by Dr. Kimberly Templeton
Authorship, Dr. Pingle Miller, Founder and President, Physician Just Equity
What is Peer Review?
The phrase “peer review” can be misinterpreted, as it can refer to review of manuscripts for publication as well as the review of a healthcare professionals’ work to provide opportunities for quality improvement and better patient outcomes. While the former meaning is discussed a lot in academia, the latter is not, leading to many trainees and practicing physicians unclear about what “peer review” in this context means. This definition of “peer review” is what this blog will discuss.
As defined by the AMA, “peer review is recognized and accepted as a means of promoting professionalism and maintaining trust. The peer review process is intended to balance physicians’ right to exercise medical judgment freely with the obligation to do so wisely and temperately.” The need for peer review is determined by statute and regulation in every state. However, how peer review is conducted should be described in hospital and/or facility by-laws and can vary. Have you read those? Do you know how peer review works at your institution? I hadn’t read them, either, early in my career, but I have now. By-laws are intended to be written by and for medical staff. It’s important to know how peer review in your organization works.
In addition, it’s important to know your rights during a peer review process. The process starts when something goes awry in terms of patient care and/or a complaint is filed that may not be directly related to a particular patient. Unfortunately, you don’t always know when a complaint has been filed and an investigation is underway, unless a requirement for that notice is specifically stated in your medical staff bylaws (Hint- read your by-laws). This is important, because if you need to leave practice for a period of time, such as for parental leave or for an illness, while a peer review investigation is underway (even if you don’t know about it), that is seen as giving up your hospital privileges while under investigation – an action reportable to the National Practitioner Data Base (NPDB). This makes it important to work proactively and find out from your hospital how you can stay up to date on whether a complaint has been filed.
Once you are aware that a complaint against you has been made and is being investigated, seek help and support. The tendency, especially for women, is to try to make it through this process alone. It is embarrassing to be under investigation. It can also trigger feelings of imposter syndrome. It can lead to depression and anxiety. As hard as it is to ask for help (or to find time to figure out how and where to ask for help), there are resources to help you navigate the process. Seek legal advice. Reach out to mentors for support. Consider contacting a physician advocacy organization like Physician Just Equity. Access mental health resources if you notice symptoms of depression or anxiety or increased feelings of burnout.
The goal of peer review should be to identify opportunities for education and training and to elevate the standard of care to best practice. Unfortunately, there are reasons that peer review processes are initiated other than to improve patient care. In these scenarios, the peer review process is used to establish a false narrative about a clinician because of non-clinical factors, despite treatment that meets the standard of care and optimal clinical outcomes. It can be used to target people who are under-represented or not from the local community, successful high performers that pose a threat to others, or those who are trying to effect change and challenge the status quo at their institution. This, too, is where legal advice to navigate the process is crucial in determining what is a legitimate complaint and what is not.
If a physician is found to have met the standard of care, nothing further happens. Everyone breathes a sigh of relief. While understandable, this is a missed opportunity for additional practice improvement. If the outcome is unfavorable, and it is found that the standard of care was not met, then this occurrence can be reported to the NPDB and, in most states, is reported to the state medical board, which often starts the process anew. Focus then shifts to protecting your reputation and your career. Because of the significant career and personal ramifications, peer review needs to be done for the right reasons and done well. When peer review is targeted against clinically competent clinicians, it needs to be addressed and stopped before their careers are upended.
There needs to be additional focus on peer review in medical practice. While we need to find ways to improve patient care and outcomes, the current process does not always get us there. In addition, it can lead to additional stress and loss of positions and careers, especially for women and the underrepresented in medicine (URiM). In addition, women and the URiM are not always part of the local groups that help guide us in where and how to seek needed support and affirmation that we are outstanding physicians that belong in medicine. Discussing peer review is uncomfortable. It is a stressful process that we’d prefer to not think about until or unless it touches us. However, we need to be prepared that this might happen during our careers, especially if we are successful and are change agents. We must work now to improve the process so that it helps patients without being detrimental to the careers of physicians.
For more information about the contextual and legal aspects or Physician Peer Review listen to Part I of the PJE + AMWA co-sponsored webinar.
For more information on bylaws, please visit the AMA Physician’s Guide to Medical Staff Organization Bylaws. This resource, provided by Libby Snelson, Esq, an expert in medical staff bylaws and peer review, is free to AMA members. And please listen to Ms. Snelson’s insightful comments and discussion on the PJE+AMWA co-sponsored webinar.
