Clinical Proctoring

AAFP Position

Clinical proctoring is an important peer review tool for physicians seeking privileges in hospitals and healthcare organizations. The American Academy of Family Physicians (AAFP) supports the development of proctoring programs, with appropriate medical staff bylaws provisions, to evaluate the clinical competence of new medical staff members seeking privileges and existing medical staff members requesting new or expanded privileges. Proctoring requirements should apply equally to all medical staff members, regardless of specialt. The AAFP supports family physicians proctoring family physicians, whenever possible.

Definitions of Clinical Proctoring

Proctoring is an objective evaluation of a physician's clinical competence by a proctor who represents, and is responsible to, the medical staff. New medical staff members seeking privileges or existing medical staff members requesting new or expanded privileges are proctored while providing the services or performing the procedure for which privileges are requested. In most instances, a proctor acts only as a monitor to evaluate the technical and cognitive skills of another physician. A proctor does not directly provide patient care, has no physician-patient relationship with the patient being treated, and does not receive a fee from the patient.

The terms proctorship and preceptorship are sometimes used interchangeably. However, a preceptorship is different in that it is an educational program in which a preceptor teaches another physician new skills and the preceptor has primary responsibility for the patient's care.

There are three types of proctoring: prospective, concurrent, and retrospective. In prospective proctoring, prior to treatment, the proctor either reviews the patient personally or reviews the patient's chart. This type of proctoring may be used if the indications for a particular procedure are difficult to determine or if the procedure is particularly risky. In concurrent proctoring, the proctor observes the applicant's work in person. This type of proctoring usually is used for invasive procedures so that the proctor can give the medical staff a firsthand account to assure them of the applicant's competence. Retrospective proctoring involves a retrospective review of patient charts by the proctor. Retrospective review is usually adequate for proctoring of noninvasive procedures.

Proctoring Guidelines for Bylaws Provisions

(1) If evidence of sufficient experience is lacking, new medical staff members and all existing medical staff members requesting new or expanded privileges should be subject to a period of proctoring, regardless of specialty.

(2) In departmentalized hospitals, each department should proctor its own new medical staff members or existing medical staff members who are requesting new or expanded privileges. For example, the family medicine department should recommend privileges for its members directly to the credentials committee without obtaining the approval of other departments, and the department also should perform the proctoring for those privileges. If there is no suitable proctor within the department, the department should select a proctor from the medical staff or recommend that the hospital obtain a particular proctor from another institution or training program. The length of the proctoring period, and/or the number of cases to be proctored or objectives to be met during proctoring, should be established by the department.

(3) In non-departmentalized hospitals, proctoring responsibilities should be assigned by the medical executive committee. The proctor should have similar qualifications to the applicant and be in the same specialty.

(4) The proctor should be impartial and have documented training and/or experience, demonstrated abilities, and current competence in the service or procedure that is the subject of the proctoring. The prodctor also should be a member of the hospital's medical staff, unless no suitable proctor is available on the medical staff (as may occur in rural hospitals). Occasional service as a proctor should be required for all medical staff members by the medical staff bylaws. In the event that no suitable proctor is available on the medical staff, the hospital should obtain a proctor from another institution or training program. The hospital should pay the expenses incurred in obtaining that proctor.

(5) The proctor's duty is to observe and evaluate the applicant and report to the department chair or medical executive committee. In the event that a proctor finds it necessary to intervene in a case, the hospital should agree in writing to indemnify the proctored physician for any damages that might result from following the proctor's orders. The medical executive committee should get written confirmation of this indemnification from the hospital's insurance carrier. The hospital also should agree to indemnify a proctor for any damages resulting from a claim of battery.

(6) The proctor should prepare a written report describing the cases proctored and evaluating the applicant's performance. The report should be submitted by the department chair to the medical executive committee. In addition to the report, the department chair should recommend on of the following to the medical executive committee: (1) the applicant should be granted the clinical privileges for which he or she applied; (2) the applicant should be required to extend the proctoring period, or (3) the applicant should have privileges restricted or terminated in accordance with the bylaws. The decision of the department should be based on the applicant's performance during the proctoring period.

(7) The proctoring report should remain confidential and should be handled in the same manner as other medical staff peer review information. Through the Board of Trustees, the medical staff should determine the following: the location in which report files will be kept; access rights (i.e., who can access the reports, when, and in what format); the procedure for an applicant to appeal a report or question the proctor who wrote it; and the policy on retention of proctoring reports.

Guidelines for Proctors

Privileges for procedures and services should be based on a physician’s documented training and/or experience and demonstrated current competence. Competence is determined and verified on the basis of evaluation of performance under clinical conditions (i.e., proctoring) rather than by the performance of an arbitrary number of procedures. Direct observation by a trained and experienced proctor is the best method for determining if a physician has the necessary knowledge and skills to perform a procedure or provide a service safely and appropriately. Concurrent proctoring should be used for invasive procedures, while retrospective proctoring may be adequate for noninvasive procedures.

Knowledge and Skills: Knowledge components of procedural skills are complex and procedure-specific; however, some general rules govern the development of proficiency in performing most procedures. The general areas of knowledge that should be mastered before one can be deemed competent are clinical, procedural, and equipment. The proctor should assess the following areas.1

  1. Clinical Knowledge
    1. General background information
    2. Indications and contraindications
    3. Physiology and pathophysiology
    4. Anatomy
    5. Limitations of the practitioner
    6. Economics
  2. Knowledge of the Equipment
    1. Technical aspects of the equipment
    2. Specific details of the equipment
    3. Operating details of the equipment
    4. Safety aspects of the equipment
  3. Knowledge of the Procedure
    1. Physical characteristics of the procedure
    2. Technique of the procedure
    3. Preparation of the patient
    4. Precautions and potential complications
    5. Limitations of the procedure
    6. Special techniques
    7. Advanced techniques

Resources

(1) Miller M D. Education, training, and proficiency of procedural skills Primary Care 1997; 24:231-241

(1995) (April 2015 BOD)