Shortcomings of Internal Peer Review
by Skip Freedman, M.D.
It's no secret that hospital peer review is a broken process. Improving the quality of care for patients by protecting them from substandard medical care — is an admirable goal and one that doctors and hospital risk managers agree on. Everyone wants patients to have consistent, high-quality treatment.
Internal Peer Review Problems
Unfortunately, institutions handling peer reviews internally soon find many flaws in the process. Internal peer reviews impact doctors’ time, bring out competitive and personal biases and, more often than not, the doctors conducting the reviews are not working in an equivalent subspecialty.
It Takes Time
Taking part in a peer review panel is just one more daunting, time-consuming task doctors add to their already overloaded schedules. Their heavy workload makes it easy to put off peer review and delay quality-of-care solutions. This draws out the peer-review process longer so it’s not current with the events in question and prevents quality-of-care improvements that the process is intended to oversee. Sometimes, the doctor’s patient workload causes doctors to give reviews short shrift.
Wary of Competition
Aware of competition, friendships and the impact on working relationships, doctors don’t like to review peers they work with day-to-day. Nonetheless, peer-review panels often are staffed with doctors who are either partners or competitors. Sometimes they also compete for recognition in their narrow specialty at the hospital or for positions on medical boards. Criticizing physician friends and associates is very difficult. Doing so for a competing physician may present legal problems.
Not Enough Same Subspecialists
In theory, any “same physician” trained and practicing in a specialty can examine a problematic event and provide objective, unbiased determinations on its cause. However, the theory clashes with reality whenever same-specialty peers are involved in working, personal or financial relationships.
Hospitals and medical groups often don’t have enough doctors with the same subspecialty. This creates conflict of interest during peer review. Trying to have mixed specialists handle peer reviews is also a problem. For example, urologists and obstetricians are both surgeons, but cannot be expected to be knowledgeable in surgical areas outside their specialty.
External peer review tries to resolve this conflict by having uninvolved doctors with the same specialty look over the case. That way, doctors reviewing the case can consider without bias whether the treatment was medically needed; whether it followed the standards of care; whether there was a sentinel event; and if so what was its cause.