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Is Hospital Peer Review a Sham? Well, Mostly Yes

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By BOB WACHTER, MDWachter pic (informal)

Dr. Sidney Wolfe, healthcare’s answer to Ralph Nader, spends most of his days unhappy with somebody.  Pragmatic, see-both-sides types like me naturally recoil from Wolfe’s reflexive indictment of institutions ranging from the FDA to Medicare.

But Wolfe’s blistering condemnation of medical staff peer review contained in the new report, Hospitals Drop the Ball on Physician Oversight (co-written by Alan Levine, both of Public Citizen’s Health Research Group) is timely and, I believe, largely correct.

The report focuses on the National Practitioner Data Bank (NPDB), established in 1986 to collect data about problem physicians, mostly to help credentials committees make informed decisions about medical staff privileging. The legislation that established the NPDB requires hospitals to submit a report whenever a physician is suspended from a medical staff for over 30 days for unprofessional behavior or incompetence. Although the public cannot access NPDB reports on individual physicians, healthcare organizations (mostly hospitals) ping the database about 4 million times per year. When it was inaugurated, the best estimates (including those of the AMA) were that the NPDB would receive 5,000-10,000 physician reports each year.

Not so much. Since its launch two decades ago, NPDB reports have averaged 650/year, and nearly half of US hospitals (2845 of 5823) have never reported a single physician! The most extreme case is that of South Dakota, where three-quarters of the hospitals have never reported a single case to the NPDB. I’m sure South Dakota has some wonderful doctors, but the idea that the state’s 56 hospitals have never had a physician who needed to be suspended for incompetence, substance abuse, sexual harassment, or disruptive behavior since the Reagan presidency is a bit of a stretch, don’t you think?

Public Citizen chronicles several cases of egregious behavior by physicians who dodged NPDB reports  – the cases either received no peer sanctions or were dealt with in ways designed to skirt the reporting requirements, such as – wink-wink – leaves-of-absence and 29-day suspensions. Most famously, a cardiologist and CT surgeon at Redding Medical Center in Northern California performed hundreds of unnecessary cardiac procedures but were not reported to the NPDB – largely because Redding’s medical staff and hospital were cowed by the physicians’ power and reluctant to kill two geese who laid many golden eggs. (Interestingly, the Joint Commission whiffed on this one too, a major reason why Congress removed its near monopoly on the hospital accreditation business last year.)

Levine and Wolfe recommend powerful medicine to fix the NPDB system, including much more vigorous legislative oversight, substantial fines to hospitals for failing to report, and linking NPDB reporting practices to accreditation standards and to Medicare’s Conditions of Participation.

A few years ago in our book Internal Bleeding, Kaveh Shojania and I described the limits of peer review; the Public Citizen report provides statistical confirmation of our observations. We wrote,

It is undeniable that hospitals do have a tendency to protect their own, sometimes at the expense of patients. Hospital “credentials committees,” which certify and periodically recertify individual doctors, are toothless tigers. Most committees rarely limit a provider’s privileges, even when there is stark evidence he presents a clear and present danger to patients. Instead, they assign a committee member to “have a chat” with the physician in question, perhaps gently suggesting he or she shouldn’t do a particular procedure anymore. They might even ask another physician, not on the committee but in a similar specialty, to “keep an eye on old Doug” and let them know if he continues to screw up, even if patients or other staff members don’t report it….

It is not that hospital credentials committees never take action. They do – removing a physician’s privileges at a hospital or recommending to the state board that a doctor’s license be suspended – when there is clear, repetitive evidence of gross negligence and incompetence. But when this happens – and it is really rare – it comes only after an orgy of soul-searching, handwringing, buck-passing, second-guessing and second chances that is painful, and sometimes embarrassing, to watch. In most cases, committee members just swallow hard and – unless the physician is under felony indictment or is so stewed that he can’t walk down a corridor without banging into both walls – the credentials are rubber-stamped.

Kaveh and I offered three reasons why medical staff self-policing is so wimpy. The first is the “fraternity of medicine” thing – no gang members like to “rat out their pals,” and in this regard, we’re no different from the Crips. The second is that credentials committee members are acutely aware of the amount of time and effort that it takes to become a practicing physician, which makes them reluctant to take away a doc’s livelihood.

A third reason, we wrote,

is simply that doctors aren’t very good organizational managers. Their people skills are usually confined to bedside chats and working with colleagues and support staff in task-oriented jobs; they aren’t particularly adept at managing conflicts and confrontations, so they avoid them. This is a pretty dumb reason to let an error-prone doctor continue to prowl the hospital wards, but because litigation… lurks behind any challenge to professional competence… many physicians are reluctant to go into that particular swamp unless the trail is awfully solid.

The fear of litigation is undoubtedly one of the major reasons why peer review doesn’t work. Although the statute establishing the NPBD provides immunity to physicians who perform good faith peer review, many hospitals and reviewers lack confidence in these protections. An American Hospital Association analysis of the NPDB concluded, “The specter of baseless, time-consuming and expensive litigation serves as a powerful disincentive to effective peer review.” If peer review is to be strengthened, these protections must be unambiguously robust.

Writing in his book Complications, Harvard surgeon and bestselling author Atul Gawande sees in the medical profession’s failure to perform aggressive peer review something understandable, even a tad noble. When it comes to disciplining a basically good but troubled doctor, “no one,” he says, “really has the heart for it.” Atul writes:

When a skilled, decent, ordinarily conscientious colleague, whom you’ve known and worked with for years, starts popping Percodans, or becomes preoccupied with personal problems, and neglects the proper care of patients, you want to help, not destroy the doctor’s career. There is no easy way to help, though. In private practice, there are no sabbaticals to offer, no leaves of absence, only disciplinary proceedings and public reports of misdeeds. As a consequence, when people try to help, they do it quietly, privately. Their intentions are good; the result usually isn’t.

There are still other reasons for the failure of peer review. When questions of clinical competency arise, there are often insufficient data to refute the inevitable arguments that “my patients are older and sicker.” When the issue is disruptive behavior, unless there has been documented scalpel throwing (by a surgeon with good aim), finding the bright line that separates the behavior of an aggressive, passionate, patient-advocate-of-a surgeon from the surgeon whose disruptive behavior creates a hostile work environment or places patients at risk can be elusive. Finally, peer review conducted by professional colleagues is fundamentally tricky – one the one hand, how could one’s practice be dispassionately reviewed by a golfing buddy? On the other, peer reviewers might well be competitors of the physician-in-question, with a financial stake in the outcome.

Is it any wonder that medical staffs kick this particular can down the road so often?

Layered on top of these traditional impediments is a new one: the paradigm shift introduced by the patient safety field. Remember, our patient safety mantra has been “no blame,” which is unlikely to be in the first verse of the Peer Review Fight Song. Haven’t we just finished convincing ourselves that most errors are due to dysfunctional systems and not bad apples? If that’s the case, who really needs peer review, anyway?

But this represents a fundamental misunderstanding of “no blame.” I struggled with this tension while writing Internal Bleeding, and went to The Source for guidance: Dr. Lucian Leape, the father of the patient safety movement. Lucian, I asked, how can we reconcile systems thinking with the necessity of standards and peer review? His answer was spot on:

There is no accountability. When we identify doctors who harm patients, we need to try to be compassionate and help them. But in the end, if they are a danger to patients, they shouldn’t be caring for them. A fundamental principle has to be the development and then the enforcement of procedures and standards. We can’t make real progress without them. When a doctor doesn’t follow them, something has to happen. Today, nothing does, and you have a vicious cycle in which people have no real incentive to follow the rules because they know there are no consequences if they don’t. So there are bad doctors and bad nurses, but the fact that we tolerate them is just another systems problem.

I’m proud to say that over the past five years, my hospital (UCSF Medical Center) has taken Leape’s challenge to heart, withdrawing clinical privileges (and filing accompanying NPDB reports) in several cases for behavior that, I’m quite confident, would have been tolerated a decade ago. This is progress. As Kissinger once said, “weakness is provocative.” As more hospitals take this tougher stance, I think we’ll see the boundaries of acceptable behavior shift everywhere. And patients will be safer for it.

A profession is group of individuals with special knowledge, who are granted privileges by society in deference to their expertise and in exchange for self-regulation. When thousands of hospitals can go 20 years without disciplining a single physician on their medical staff, our status as a profession is called into question.

In the end, peer review is about answering one deceptively simple question: Is it more important to protect problem physicians or vulnerable patients? If we can’t answer that question correctly, we should not be surprised when the Sid Wolfes of the world call us to task, nor when we find ourselves under an unpleasant media, legislative, and regulatory microscope. Professions don’t need that kind of outside scrutiny to do the right thing, but we just might.

Dr. Robert Wachter is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog “Wachter’s World.”

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16 replies »

  3. Great article! We at Medprex have tried to solve many of these issues through simple software utilized by a cooperative of hospitals and physician groups to launch a secure Internet-based platform for unbiased, independent peer reviews from matching board certified providers to ensure standards of quality patient care are met. Our peer review software is free for internal PR management, but cases sent to the exchange have a per diem fee.

  5. Great article but you missed one other problem. We are wasting millions of dollars on this credentialing “processes” in health care. Hospitals verify credentials, health plans verify credentials, no one reports incidents, but they all check it. Imagine the thousands of hours spent checking, requiring forms, etc. We would do well for health care to have one credentialing system.

  6. I found Dr. Johnson’s comments very interesting. Physicians have a learned and achieved a lot, just by virtue of graduating from their residency program, and tend to be self confident and narcissistic, to varying degrees. Therefore, I don’t think that peer review can ever become “nurturing” unless it only involves praise. But peer review could become ordinary standard – meaning that you expect a couple of your cases to be reviewed regularly, and that this is the normal case for every physician, even without a patient complaint. But of course, routinely reviewing cases of other docs adds to the loads of paperwork and other “nonproductive” aspects of the physician workday, and would increase health care costs and decrease physician availability. And unless reviewers also criticized superfluous testing, it would likely result in even more unneeded testing.

  7. Public peer review is not peer review. The NPDB is a failure in that regard because it was instituted to solve a political problem.
    Out state’s Physician Health Plan quietly treats doctors with personal issues that will cost the doc his/her licence if not resolved.
    Our hospital exec committee deals with peer issues based on criteria, not personality. These activities are specifically shielded from discovery and public scrutiny.
    Congress and the legal profession should do as well.

  8. The meaning of sham peer review has been glibly subverted by the professors opining on this blog and others.
    Sham peer review has been and continues to be used as an administrative tool by hospital non-medical and financially guided leadership to silence the physician critics who complain about the administrative policies that compromise the safety of patients. Wolfe, Wachter, and others should awaken to the abuses of peer review that have adversely affected the careers of highly competent physicians.
    If a doc sucks up to the administration and makes money for them (unnecessary cardiac surgery), unless egregious, there will never be discipline, whatever “discipline” means.
    Hospital administrators’ conduct deserves scrutiny.
    There needs to be a board of physicians empowered to administer conduct review of the hospital CEO’s. Since the Joint Commission is a carefully veiled hospital trade group, of the hospitals’, for the hospitals’, and by the hospitals’ administrators, patients will continue to have their safety compromised by such organizations and hospital leadership.
    Sidney Wolfe, are you reading this?

  9. Yes, peer review is ineffective.
    Yes, peer review is not done competently. We do not have a procedure, a system, or social values that would engender productive peer review. Why?
    1: We have no culture of, or profession-wide, system of physician performance review after training.
    2: We have a long tradition of emotionally-abusive performance review during training (degradation, unrealistic perfectionism, sarcasm), with the socratic method often implemented cruelly by mentors. (This has improved.)
    3: Peer review in most institutions is a fault-finding process. In normal society, we earn the right to criticize by recognizing and acknowledging what was done well.
    4: Peer review is almost always formal, impersonal, and without empathy. While conversation is not always ideal, diplomacy by the reviewer is always useful, especially acknowledging that the review is limited by being based on the written record, not personal observation, and that perfection is not expected but (at least circumstantial evidence of) prudence and self-correction are.
    5: “Nurturant” peer review needs to precede punitive peer review in order to make it acceptably less threatening to reviewed physicians. It is extremely important that a “death penalty” not be the first step in discipline.
    6: Physicians under review, for all these reasons and egocentrism, insecurity, and rigidity tend to take even suggestions as personal criticism.
    7: Exhaustion is common in our profession, and does not breed calm or diplomacy, either in the reviewer or the reviewed.
    8: All peer discipline should augment and inspire self-discipline and self-correction.
    9: This list could be continued for a long time…
    In a nutshell, effective peer review will occur only when we make it a constructive and helpful part of our professional culture. I think we’re 2 professional generations away from this, even with coordinated effort.

  11. Great article.  And yet, I think it lacks clarity about different kinds of physician wrongdoing.
     First, there is true negligence, such as not properly examining a patient, not reacting to an alarming test result etc. … the underlying cause for this may be substance abuse; and I would lump inappropriate behavior into this same category.
     The second category is the difficult issue of competence.  Except for the most egregious cases, we are dealing with a slippery slope from obvious incompetence to physicians that just happen to miss a very difficult diagnosis.  There is ample research that physicians are actually biased against their colleagues, namely with 1. hindsight bias (i.e. selectively interpreting a difficult case scenario by emphasizing the warning signs that seem to be obvious if you have outcome knowledge) and 2. outcome bias (if a patient suffers permanent damage, the exact same care is deemed worse by peer reviewers than in the case of a patient who had only transient damage).
     Dr. Wachter talks almost exlusively about the first kind of wrongdoing and makes the case that peer review is mostly ineffective.  Probably so (I have actually seen cases of quite tough and functioning peer review).   I would argue that the whole hospital peer review system is flawed in its conception.  One would be better served by the state boards taking a more active role (for instance, one could have a disciplinary committee with rotating physician members from all over the state), and the actual factual review of cases should be sent out of state anyways (and done completely anonymized, both ways).  What logic is there behind a hospital board deciding about privileges?  Do we have state or county driver’s licenses?
     Re. the issue of competence, I would argue that physicians are often negatively biased against each other, claiming they know better, with the help of the powerful restrospectroscope (i.e. after the outcome is clear to everyone).  In general, our current tort system is biased against reasonable, careful physicians with honest mistakes in judgement (certainly, there are also egregious mistakes that go unnoticed, but that’s not the point here), and even though most courts understand that honest mistakes do not constitute malpractice (http://www.acr.org/MainMenuCategories/about_us/committees/gpr-srp/MedicalLegalCommittee/MalpracticeWisconsinDecisionDoc6.aspx , juries may still decide against the doctor for a variety of reasons.  If you look (and trial lawyers know where to look), you will get your experts who will stretch the truth to the point of distortion when witnessing against another physician.  So it is no longer true that docs never hurt other docs.

  12. Great article.  And yet, I think it lacks clarity about different kinds of physician wrongdoing.
     First, there is true negligence, such as not properly examining a patient, not reacting to an alarming test result etc. … the underlying cause for this may be substance abuse; and I would lump inappropriate behavior into this same category.
     The second category is the difficult issue of competence.  Except for the most egregious cases, we are dealing with a slippery slope from obvious incompetence to physicians that just happen to miss a very difficult diagnosis.  There is ample research that physicians are actually biased against their colleagues, namely with 1. hindsight bias (i.e. selectively interpreting a difficult case scenario by emphasizing the warning signs that seem to be obvious if you have outcome knowledge) and 2. outcome bias (if a patient suffers permanent damage, the exact same care is deemed worse by peer reviewers than in the case of a patient who had only transient damage).
     Dr. Wachter talks almost exlusively about the first kind of wrongdoing and makes the case that peer review is mostly ineffective.  Probably so (I have actually seen cases of quite tough and functioning peer review).   I would argue that the whole hospital peer review system is flawed in its conception.  One would be better served by the state boards taking a more active role (for instance, one could have a disciplinary committee with rotating physician members from all over the state), and the actual factual review of cases should be sent out of state anyways (and done completely anonymized, both ways).  What logic is there behind a hospital board deciding about privileges?  Do we have state or county driver’s licenses?
     Re. the issue of competence, I would argue that physicians are often negatively biased against each other, claiming they know better, with the help of the powerful restrospectroscope (i.e. after the outcome is clear to everyone).  In general, our current tort system is biased against reasonable, careful physicians with honest mistakes in judgement (certainly, there are also egregious mistakes that go unnoticed, but that’s not the point here), and even though most courts understand that honest mistakes do not constitute malpractice (http://www.acr.org/MainMenuCategories/about_us/committees/gpr-srp/MedicalLegalCommittee/MalpracticeWisconsinDecisionDoc6.aspx , juries may still decide against the doctor for a variety of reasons.  If you look (and trial lawyers know where to look), you will get your experts who will stretch the truth to the point of distortion when witnessing against another physician.  So it is no longer true that docs never hurt other docs.

  13. Agree that hospital peer review is flaccid. What if physicians were scrutinized for excessive and unnecessary medical intervention, not just on lapses of medical performance? No hospital would support this effort since they benefit enormously from the billions of dollars of unneeded CAT scans, catheterizations, medications and specialty consultations. This is the hope of comparative effectiveness research, which may never get off the ground. Obama’s health care reform plan is starting to ‘coast’ uphill. http://www.MDWhistleblower.blogspot.com

  14. We must be extra careful in ensuring that these ‘credentialing committees’ are not used for economic purposes and becoming Mccarthistic like in pursuing ‘unprofessional behavior’ that is either trivial or unsubstantiated. The destructive nature of unbridled power must be kept in check. There needs to be an alternate choice between ‘having a chat’ and ‘reporting to the NPDB’ – we need to set a standard in the community setting for some middle ground.

  15. Unfortunately, I can attest that this post is largely true also on the community hospital level, although I believe it is slowly changing. When I served on hospital medical executive committees considering such cases, it was usually the case that everyone recognized the seriousness of the infraction, but when it came to the consequences, that’s where they failed. I was often the lone ranger trying to enforce stronger punishment, because I was hospital based and therefore immune from the “good old boy” consequences.
    It would be a shame to give peer review to an outside authority because it’s usually the local docs who know the situation and the physician in question best. We just need a way to kick them in the pants and give them some guts to proceed the way they know they should.
    Good post on an important topic.

  16. Coincidently, I am half a way through an article on this topic. What I understand is the problem is much more serious and even more serious is lack of offer to a solution. Just like, for every traffic ticket there are a lot more that go with morning and so many more are just few miles above the speed limit and are not even considered violators; so is the case-most likely- with this issue.
    I might be interested in discussing our solution proposal to those in authority and with interest in solving….If anyone wants to contact proactively, I would gladly entertain a discussion. I can be reached via my blog or web.
    PS: THE article is not yet posted anywahere.
    rgds
    ravi
    blogs.biproinc.com/healthcare
    http://www.biproinc.com