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When Both Luck and Being Good Run Out on You…Thoughts on Clinical Peer Review in Medicine

Christopher Beach, MD, FACEP

Beach2014Providing emergency care at the highest level day-in and day-out is challenging.  Some days we really do feel that, “it is better to be lucky than good.”  There are innumerable nuances to the dance steps we go through, enough to drive a choreographer insane. [ For instance, this PMD wants this type of consultant, this doctor likes this hospitalist service, this specialist always wants an MRI, someone wants to be called at all hours/someone doesn’t want to ever be called, and on and on.]  Some days, even your best is not enough to keep step with the tune.  And, when both luck and being good run out on you, inevitably there is a letter in your inbox from the Clinical Peer Review department asking for information about the care you provided to a patient.

Thus the peer review process begins.  You cross your fingers, ask for help and advice and pray that ‘luck’ finds its way back to your side.  Dr. Ignaz Semmelweis, a Hungarian obstetrician in the 1840’s discovered that simply washing hands before delivering a baby would drastically reduce the incidence of post-partum fever in women.  Semmelweis’ superiors, however, disliked his personality and fought him at every turn. The Viennese medical society rejected his findings and outcast him. Driven from his job, Semmelweis suffered a breakdown and died in a mental hospital.

Fact is – he had it right.  Who would have guessed that hand-washing would still be an important safety initiative in 2014?  It is evident that hand-washing is important, but that is not the focus of this article, instead, it is important to focus on how we address the clinical peer review process.  Perhaps it is a particularly ‘spicy’ topic to discuss.  Nonetheless, it affects quality and safety in important ways.  “Peer review” is defined as the evaluation of the quality of care provided by individual practitioners, including identification of opportunities to improve care by individuals with the appropriate subject matter expertise to make this evaluation. 

A “peer” is defined as an individual practicing in the same profession. The level of subject matter expertise required to provide meaningful evaluation of care will determine what “practicing in the same profession” means on a case-by-case basis.  ‘The first prototype is recommended in the Ethics of the Physician written by Ishaq bin Ali al-Rahwi (854–931). His work states that a visiting physician must make duplicate notes of a patient's condition on every visit. When the patient was cured or had died, the notes of the physician were examined by a local medical council of other physicians, who would decide whether the treatment had met the required standards of medical care.’ (1)

The Health Care Quality Improvement Act does not provide for due process so it is important that, if and whenever possible, the physician assures that the committee understands the concerns and issues at play that contributed to the care decisions at the time.  In the past, a physician could go so far as the courts to enact their ‘due process’ or plead their point, but no longer is this entirely true.  That said, most peer review committees allow for physician input in some fashion.  In many instances, the committee will ask that you elucidate your thought process, but there may be times when the committee –which is supposed to be comprised of your peers—does not quite understand your current environment of practice.  [Do your best to explain your decisions, but also do your best to make sure you have an advocate who understands the process and might be able to speak on your behalf.] The truth is that most peers do not understand the nuances of the ER. It is an invaluable asset to have a member of your department sit on such a committee. 

Fortunately there is very little duplicity these days in peer review.  In the past some would use this forum as a way to threaten a competitor or a rival in business.  Hopefully our industry has moved past this type of behavior.  Very few decisions are ‘black and white’; most are shades of grey.  It is truly important and part of the leader’s responsibility to do their best to understand the situation ‘at the time’ and judge based on what a true peer would have done given similar circumstances.  There are many grading scales.  As the time comes to grade the level of care, doing so gently, ideally in an educational and supportive way helps everyone grow from this experience, rather than walking away bitter, ashamed and with feelings of failure.  To the extent we can all learn and lift each other higher through challenging circumstances like these, we find ways to turn traditional negatives into positives for the individual and the institution.

In today’s world we are fortunate that more physicians have come to respect the challenging nature of what we do in the ED day-to-day.  Our job is not easy (whose is?), but it is fulfilling.  [We are the place most end up when they have no place to go and nobody to turn to.] However, we are imperfect and will undergo peer review from time-to-time.  It is important that such processes remain.  It is also important that we understand them and use them to benefit ourselves and our patients.  It is a privilege when others offer ways to improve our individual practice, and so more effectively help heal our patients.

1. ^ Spier, Ray (2002). "The history of the peer-review process". Trends in Biotechnology 20 (8): 357–8. doi:10.1016/S0167-7799(02)01985-6. PMID 12127284


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