
There may be some candidates that cannot show they’ve maintained clinical competence and should be referred to get experience elsewhere. It will likely be easier to show clinical competence once they have worked in an urgent care before they work in an ED. Depending on the absence from the clinical arena and the state guidelines, some physicians may need to undergo formal training, perhaps at a residency.
Conditional Privileges
Once you’re able to show that your potential new hire has a license and is competent, it’s likely the credentialing team will ask for a more formal reentry plan. Remember, the credentialing committee is charged with making sure that those who care for patients, are competent to do so. Some hospital bylaws may require the practitioner to disclose if their extended gap in practice was related to a physical or mental health issue and is so, may require a report from a physician that the provider can safely exercise the clinical privileges requested.
Ultimately, expect guard rails to be put in place until the candidate can prove they are fully competent to provide care. There are a variety of options, and these may serve as a step wise progression towards independent practice. You may need to employ all of following. And keep in mind, that any plan devised must have the support of the department chair, credentials committee, medical executive committee, and hospital board.
Continuing Medical Education—Although any Category 1 CME can be used to keep a license up to date, it is certainly a reasonable consideration to ask someone who has not practiced clinically to obtain clinically relevant CME in emergency medicine. As mentioned above, showing proof of clinical competency starts with completion of appropriate CME and/or maintaining annual board status certification.
Simulation training—Prior to starting in the ED, it may be valuable and necessary to undergo live training in a simulation center. This could be to review high acuity patients such as those seen in ATLS and ACLS or used to review other scenarios like sepsis, altered mental status, and patients with undifferentiated shock.
Proctoring—This is real time evaluation by an active provider of a patient after they were seen by the physician undergoing the reentry plan. The supervising physician sees the patient independently, reviews the record of the doc in question, and provides feedback and guidance.
This is obviously labor intensive and perhaps may be used for the first 30-50 patients before performing a review to see if transitioning to a more focused patient population such as ESI 1-3 patients for another specified number of patients. The cost of this proctoring arrangement, in which the provider is another body on the schedule, is sometimes borne by the provider and sometimes negotiated by the group to be covered, or split, by the employer. These details need to be finalized prior to the start of the credentialing process.
Second Opinion—This level allows the returning physician to have a slightly more independent practice. Although the plan must outline whether this is for all patients or just selected patients, such as higher acuity or procedures, supervision is ultimately maintained by a fully credentialed physician who hears about each patient and weighs in on the plan. Like proctoring, this is likely targeted on a fixed number of patients, and if the candidate is deemed competent, they can advance to more independent practice.
Monitoring—Whether we realize it or not, all practitioners have regular evaluations completed based on performance. This is the whole purpose of our semiannual Ongoing Professional Practice Evaluations (OPPE) that medical directors complete.
New providers have evaluations to confirm competence through the Focused Professional Practice Evaluations (FPPE). Monitoring with chart review and quality audits may take place for weeks to months. This could include auditing a sampling of admitted patients, high acuity patients such as code stroke, STEMI, respiratory failure, and cardiac arrests, as well as random discharged patients and 72 hour returns who require admission.
Path to full credentialing
The reentry plan should be handled like a performance improvement plan. Ultimately, credentialing will be based on compliance with the plan and successfully navigating each step. The department medical director will need to be very hands on with reviewing each step of the process, making sure that evaluations are reviewed and that progression through the plan is consistent with the evaluations.
Monitoring should also be accomplished by a designated committee who reviews the data and evaluations. Ultimately, this committee will make the recommendation to the credentials committee that the candidate is ready to come off the plan and be fully credentialed.
Conclusions
There are many reasons why physicians may have a prolonged leave of absence from clinical medicine. While I often joke that it takes me a shift or so to get my muscle memory back with the clicks after a long vacation, I’ve seen plenty of docs come back from three- to six-month absences without missing a beat.
Hospital credentialing is designed for patient safety and is not an easy process so a “tryout” may be out the question. But you can work through the process to increase the chances of success upon their return. For the right doc, the reentry plan and monitoring will be worth it in the long run.
