Dermatology. Practice area 132. Background

Transcription

1 Practice area 132 Clinical PRIVILEGE WHITE PAPER Dermatology Background Dermatology is the medical specialty concerned with diseases and conditions of the skin, hair, and nails. Dermatologists are physicians who specialize in managing adults and children with benign and malignant disorders of the skin, hair, nails, and adjacent mucous membranes. According to the American Board of Dermatology (ABD), dermatologists have training and experience in the following: The diagnosis and treatment of skin cancers, melanomas, moles, and other tumors of the skin The management of contact dermatitis and other inflammatory skin disorders The recognition of skin manifestations of systemic and infectious diseases Dermatopathology Surgical techniques used in dermatology Dermatologists also help manage cosmetic skin disorders, including hair loss, scars, and skin changes associated with aging. The postgraduate training for dermatologists is four years. Physicians may either enter a three-year full-time residency program after completing a broad-based clinical year of training in an Accreditation Council for Graduate Medical Education (ACGME) accredited program, or the physician may enter a four-year dermatology training program during which the first year is spent on broad-based clinical education. Osteopathic physicians must complete a one-year American Osteopathic Association (AOA) approved internship year and three years of dermatology residency training in an AOA-accredited program. The ABD is the certifying board for dermatologists. The American Board of Medical Specialties (ABMS) recognizes two subspecialties of dermatology: pediatric dermatology and dermatopathology. Physicians who have completed additional training and are certified in dermatology may become board-certified by the ABD in pediatric dermatology or dermapathology. The American Osteopathic Board of Dermatology (AOBD) offers certification for dermatologists, as well as certificates of added qualifications in pediatric dermatology and Mohs micrographic surgery. A supplement to Briefings on Credentialing 781/ /10

2 In addition to the two subspecialties recognized by the ABMS and ABD, dermatologists may also complete an ACGME-accredited procedural dermatology fellowship. Procedural dermatology is the subspecialty that is concerned with the study, diagnosis, and surgical treatment of diseases of the skin and adjacent mucous membranes, cutaneous appendages, hair, nails, and subcutaneous tissue. This one-year program includes dermatologic surgery, which may be learned in an ACGME-accredited dermatology residency training program. Although recognized by the ACGME, a certification examination process in procedural dermatology is not currently available. Involved specialties Dermatologists and procedural dermatologists Positions of societies and academies AAD The American Academy of Dermatology (AAD) does not publish a position statement regarding the credentialing or privileging of dermatologists. However, the AAD does recognize the following certifying boards in the United States or Canada: the ABD, the Royal College of Physicians and Surgeons of Canada (RCPSC), and the AOBD. Positions of other interested parties ABD The ABD grants certification in dermatology. Candidates for certification must satisfy the following general qualifications and residency training requirements before they are eligible to take the certifying examination. General qualifications to be eligible for the exam are: Graduation from a medical school in the United States accredited by the Liaison Committee for Medical Education, an accredited medical school in Canada, an accredited osteopathic school in the United States, or if a graduate of a foreign medical school, must possess the standard certificate of the Educational Commission for Foreign Medical Graduates Hold a currently valid, full, and unrestricted license to practice medicine or osteopathy in the state or province of residence in either the United States or Canada Never have engaged in conduct that, in the judgment of the ABD, reflects unethical activity relating to the practice of medicine or casts significant doubt on the ability of applicants to practice in the best interests of patients Candidates for certification are required to complete a total of four years of postgraduate training, which included the following: A first year of clinical training in one of the following types of broad-based programs in the United States accredited by 2 A supplement to Briefings on Credentialing 781/ /10

3 the ACGME or a similar program in Canada accredited by the RCPSC: a first-year residency in emergency medicine, family practice, general surgery, internal medicine, OB/ GYN, or pediatrics Three years of full-time training as a resident in a dermatology residency training program in the United States accredited by the ACGME or three years of full-time training as a resident in a dermatology residency training program in Canada accredited by the RCPSC According to the ABD, all residents also should participate in basic science and/or clinical research during their training, lasting three or fewer months per a three-year period. AOA The AOA grants certification in dermatology through the AOBD. To be eligible to receive certification, applicants must meet the following minimum requirements: Be a graduate of an AOA-approved college of osteopathic medicine Be licensed to practice in the state or territory where the applicant s practice is being conducted Show evidence of conformity to the standards set in the AOA Code of Ethics Be a member in good standing of the AOA or the Canadian Osteopathic Association for a continuous period of at least two years immediately prior to the date of certification Have satisfactorily completed an AOA-approved internship Have completed three years of AOA-approved training related to the specialty of dermatology The applicant may take the examination at the first annual meeting following the completion of the required three years of approved training, providing the documentation is in order and completed by April of that year. Additionally, candidates must write three papers consisting of basic science or clinical subjects approved by trainee s program director. All papers must be suitable for publication, and two must be presented at the American Osteopathic College of Dermatology s annual or midyear meeting. ACGME In its Program Requirements for Graduate Medical Education in Dermatology (2007), the ACGME states that graduate medical education programs in dermatology must include the following: Either three or four years of graduate medical education. Three-year programs are preceded by a broad-based clinical A supplement to Briefings on Credentialing 781/ /10 3

4 year of training in a program accredited by the ACGME or similar program accredited in Canada. Four-year programs must provide a broad-based clinical experience during the first year and three years of dermatology education in the second through fourth year of the program. The resident s time throughout each year beyond the first year must include direct care of outpatients and inpatients. This must include clinical conferences and didactic lectures related to patient care, consultations, inpatient rounds, dermatologic surgery, dermatopathology, and other dermatology-related subspecialty rotations. Scholarly activity should be integrated into these clinical activities. Residents should gain experience in techniques supporting diagnoses in the general field of medical dermatology (e.g., patch testing, KOH examination, Tzanck smears). Other essential elements of clinical exposure include photomedicine, phototherapy, topical pharmacotherapy, and systemic pharmacotherapy. Residents should become competent to perform many surgical techniques, which are divided into three categories: During training, residents should achieve competency in biopsy techniques, destruction of benign and malignant tumors, use of lasers for the treatment of superficial vascular tumors, and excision of benign and malignant tumors with simple, intermediate, and complex repair techniques including flaps and grafts. Significant exposure to other procedures either through direct observation or as an assistant at surgery is required. Examples in this category include Mohs micrographic surgery and reconstruction of theses defects, the application of a wide range of lasers and other energy sources, sclerotherapy, botulinum toxin injection, soft tissue augmentation, and chemical peels. Residents should receive education relating to certain cosmetic techniques without necessarily affording direct exposure. Among these techniques are liposuction, scar revision, and dermabrasion. The program s experience in cosmetic surgery may vary; however, didactic training in this area is required. Residents also should gain experience in the diagnosis and management of the wide range of skin diseases seen in infants and children. Properly supervised experience in consultative inpatient neonatal and pediatric dermatology is also essential. 4 A supplement to Briefings on Credentialing 781/ /10

5 Residents must gain experience with pediatric patients with the following conditions: atopic dermatitis; psoriasis; blistering disorders; infectious diseases; and medically complicated, cutaneous manifestations of multisystem diseases. For pediatric patients, residents must also gain experience in the diagnosis and age-appropriate management of birthmarks, genodermatoses, and cutaneous signs of child abuse. In addition, residents must develop competence in the performance of the following diagnostic and therapeutic techniques: skin biopsy, excision, patch testing, intralesional injections, and phototherapy. The ACGME also publishes ACGME Program Requirements for Graduate Medical Education in Procedural Dermatology (2010). Procedural dermatology programs are 12 months in duration. According to the ACGME, procedural dermatology is divided into three broad categories: Cutaneous oncologic surgery involves medical, surgical, and dermatopathological knowledge of cutaneous neoplasms. Cutaneous reconstructive surgery includes the repair of skin defects that result from the surgical removal of tumors or other skin disease and scar revision, and is based on knowledge of cutaneous anatomy, wound healing, and cutaneous repair techniques. Cutaneous cosmetic surgery incorporates medical, surgical, and dermatopathologic knowledge of cutaneous disorders and the aging of the skin. It focuses on the study and performance of procedures that have been developed by dermatologists to improve the appearance of the skin and control cutaneous disease. Additionally, the ACGME states that residents must demonstrate proficiency in performing procedures. Residents must: Be competent in skin neoplasm destruction techniques, excision, and Mohs micrographic surgery Be competent in cutaneous reconstructive surgery, including random pattern and axial flap repair, grafting techniques, and staged reconstructive techniques Perform at least 400 surgical cases, of which at least 200 are Mohs micrographic surgery procedures Demonstrate advanced evaluation and management skills for all cutaneous surgical patients, including preoperative, perioperative, and postoperative evaluation A supplement to Briefings on Credentialing 781/ /10 5

6 Demonstrate proficiency in the early identification of benign premalignant and malignant skin lesions through unaided and aided visual morphologic recognition Maintain certification in advanced cardiac life support AOA The AOA s Basic Standards for Residency Training in Dermatology states that training programs will educate residents on the recognition and treatment during the chronological progression of the integumentary system to provide total healthcare delivery as it relates to dermatology and dermatologic physical modalities. Residents will also receive training on gross and histodermatopathology, therapeutic radiology and phototherapy, medical mycology, allergy and immunology, dermatologic surgery and oncology, medical dermatology, and dermatologic physical modalities. Additionally, residents must keep a log of the supervised procedures, such as excisions, cryotherapy, laser therapy, injectable implants, intralesional therapy, sclerotherapy, electrocautery, hair transplants, PUVA, dermabrasion, chemical peels, and other dermatological surgical procedures. Residents must also perform a minimum of 15 inpatient hospital or nursing home consultations each year of their residency or a total of 45 in a three-year period. The Joint Commission The Joint Commission (formerly JCAHO) has no formal position concerning the delineation of privileges for dermatology. However, in its Comprehensive Accreditation Manual for Hospitals, The Joint Commission states, The hospital collects information regarding each practitioner s current license status, training, experience, competence, and ability to perform the requested privilege (MS ). In the rationale for MS , The Joint Commission states that there must be a reliable and consistent system in place to process applications and verify credentials. The organized medical staff must then review and evaluate the data collected. The resultant privilege recommendations to the governing body are based on the assessment of the data. The Joint Commission further states, The organized medical staff reviews and analyzes information regarding each requesting practitioner s current licensure status, training, experience, current competence, and ability to perform the requested privilege (MS ). 6 A supplement to Briefings on Credentialing 781/ /10

7 In the EPs for standard MS , The Joint Commission says the information review and analysis process is clearly defined. The organization, based on recommendations by the organized medical staff and approval by the governing body, develops criteria that will be considered in the decision to grant, limit, or deny a request for privileges. The Joint Commission further states, Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privileges, or to revoke an existing privilege prior to or at the time of renewal (MS ). In the EPs for MS , The Joint Commission says there is a clearly defined process facilitating the evaluation of each practitioner s professional practice, in which the type of information collected is determined by individual departments and approved by the organized medical staff. Information resulting from the ongoing professional practice evaluation is used to determine whether to continue, limit, or revoke any existing privilege. CRC draft criteria Minimum threshold criteria for requesting core privileges in dermatology References The following draft criteria are intended to serve solely as a starting point for the development of an institution s policy regarding this practice area. Basic education: MD or DO Minimum formal training: Successful completion of an ACGME- or AOA-accredited residency in dermatology and/or current certification or active participation in the examination process (with achievement of certification within [n] years) leading to certification in dermatology by the ABD or AOBD. Required previous experience: Applicants for initial appointment must be able to demonstrate provision of outpatient or consultative care, reflective of the scope of privileges requested, to at least 12 patients during the prior 12 months or demonstrate successful completion of an ACGME- or AOAaccredited residency or clinical fellowship within the prior 12 months. If recently trained, a letter of reference must come from the director of the applicant s dermatology training program. Alternatively, a letter of reference regarding competence A supplement to Briefings on Credentialing 781/ /10 7

8 should come from the applicable department chair or service chief at the institution where the applicant most recently practiced. Core privileges in dermatology Core privileges in dermatology include the ability to admit, evaluate, diagnose, treat, and provide consultation to patients of all ages, with benign and malignant disorders of the skin, mouth, external genitalia, hair, and nails, as well as sexually transmitted diseases. Core privileges also include the diagnosis and treatment of skin cancers, melanomas, moles, and other tumors of the skin, management of contact dermatitis and other allergic and nonallergic skin disorders, cosmetic disorders of the skin such as hair loss and scars, the skin changes associated with aging, and recognition of skin manifestations of systemic and infectious diseases. Privileges also include the ability to assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include the performance of the following core procedures: Botulinum toxin injection Chemical face peels Collagen injections Cryosurgery Destruction of benign and malignant tumors Electrosurgery Excision of benign and malignant tumors with simple, intermediate, and complex repair techniques including flaps and grafts Interpretation of specially prepared tissue sections, cellular scrapings, and smears of skin lesions by means of routine and special (electron and fluorescent) microscopes Intralesional injections Patch tests Perform history and physical exam Photomedicine, phototherapy, and topical/systemic pharmacotherapy Potassium hydroxide examination Scalp surgery Sclerotherapy Skin and nail biopsy Soft tissue augmentation Tzanck smears 8 A supplement to Briefings on Credentialing 781/ /10

9 Special noncore privileges in dermatology If desired, noncore privileges are requested individually in addition to requesting the core. Each individual requesting noncore privileges must meet the specific threshold criteria governing the exercise of the privilege requested, including training, required previous experience, and for maintenance of clinical competence. Special requests may include: Laser use Mohs micrograph surgery Liposuction Dermabrasion Administration of sedation and analgesia Reappointment Reappointment should be based on unbiased, objective results of care according to the organization s existing quality assurance mechanism. Applicants must demonstrate current competence and provision of care to 24 outpatient/consultative patients with acceptable results, reflective of the scope of privileges requested for the previous 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current physical and mental ability to perform privileges requested is required of all applicants for renewal of privileges. Minimum threshold criteria for requesting core privileges in procedural dermatology Basic education: MD or DO Minimum formal training: Successful completion of an ACGMEor AOA-accredited residency in dermatology, followed by successful completion of a fellowship in procedural dermatology and/ or current certification or active participation in the examination process (with achievement of certification within [n] years) leading to certification in dermatology by the ABD or AOBD. Required previous experience: Applicants for initial appointment must be able to demonstrate 400 dermasurgical procedures, reflective of the privileges requested, for the previous 12 months or successful completion of an ACGME- or AOA-accredited residency or clinical fellowship within the previous 12 months. References If recently trained, a letter of reference must come from the director of the applicant s training program in procedural dermatology. Alternatively, a letter of reference regarding competence should come from the applicable department chair or service chief at the institution where the applicant most recently practiced. A supplement to Briefings on Credentialing 781/ /10 9

10 Core privileges in procedural dermatology Core privileges in procedural dermatology include the ability to admit, evaluate, diagnose, provide consultation, and surgically treat diseases of the skin and adjacent mucous membranes, cutaneous appendages, hair, nails, and subcutaneous tissue to patients of all ages. Core privileges also include the ability to assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges also include performance of the following procedures: Performance of destruction techniques (electrosurgical, cryosurgical, chemical, and laser) Excision of skin cancers, warts, and other skin lesions, followed by a layered closure Mohs micrographic surgery Hair transplantation Skin rejuvenation techniques (dermabrasion, chemical peel, laser resurfacing, or rhinophyma correction) Laser surgery Laser phototherapy Nail surgery Small-volume tumescent liposuction Cutaneous soft tissue augmentation with injectable filler material Sclerotherapy Electrosurgery for benign and malignant lesions (electrocoagulation, electrofulguration, electrodesiccation, electrosection, and electrocautery) Scalpel surgery Wedge excision (lip and ear) Reappointment Reappointment should be based on unbiased, objective results of care according to the organization s existing quality assurance mechanism. Applicants must demonstrate that they have maintained competence by showing evidence that they have provided an adequate volume of experience ([n] dermasurgical procedures) with acceptable results in the privileges requested for the previous 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current physical and mental ability to perform privileges requested is required of all applicants for renewal of privileges. 10 A supplement to Briefings on Credentialing 781/ /10

11 For more information For more information regarding this practice area, contact: Accreditation Council for Graduate Medical Education 515 North State Street, Suite 2000 Chicago, IL Telephone: 312/ Fax: 312/ Website: American Academy of Dermatology P.O. Box 4014 Schaumburg, IL Telephone: 847/ Fax: 847/ Website: American Board of Dermatology P.O. Box Henry Ford Health System 1 Ford Place Detroit, MI Telephone: 313/ Fax: 313/ abderm@hfhs.org Website: American Osteopathic Association 142 East Ontario Street Chicago, IL Telephone: 800/ Fax: 312/ Website: The Joint Commission One Renaissance Boulevard Oakbrook Terrace, IL Telephone: 630/ Fax: 630/ Website: A supplement to Briefings on Credentialing 781/ /10 11

12 Privilege request form Dermatology To be eligible to request clinical privileges in dermatology, an applicant must meet the following minimum threshold criteria: Basic education: MD or DO Minimum formal training: Successful completion of an ACGME- or AOA-accredited residency in dermatology and/or current certification or active participation in the examination process (with achievement of certification within [n] years) leading to certification in dermatology by the ABD or AOBD. Required previous experience: Applicants for initial appointment must be able to demonstrate provision of outpatient or consultative care, reflective of the scope of privileges requested, to at least 12 patients during the previous 12 months or demonstrate successful completion of an ACGME- or AOA-accredited residency or clinical fellowship within the previous 12 months. References: If recently trained, a letter of reference must come from the director of the applicant s training program in dermatology. Alternatively, a letter of reference regarding competence should come from the applicable department chair or service chief at the institution where the applicant most recently practiced. Core privileges in dermatology: Core privileges in dermatology include the ability to admit, evaluate, diagnose, treat, and provide consultation to patients of all ages, with benign and malignant disorders of the skin, mouth, external genitalia, hair, and nails, as well as sexually transmitted diseases. Core privileges also include the diagnosis and treatment of skin cancers, melanomas, moles, and other tumors of the skin, management of contact dermatitis and other allergic and nonallergic skin disorders, cosmetic disorders of the skin such as hair loss and scars, the skin changes associated with aging, and recognition of skin manifestations of systemic and infectious diseases. Privileges also include the ability to assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include the performance of the following core procedures: Botulinum toxin injection Chemical face peels Collagen injections Cryosurgery Destruction of benign and malignant tumors Electrosurgery Excision of benign and malignant tumors with simple, intermediate, and complex repair techniques, including flaps and grafts 12 A supplement to Briefings on Credentialing 781/ /10

13 Interpretation of specially prepared tissue sections, cellular scrapings, and smears of skin lesions by means of routine and special (electron and fluorescent) microscopes Intralesional injections Patch tests Perform history and physical exam Photomedicine, phototherapy, and topical/systemic pharmacotherapy Potassium hydroxide examination Scalp surgery Sclerotherapy Skin and nail biopsy Soft tissue augmentation Tzanck smears Special requests: Special requests in dermatology include: Laser use Mohs micrograph surgery Liposuction Dermabrasion Administration of sedation and analgesia Reappointment: Reappointment should be based on unbiased, objective results of care according to the organization s existing quality assurance mechanism. Applicants must demonstrate current competence and provision of care to 24 outpatient/ consultative patients with acceptable results, reflective of the scope of privileges requested for the previous 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current physical and mental ability to perform privileges requested is required of all applicants for renewal of privileges. I understand that by making this request, I am bound by the applicable bylaws or policies of the hospital, and hereby stipulate that I meet the minimum threshold criteria for this request. Practitioner s signature: Typed or printed name: Date: A supplement to Briefings on Credentialing 781/ /10 13

14 Privilege request form Procedural dermatology To be eligible to request clinical privileges in procedural dermatology, an applicant must meet the following minimum threshold criteria: Basic education: MD or DO Minimum formal training: Successful completion of an ACGME- or AOA-accredited residency in dermatology, followed by successful completion of a fellowship in procedural dermatology and/or current certification or active participation in the examination process (with achievement of certification within [n] years) leading to certification in dermatology by the ABD or AOBD. Required previous experience: Applicants for initial appointment must be able to demonstrate 400 dermasurgical procedures, reflective of the privileges requested, for the previous 12 months or successful completion of an ACGME- or AOA-accredited residency or clinical fellowship within the previous 12 months. References: If recently trained, a letter of reference must come from the director of the applicant s training program in procedural dermatology. Alternatively, a letter of reference regarding competence should come from the applicable department chair or service chief at the institution where the applicant most recently practiced. Core privileges in procedural dermatology: Core privileges in procedural dermatology include the ability to admit, evaluate, diagnose, provide consultation, and surgically treat diseases of the skin and adjacent mucous membranes, cutaneous appendages, hair, nails, and subcutaneous tissue to patients of all ages. Core privileges also include the ability to assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges also include performance of the following procedures: Performance of destruction techniques (electrosurgical, cryosurgical, chemical, and laser) Excision of skin cancers, warts, and other skin lesions, followed by a layered closure Mohs micrographic surgery Hair transplantation Skin rejuvenation techniques (dermabrasion, chemical peel, laser resurfacing, or rhinophyma correction) Laser surgery Laser phototherapy Nail surgery Small-volume tumescent liposuction Cutaneous soft tissue augmentation with injectable filler material Sclerotherapy 14 A supplement to Briefings on Credentialing 781/ /10

15 Electrosurgery for benign and malignant lesions (electrocoagulation, electrofulguration, electrodesiccation, electrosection, andelectrocautery) Scalpel surgery Wedge excision (lip and ear) Reappointment: Reappointment should be based on unbiased, objective results of care according to the organization s existing quality assurance mechanism. Applicants must demonstrate that they have maintained competence by showing evidence that they have provided an adequate volume of experience ([n] dermasurgical procedures) with acceptable results in the privileges requested for the previous 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current physical and mental ability to perform privileges requested is required of all applicants for renewal of privileges. I understand that by making this request, I am bound by the applicable bylaws or policies of the hospital, and hereby stipulate that I meet the minimum threshold criteria for this request. Practitioner s signature: Typed or printed name: Date: A supplement to Briefings on Credentialing 781/ /10 15

16 Editorial Advisory Board Clinical Privilege White Papers Associate Group Publisher: Erin Callahan, Associate Editor: Julie McCoy, William J. Carbone Chief Executive Officer American Board of Physician Specialties Atlanta, GA Darrell L. Cass, MD, FACS, FAAP Codirector, Center for Fetal Surgery Texas Children s Hospital Houston, TX Jack Cox, MD Senior Vice President/Chief Quality Officer Hoag Memorial Hospital Presbyterian Newport Beach, CA Stephen H. Hochschuler, MD Cofounder and Chair Texas Back Institute Phoenix, AZ Bruce Lindsay, MD Professor of Medicine Director, Cardiac Electrophysiology Washington University School of Medicine St. Louis, MO Sally J Pelletier, CPCS, CPMSM President - Best Practices Consulting Group Intervale, NH Beverly Pybus Senior Consultant The Greeley Company, a division of HCPro, Inc. Marblehead, MA Richard A. Sheff, MD Chair and Executive Director The Greeley Company, a division of HCPro, Inc. Marblehead, MA The information contained in this document is general. It has been designed and is intended for use by hospitals and their credentials committees in developing their own local approaches and policies for various credentialing issues. This information, including the materials, opinions, and draft criteria set forth herein, should not be adopted for use without careful consideration, discussion, additional research by physicians and counsel in local settings, and adaptation to local needs. The Credentialing Resource Center does not provide legal or clinical advice; for such advice, the counsel of competent individuals in these fields must be obtained. Reproduction in any form outside the recipient s institution is forbidden without prior written permission. Copyright 2010 HCPro, Inc., Marblehead, MA A supplement to Briefings on Credentialing 781/ /10