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Reviewing Peer Review Posit: Peer review can be prejudicial, abusive, or self interested. To significantly improve medical care, it should become preventive rather than punitive, based on well documented measures of best practice. Where circumstances require privileges to be withdrawn or denied, the entire record should be available for litigation. THE CURRENT Sierra Sacramento Valley Medicine e.posit generated 134 responses. Posits are deliberately strident or extreme statements, intended to promote discussion. Posits are not polls, and do not necessarily reflect the views of SSV Medicine, the Medical Society or its Board of Directors. Peer review is a system developed to encourage the self-policing among hospital staff. Any system can be abused peer review is no exception. But that is not a good enough reason to throw the baby out with the bathwater. What peer review should do, at its best, is to facilitate the review of difficult cases among peers for the purposes of learning both what to do, and what not to do. At its best, it elevates all of our practice styles. To achieve this goal, it must be protected to ensure open and honest discussion. It strikes me that lawyers are not the enemy and any good lawyer should be able to gather adequate information for litigation without access to what has been protected peer review information. I personally have not seen this system abused, but would not be so naïve as to assume it has never been so. So the real issue is not to trash a system that at least in some hospitals is working, but how to ensure that it works in all settings. This is much harder, but will result in a non-punitive, educational forum. - Marsha Gollober, M.D. There are three posits, each of which is independent. Theoretically, unbiased peer review leads to thoughtful, logical outcomes that lead to improved quality of care. However, though not ideal, doctors on peer review boards are in fact human, and make decisions based on their frame of reference - At times that may lead to "prejudicial, abusive or self-interested" comments and/or decisions. I've heard individuals base their idea of 'standard of practice' on their own practice style. Given that there are not 'well documented measures of best practice' for absolutely every contingency and behavior, that may be all we have, but in many cases it is less than ideal. Group dynamics also influence decisions, with individuals at times voting for a position that might conflict with ideas and feelings they might have had in a quiet moment, unbiased by a vocal committee member. The only way to avoid the problems of human nature in peer review would be to employ computers to determine compliance with best practice: Horrific scenarios of 'garbage in = garbage out' and 'search yields no results' would ensue. So we are left with humans judging the behavior and practice of other humans. Clearly peer review should implement preventative action, rather than punitive. We do not need to reinvent the wheel: Reams of psychological and motivational data prove that change is best accomplished with constructive feedback. Only when it is obvious that a physician will not change or is an imminent danger to patients' lives, should punitive action be taken. We all make mistakes. Again the human factor. If every mistake were met with punishment and/or banishment, there would be no doctors left to care for patients. The last statement somehow forgets that there is a patient involved, to whom the medical record belongs. Not all peer review proceedings are initiated by the patient or patient's family. If a physician wishes to contest denial of privileges, and litigation occurs, the patient's consent is necessary for exposure of the medical record. - Ann Gerhardt M. D. Although it can happen, peer review, in my experience, has not been prejudicial, abusive or self interested. "Preventive" proceedures can be ineffective. - Dennis Marks, M.D. In my career as chief of a hospital department and working for Medicare, I have seen evidence that peer review can be prejudicial, abusive, and self-interested. To significantly improve medical care, the peer review process must work better for results intended-to protect patients from improper care, and to reduce the likelihood of medical errors. Perhaps there are other goals as well. Peer review cannot be preventive because first something must happen to warrant a review of it. The process that leads to proper training and credentialing is preventive. Peer review can be punitive if action reviewed warrants punishment. The goal of a peer review process is not punitive, but the result can be punitive, dependent upon the nature of the problem and the response of the physician reviewed. The standards upon which peer review decisions are based must be peer-review published or specialty society accepted standards of medical practice. Where circumstances require privileges to be withdrawn or denied, the entire record should be available for discovery, but only upon request of the physician reviewed or in cases of criminal prosecution. Peer reviewers must be protected from responses that would suppress proper peer review, so long as the reviewers do not disregard the rights of the person reviewed. How this goal is best accomplished is uncertain to me. One option is through a panel of reviewers who do not work in the community of the person reviewed. - Gerald N. Rogan, MD Peer review should be "no-fault" and geared toward identifying preventable/"fixable" errors in a non-punitive, education-based manner. The goal should be prevention of errors, not punishment, with the exception of clear-cut negligence. - James Sehr, M.D. I have heard about prejudicial peer review, but to my knowledge have not experienced it myself. Good guidelines for practice patterns are now universally available. When they are ignored and patients suffer, probation with education might be tried before the doctor's are withdrawn.It depends upon how severe the infraction was... - Byron Demorest,M. D. Posit is provocative, as usual. Is it possible that it can be prejudicial, abusive or self interested? As Attorneys love to point out, anything is possible. But in over 10 years of doing peer review, I have never seen any evidence of this. In fact, the exact opposite is the norm. Peer review panels bend over backwards to be fair and objective. To suggest otherwise is a frank insult to anyone who volunteers their time for the betterment of our profession. Preventative versus punitive? Those are different steps in the graduated intervention to improve patient care. It's not either or, it is always both. With respect to public record, don't be ridiculous. Making details of Peer Review decisions available will insure that honest Peer review and intervention will never happen again.. - D. Hause, M. D. All peer review should include the person being reviewed for their opinion before a final decision is determined. Training and systems coordination should always be the goal. It is only after purposeful, very severe, or repeated problems, despite training for issues of the same nature, that resrictions should be levied. Evalyn Horowitz, M. D. This appears reactive to negative feelings about peer review. I feel peer review is essential to maintain optimal quality of care--it is designed to be educational, but if necessary should have the ability to set limits to a provider if necessary. If physician don't support active peer review, it will be taken over by non-physicians and will be punitive, non-clinical and adversarial - Jim Margolis, M.D. Peer Review is not punitive. Rather, it allows your peers to intervene and educate before the problem becomes irreversible. There already exist mechanisms for appeal of privilege decisions. Non-confidential peer review subject to litigation would essentially destroy the peer review process. While I am aware of complaints about peer review, I believe the majority of time, peer review is done fairly and in the best interest of the physician. It is also a tremendous learning experience for the reviewers. - Joanne Berkowitz, M.D. The peer review process should be educational, and hence preventative. If the findings of a peer review committee lead to the withdrawal of privileges then the committee chair should represent the composite view of the committee. Opinions of individual committee members, however, should remain privileged and protected. In this way, committee members can be honest in their views and don't have to worry about retribution from the physician on review. - Steve Orkand, M.D. My experience sitting on this committee years ago convinced me that without accountability the peer review process can be seriously flawed. - Norman Poppen, M.D. I Agree. Please view the website(s) of the Semmelweis Society for a more extensive treatment of this vital and all too common problem. - Lee Welter, M.D. Preventive rather than punitive" suggests the Med Society is going to get into the business of medical education. If doctors are not keeping up in their field, there will be need for punitive action. I agree that all of the records should be available if punitive action is being considered and that there are assurances that the physicians reviewing the complete record are experts relative to the case in question. - Scotte Dogget, M.D. I agree. I am having trouble with the concept of preventative peer review. I am not at all sure what that would entail. While it is true that individual peer review may potentially be prejudicial, when done by a committee this would tend to mitigate any personal bias'. On the other hand, I am not sure how to do peer review otherwise. Always a sticky wicket. - Sidney Scudder, M.D. |
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