Career Resources articles posted on NEJM CareerCenter are produced by freelance health care writers as an advertising service of the publishing division of the Massachusetts Medical Society and should not be construed as coming from the New England Journal of Medicine, nor do they represent the views of the New England Journal of Medicine or the Massachusetts Medical Society.
By Thomas Crawford, MBA, FACHE, faculty, Department of Urology, College of Medicine, and affiliate faculty, Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, and Samantha Azadian, student, University of Florida
If your employment is contingent upon being able to admit, treat, or operate on patients within a hospital setting or you are accepting an employed position with a hospital, you need to review the hospital’s medical staff bylaws and rules and regulations. The bylaws serve as the formal self-governance structure of the physicians and, if applicable, other licensed and credentialed providers, such as psychologists and dentists, as delegated by the board of trustees. The rules and regulations outline institutional policies and protocols, such as admitting and emergency room processes; records and charting; and laboratory service orders. Sequentially, you should review the bylaws before accepting an employment opportunity, and you need to review the rules and regulations prior to treating a patient within the hospital.
Beyond the governance structure, including officers and committee responsibilities, the bylaws outline the following items that may affect your job satisfaction or, potentially, your employment status:
- Qualifications for membership and privileges
- Decision-making methods and conflict resolution
- Investigations, corrective action plans, and hearing and appeal plans
- Emergency corrective action
- Automatic suspension and termination
- Hearing and appeal processes
- Final decisions by the board of trustees
- Meeting attendance requirements
When reading the medical staff bylaws and rules and regulations, do not skim through the document. Be sure to pay attention to any item that may directly influence or impact you now or in the future.
Example of Medical Staff Bylaws
The following vignette is not uncommon to hospital bylaws from around the country:
Affiliate and/or Active Staff shall live and maintain an office in __________________ County.
For the purposes of providing call coverage — the Affiliate and/or Active Staff shall live within 30 minutes of the hospital’s Emergency Department as traveled on town-maintained roads.
This covenant underscores the necessity of reviewing the bylaws and conducting an external cultural assessment prior to accepting an employment offer. Essentially, if you want to move to another county, yet continue your employment at your current practice or hospital, you could have your hospital privileges revoked or non-renewed based on your place of residence. Why? Because you would be unable to admit, operate, or treat your patients within the hospital setting, and this typically will result in a termination or voluntary resignation if the conflict cannot be remedied to the satisfaction of the hospital.
Unfortunately, I have seen this scenario disrupt physicians that wanted their children to attend more competitive public school systems that were outside of their hospitals’ catchment areas. The employed physicians were told if they violated the medical staff bylaws, it would be grounds for termination for cause based on the premise that they would not be able to respond in a timely manner to their respective Emergency Departments when on call. Note — a potentially unwelcome impact on your personal or professional lives is not limited to the bylaws; on the contrary, the rules and regulations of the medical staff will also need to be understood before commencing your practice.
Example of Rules and Regulations of the Medical Staff
The following rule is common within the rules and regulations of a preponderance of hospitals.
“Adherence — in the event a physician does not comply with these Rules and Regulations, the President shall inform the Administration to discontinue admitting patients of this physician except in Emergencies.”
What does this mean? I have been placed in a position to interpret a similar rule, and my institutional interpretation was as follows: If you were not in compliance with a rule or policy (re-credentialing paperwork or medical records were incomplete, for example), your hospital privileges would be administratively suspended; however, you were still expected to take an equitable share of emergency department call (“except in emergencies”). If you were in a private practice, your ability to generate income would be significantly limited, or if you were employed by the hospital, your paycheck could be reduced or withheld, even though you continued to provide equitable call coverage.
The medical staff bylaws and the rules and regulations should be provided to you upon request. Although there are minor nuances from institution to institution, you will find that both documents have similar frameworks for content, regardless of location. Lastly please know that, generally speaking, both documents are approved at the board level. The importance of this caveat was underscored to me during a presentation to 200 physicians in New Orleans. Essentially, I was presenting the afore-referenced material when I had a resident physician in the audience make the following comment loud enough for everyone to hear: “The bylaws belong to the medical staff, we’ll change them.” My response, “The bylaws belong to the institution, any revisions are approved by the board, and the board will look to the CEO to determine if the requested modifications will impact the safety of the care or increase the organization’s expense exposure.” Feeling defeated, the early careerist looked at me, and shook his head to which I stated, “Do yourself a favor, limit the potential for an unwanted surprise by reading the documents before you sign your contract.”