The problem with peer review; The dirty little secret of medicine - Yes, the medical profession does “self-police”. In every hospital there are so called peer review committees that have oversight power to review the actions of physicians on staff at the hospital. These committee’s were mandated by the 1986 Federal Health Care Quality Improvement Act. The intentions of this law were noble; try and provide a first line of quality assurance while doing so in a confidential and discrete manner.

It is well known that physicians are very reluctant to report on other physicians for fear of being slapped with a suit for slander and so it was hopped that these committees (the members of which were given immunity) would address this problem. However, there is a growing body of evidence including individual physician experiences that this peer review process is potentially seriously flawed and has the ability to silence physician “whistleblowers” and act as a tool of the hospital administration to go after it’s enemies.

The classic scenario works like this;

A physician becomes concerned about substandard care and potential threats to patient safety at a local hospital where they work. The physician either files formal complaints or takes their concerns directly to the hospital administration. The administration either labels these complaints as “disruptive” physician behavior or jacks up some bogus or significantly inflated charges of poor patient care by the physician. These charges are taken to a peer review committee often made up of individuals chosen directly or indirectly by the administration or who have their own personal bias against the physician in question. The committee then votes to remove the staff privileges of the physician and it’s all downhill from there.

Usually the physician will file suit against the administration but most courts will defer to the internal governing mechanisms of the hospital and ignore as irrelevant the surrounding context of the original complaints of poor patient care at the hospital. With a small fortune in legal bills and no income the physician is forced to declare bankruptcy and seek employment elsewhere. However, because the suspension or revocation of privileges is reported to the state medical board and the National Practitioner Data Bank (another product of the 1986 Federal Health Care Quality Improvement Act) the physician either gets their license suspended or finds it next to impossible to get work anywhere else in the US.

The majority of the time physician concerns about quality and patient safety are properly addressed without the administration going after the whistleblower but increasingly the system put in place by the 1986 law is being used to silence the messenger. According to the Pittsburgh Post-Gazette a 2001 report by the University of Baltimore found a serious potential for abuse by the hospital peer review system.

The report found that whistleblower physicians who alienate hospital officials are vulnerable to having their admitting privileges taken away, with devastating effects on their practices. Because the federal Health Care Quality Improvement Act protects peer review panels if they are sued, it also can have the effect of protecting a malicious peer-review group motivated by spite, prejudice or a desire to cripple a competitor’s practice, the authors said.

What’s more is that these peer review committees tend to operate in their own little worlds being only loosely governed by the hospital’s bylaws. They are not courts of law, the committee members usually have no experience with legal procedure, and a such there is the potential for them to become the closest thing to a legalized “Kangaroo Court” in this country as you can get. A physician reader let me know about his own devastating experiences with these committees.

“In these proceedings, it is a trial. But it is unlike any ‘trial’, you have ever imagined. It is a chapter out of ‘Alice in Wonderland’. The emphasis is all on ‘procedure’. There is NO due process. There are NO rules of evidence. Hearsay, opinion, rumors, innuendo, and outright lies are completely acceptable as testimony. Truth, facts, and evidence are irrelevant. All that matters is procedure. The board can decide that a physician improperly performed a hysterectomy on a MAN, and it cannot be challenged in court as long as ‘proper procedure’ was followed in making the determination. I am not kidding. If this were not so serious, it would be hilarious.”

Most lay persons should be astounded (or at least skeptical) to hear of such abuses. Why? Except for an excellent four part series on this issue by the Pittsburgh Post-Gazette (Part I), the vast majority of the media ignore this story assuming that the public has little interest in what they see as political infighting between physicians and hospital administrations or they simply don’t believe these physicians.

Physicians who are victims of this process often go to the media with amazing stories of abuse and wrongful accusations but the media reacts as if a drug addict is coming to them claiming to be the victim of abuse and wrongful accusations. In the public eye, physicians who are accused of endangering patients or of being disruptive are guilty until proven otherwise. The problem of course is that they often don’t get the chance or forum to prove them innocent.

The problem can even extend beyond retaliation against whistleblowers. Peer review committees and the peer review process can be hijacked as a tool to be used by other physicians or hospital administrations to get rid of competition or physicians they have interpersonal conflicts with. Last September I profiled the case of the Dallas cardiologist Lawrence R. Poliner who was suspended based on apparently trumped up charges of poor patient care at a hospital where he was newly in competition with several other cardiologists. Dr. Poliner sued and in a rare ruling won a massive settlement. Apparently the jury saw through the politically motivated attempt to oust Dr. Poliner but this case appears to be the exception by far.

There are solutions to this problem. Despite the expense, hospitals should liberally use independent outside review when evaluating a case of reported poor patient care, incompetence, or physician misconduct. This helps to protect the hospital against accusations of trumped up charges and helps to inject some sense of impartiality into the peer review process. Another solution would be to establish independent state peer review committees that would have no professional or personal bias and who’s rulings would be binding to both the hospital and the physician.

It’s not just that too many good physicians are becoming victims simply because they dared to report poor patient care but the system can’t properly deal with truly negligent poor physicians who tend to be protected because of their economic value to the hospital. I’d be willing to guess that many physicians in this country know of at least one other physician who is widely regarded to be a potential threat to patient care but no one is willing to speak up because the physician in question brings a lot of business to the hospital and has considerable political clout.

In my experience, it is never those physicians who regularly place patients at risk with questionable medical practices or outright negligence that are the ones who raise concerns about patient care. Rather, it is the firebrands. It is those hotheaded physicians who are passionate about patient care and the quality of medical treatment who raise hell, take their grievances to hospital administrations, and demand change. And unless these same physicians are economically valuable to the hospital and/or have considerable political clout then they might as well kiss their careers goodbye. In this case squeaky wheel gets the axe.

For more information please check out the Semmelweis Society International web site on sham peer review. If you have any experiences with this type of peer review abuse I’d like to hear about it. Feel free to leave stories in the comments section.