Is peer review worth saving?
An increasingly vocal group of physicians says the hospital peer review process is misused to strike down competitors and outliers.
Not only is the peer review process corrupt, it's ineffective, says Ralph M. Bard, a physician turned attorney in Tullahoma, TN. "To Err Is Human, the Institute of Medicine's report on patient safety, was released after HCQIA and the NPDB had been in place for many years. Yet the report shows a high rate of medical errors—and that error rate remains high. Rather than being used to weed out bad doctors, peer review as it exists today is used primarily as a weapon against young, vulnerable practitioners."
Peer review wasn't intended as a means to oust qualified physicians to the benefit of their more economically successful competitors, says James Lewis Griffith Sr., a malpractice attorney in Philadelphia. "Too often, however, the golden rule applies: He who has the gold makes the rules."
Conversely, attempts to initiate the peer review process against well-connected physicians can be hazardous to one's career, says Mary H. Johnson of Asheboro, NC. Johnson, a pediatrician and former National Health Service Corps provider, asserts that she was fired from her hospital job after filing a peer review report on a colleague who had badly mismanaged a newborn's care. "The abuse of peer review for economic reasons or to perpetuate a cover-up is medicine's dirtiest little secret," Johnson says.
Bard, whose clients are primarily physicians attempting to counter peer review accusations, left medicine after tangling with a peer review panel. "I was targeted when I pointed out that the hospital's fees were too high and the nurses were poorly trained," says Bard. "They examined every chart I had. No physician can withstand that type of scrutiny." Bard currently serves as vice president of the Semmelweis Society, an organization formed to help physicians ensnared in what Bard calls "sham peer review." The society takes its name from Ignaz Semmelweis, the Hungarian obstetrician who pioneered the field of antisepsis but died a broken man after antagonizing his superiors.
"Where are the checks and balances?" wonders internist Linda Peeno, a healthcare ethicist and consultant who formerly served as a medical reviewer for Humana and as medical director of Blue Cross Blue Shield of Kentucky. "Hospital peer review is one of the most closed boxes in the healthcare system. Where's the outside, independent assessment to determine whether this information is being gathered or used appropriately? The people in charge—those who have the greatest economic and administrative incentives to select and use this data against physicians—are the ones who have access to it."
The other side: Peer review is underused On the other side of the polarized peer review debate are those who claim that the process is used far too seldom because physicians are loath to criticize their colleagues.
"Most medical staffs aren't aggressive on these subjects," says Philadelphia attorney Alice G. Gosfield. "Physicians judging their colleagues are very concerned about the potential impact of peer review, so they'll go through all kinds of contortions to avoid taking action. So, when physicians or administrators move forward, it's usually justifiable.
"A peer review is an emotionally devastating event for a physician," Gosfield continues. "As badly as physicians handle malpractice cases, it's far worse to be criticized by colleagues with respect to professional performance. Sometimes reviews do stem from clinical judgment differences or personality issues. In my experience, they're rarely motivated by economic competition."
In their book, Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes, physicians Robert Wachter and Kaveh Shojania indicate that, in the medical profession, self-policing is "inept and ineffectual." When disciplinary action is taken, Wachter and Shojania note—say, removing a physician's hospital privileges or recommending to the state board that a doctor's license be suspended—"it comes only after an orgy of soul-searching, hand-wringing, buck-passing, second-guessing and second chances that is painful, and sometime embarrassing, to watch."