The Peer Review Process: Welcome Back to High School

In 1986, Congress enacted the Health Care Quality Improvement Act (HCQIA) in an effort to reduce the number of medical errors which were contributing to preventable patient deaths. Included in this act was the creation of a “peer-review” system, which is run and controlled by each hospital’s own administration. Ideally, the peer-review process is meant to be a learning process where medical errors are identified, the physicians involved are educated, and measures are taken to promote and enhance the quality care that is delivered to patients in the future.

However, in the eighteen years since the establishment of this so-called “peer-review” process we have failed to see a significant decrease in the number of medical errors and resulting patient deaths. This has led to the questioning of the validity of the peer-review system by some critics. Is the peer review system really about achieving the highest quality of care, or is it like being in high school all over again with a powerful “in-crowd” exhibiting favoritism, prejudice and ulterior motives for their own political or financial gain.

“In the 30 years that I’ve been a health law attorney, I’ve never seen anyone who admits a lot of patients and is well-liked have a problem with the hospital disciplinary mechanism. On the other hand, if you’re competing with such a doctor, especially if you’re new to the hospital or on the wrong side of hospital politics, you’re a potential target.” ~ Steven Kern, Health Law Attorney

So who are these “Peers” that are reviewing their “Colleagues” anyway? What are the qualifications they possess which makes their level of care automatically superior to the physicians they are reviewing? Just like those cliques back in high school, most of the time members of these committees are nothing more than the buddies of hospital administrators.   These are typically the older physicians who have been around a long time, have an established referral base, and bring money into the hospital. But being rulers of the playground for so long also comes with the insecurity of eventually losing their hold on the medical community. This leads to the improper use of the peer-review process which has caused some physicians to lose all confidence in the system.

Some would go so far as to call the peer-review process corrupt. There have been numerous publications and case reports of physicians who have been awarded significant financial compensation through litigation as a result of what is being called “Sham Peer Reviews”.  There is evidence pointing to the use of peer review as a tactic against physicians who might attract paying patients away from the hospital, or from established physicians preferred by the hospital. Some reports claim that the main objective of many of today’s peer-review committees is to weed out competing physicians.1

Ralph M. Bard, a physician-turned-attorney, states “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. Those that are targeted are frequently younger, better trained, but less established doctors.”

More concerning is the possibility that some hospitals use the peer-review system to silence and discipline physicians who speak out on behalf of patients against substandard hospital practices. In an article in the Pittsburgh Post-Gazette, Steve Twedt writes “Doctors who are sworn to protect their patients from harm increasingly face investigation, sanctions, and even financial ruin if they challenge hospital practices because they believe those practices adversely impact on patient care.”

As a young physician, I’d like to believe in the good of the system. It was, after all, created with the best interest of the patient in mind. However, no process runs 100% perfectly. At some point there are personal/political motivations driving any committee, whether it’s a peer-review committee or a parent/teacher association. The part that bothers me though is when a young physician’s attempts to improve the quality of patient care by pointing out deficiencies that exist in a hospital or physician’s practices falls on deaf ears because such improvements would come at a cost to the hospital, or because the physician in question has been a well established member of the medical staff for the last four decades.

Then again, I guess it would be kind of awkward asking your golfing partner to change the way he/she practices medicine in order to uphold the highest standards of patient care.

References

  1. Lauth, Leigh Ann The Patient Safety and Quality Improvement Act of 2005: An Invitation for Sham Peer Review, Indiana Health L. Rev. 151 (2007).
  2. Garfinkel-Weiss Gail, Is Peer Review Worth Saving? Med. Econ., Feb. 18 (2005).
  3. Waite V and Walker R, Medical and Surgical Peer Review, 168 Am. J. of Surgery 1 (July 1994)
  4. Twedt, Steve “The Cost of Courage” Pittsburgh Post-Gazette, October 26, 2003.
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