Wednesday, February 23, 2005

Peer Review: Friend or Foe????
From Medical Economics:Is peer review worth saving?
Of the following statements, which best describes hospital peer review?

It's an impartial means of identifying and dealing with errant physicians.
It has been transformed into a weapon that enables established physicians and hospital administrators to dispatch mavericks, whistleblowers, rivals, and other nonconformists.

Your answer might depend on whether or not you're a hospital insider. Like other supercharged topics, such as malpractice litigation and tort reform, hospital peer review rarely elicits a neutral shrug from members of the medical community.
To some peer review is a blunt tool to maintain the party line:
"In the 30 years that I've been a health law attorney," says Kern, "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."
So is peer review the hammer to beat down the nail that sticks out?
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."
Woe betide the "whistleblower":
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.
But according to some, peer review does not go far enough:
"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."
As a method of policing, peer review is felt to be ineffective at best:
In fact, peer review and other quality assurance efforts are so inadequate, says a malpractice claims specialist who requested anonymity, that more bad doctors are identified by insurance companies after claims are filed than are identified by their peers. "Hospital-based peer review is an ineffective way of dealing with bad doctors or questionable medical care. Physicians are more likely to be sheltered by peer review than to have it used as a weapon against them."
Some recommendations to improve the process:
Many observers who say that the peer review system is broken contend that the process needs, above all, to be made more objective. "If we're going to conduct peer review," says Linda Peeno, "an outside body should do it." This is difficult in small communities, where everyone knows everyone else, but one way to surmount that problem is to form reciprocal agreements with neighboring communities: We'll review your cases and you can review ours. Or a specialty board can hear the case
Outside review is key in avoiding the appearance of a conflict of interest on the part of the reviewers. Stories like this could be avoided.
Peer review is a necessary evil in today's world. I have served on peer review committees in the past and it is unpleasant to call one's colleagues onto the carpet, even when it is richly deserved. Currently under Georgia law peer review is non-discoverable in a civil action. This permits frank discussion of the matter at hand without having it used as fodder in the courtroom. But my friends south of the border may be hesitant to participate in peer review in the near future:
That shield has begun to crack, however. In November the Florida electorate endorsed a constitutional amendment—touted as a patient-safety measure—that would eliminate confidentiality from the peer review process. In response, the AMA, at its interim House of Delegates meeting in December voted to seek federal legislation to prohibit discovery of records, information, and documents obtained during the course of professional peer review proceedings.
Given all this, it's not surprising that physicians have to be brought kicking and screaming into peer review, on both sides of the table.
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