Clinical Proctoring

AAFP Position

The AAFP believes the use of clinical proctoring is an important peer review tool for physicians seeking privileges in hospitals and healthcare organizations. The AAFP supports the development of proctoring programs, with appropriate medical staff bylaws provisions, to evaluate the clinical competency of new medical staff members and existing medical staff members who request new privileges. The AAFP strongly believes that proctoring requirements apply equally to all medical staff members, regardless of specialty, and that family physicians proctor 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. Initial applicants seeking privileges or existing medical staff members requesting new or expanded privileges are proctored while providing the services for which privileges are requested. In most instances, a proctor acts only as a monitor to evaluate technical and cognitive skills of another physician. A proctor does not directly participate in patient care, has no physician-patient relationship with the patient being treated, does not receive a fee from the patient, and represents and is responsible to the medical staff.

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

There are three types of proctoring: prospective, concurrent, and retrospective. Prospective proctoring is a review by the proctor of either the patient's chart or the patient personally before treatment. 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. Concurrent proctoring is when the proctor actually observes the physician's work. This is usually used for invasive procedures so that the medical staff has first-hand knowledge necessary to satisfy itself that the physician is competent. Retrospective proctoring involves a retrospective review of patient charts by the proctoring physician. Retrospective review is usually adequate for proctoring of noninvasive procedures.

Proctoring Guidelines for Bylaws Provisions

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

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

(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 and should be a member of the hospital's medical staff. Occasional service as a proctor should be required for all medical staff members by the medical staff bylaws. If no suitable proctor is available on the medical staff (as may occur in rural hospitals), 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, evaluate, and report to the department chair or medical executive committee. In the event a proctor finds it necessary to move beyond observation and evaluation and to intervene in a case, the hospital should agree in writing to indemnify the proctored physician for any damages that might occur from following the proctor's orders. (The medical executive committee should get written confirmation of this from the hospital's insurance carrier.) Likewise, the hospital 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 to the executive committee that the physician either (1) continue to exercise the clinical privileges initially granted, (2) be required to extend the proctoring period, or (3) have privileges restricted or terminated in accordance with the bylaws. The decision of the department should be based on the physician's performance during the proctorship period.

(7) The proctoring report should remain confidential and should be handled as other medical staff peer review information. The medical staff, through the Board of Trustees, should determine where the files will be kept, who will have access, when and in what format; the procedure for physicians to appeal the reports or question the proctor who wrote them; and policy on retention of proctoring reports.

Guidelines for Serving as a Proctor

It is AAFP policy that 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 by evaluation of performance under clinical conditions (proctoring) rather than by an arbitrary number of procedures. Direct observation by trained and experienced practitioners is the best method for determining if a physician has the knowledge and skills to perform a procedure 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) (2010 COD)