Much Ado about Peer Review

By Clive Riddle, July 14, 2010

JAMA’s current issue features the article: Physicians' Perceptions, Preparedness for reporting, and Experiences Related to Impaired and Incompetent Colleagues, by Catherine M. DesRoches, DrPH et.al. [JAMA. 2010;304(2):187-193. doi:10.1001/jama.2010.921]. The article presents survey results regarding physician peer monitoring and reporting, which nationally polled “2938 eligible physicians practicing in the United States in 2009 in anesthesiology, cardiology, family practice, general surgery, internal medicine, pediatrics, and psychiatry. Overall, 1891 physicians (64.4%) responded.”

The survey asked "In the last three years, have you had direct, personal knowledge of a physician who was impaired or incompetent to practice medicine in your hospital, group, or practice?" The study found that:

• 64% agreed with the professional commitment to report physicians who are significantly impaired or otherwise incompetent to practice.
• 69% said they were prepared to effectively deal with and report impaired colleagues in their medical practice
• 36% do not feel obligated by professional commitment to report such physicians
• 17% had direct personal knowledge of a physician colleague who was incompetent to practice medicine in their hospital, group, or practice.
• Of the 17% with this knowledge, 67% reported this colleague to the relevant authority.
• Physicians working in hospitals or medical schools; and physicians with l0 years or fewer experience, were most likely to report impaired or incompetent colleagues.
• Pediatricians and family practice physicians were the least likely to say they felt prepared to deal such colleagues; anesthesiologist and psychologists apparently felt most prepared
• Most cited reasons for taking no action was (1) belief that someone else was taking care of the problem (19%) belief that nothing would happen as a result of the report (15%) and fear of retribution (12%)

The study concluded that “physicians support the professional commitment to report all instances of impaired or incompetent colleagues in their medical practice to a relevant authority; however, when faced with these situations, many do not report” " Matthew Wynia, director of the AMA Institute for Ethics, comments that “I don't think there's any excuse for less than 100 percent of physicians holding true to these ideals." A free JAMA podcast by JAMA’s editor in chief discussing the survey as part of commentary on the current issue is available for download.

Headlines regarding the article accentuate the minority percentage of physicians who do not report:

Los Angeles Times:  Study shows doctors often eschew watchdog role

CBS News:  Many Docs Don't Blow Whistle On Colleagues

The Washington Post:  Do doctors rat on each other?

This is certainly not the first study to address the issue of physician peer review. Some recent examples include California’s legislatively mandated study, which was released by sub-contractor Lumetra as the Comprehensive Study of Peer Review in California: Final Report, July 31, 2008 which found it was “apparent is that the present peer review system is broken for various reasons and is in need of a major fix”; from Public Citizen-  Hospitals Drop the Ball on Physician Oversight , released May 27, 2009 which concluded a “lack of detection and widespread under-reporting to the National Practitioner Data Bank raise serious questions about hospital peer review.” Modern Physician magazine, in their June 8, 2009 issue ran a lengthy article discussing the debate about the Public Citizen report .

Here’s a few observations for consideration on this issue:

• Regulated peer review focuses on the hospital setting, and is built on a 20^th century model in which a greater degree of care was delivered in a hospital setting. Physician behavior and actions outside the hospital setting are typically under-addressed by state or federal regulations
• Physicians, excel as they do as a profession, are still human, and subject to similar mindsets, pressures and workplace issues as other professions. Who really thinks any other profession subject to peer review would have better reporting outcomes?
• Accountability for professional competence in any profession is much stronger when there is an organization structure that the professional is employed by, or financially belongs to. Organization accountability can be an even stronger continuous force for some than regulatory or even ethical accountability.  Thus large medical groups, medical schools, VA, group health plans and other such entities tend to have less of a problem in this area than open medical staffs. Note the survey findings that “physicians working in hospitals or medical schools; and physicians with l0 years or fewer experience, were most likely to report impaired or incompetent colleagues.” As younger physicians have a greater tendency to practice in larger medical groups and organizations, this issue should experience improvement over time.