Is Hospital Peer Review a Sham? Well, Mostly Yes

By  |  June 1, 2009 |  19 

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 not had a single 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 self-regulating profession must called into doubt.

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.


  1. Erik June 2, 2009 at 2:31 am - Reply

    This mentality starts early in medical education. Who has every heard of a medical stuent being expelled or a resident being fired? The emphasis is on “helping the learner” instead of identifying who needs extra help vs who is a sociopath beyond redemption.

    There are some people who should not be taking care of patients. There are also some very good doctors who need someone else to point out one thing they consistently do wrong (or at in a socially inept manner).

    When I was in med school, we were told “if you made it in, you’ll make it out” which means either my med school only chose amazing students or, more likely, it had an overly positive assessment of it’s ability to choose students and the student body.

    As long as the emphasis is on “looking like we are fixing this” instead of actually figuring out if the doc (student/resident/attending) belongs in the profession, nothing will change. It’s not that hard to figure out who just had a bad day vs who really represents a danger to patients and the hospital itself. Just ask the nurses – do you want to work with this person?

  2. DZA June 2, 2009 at 2:46 pm - Reply

    and which profession, exactly, does this sort of policing better? lawyers? bankers? financiers? politicians? you get my drift…

  3. Kerry O'Connell June 2, 2009 at 3:08 pm - Reply

    Good article! There is a 4th reason why peer review does not work. The physician reviewers know in their hearts that there really isn’t that much difference between themselves and the Doctor’s being scrutinized. All doctors cause unintentional harm on a regular basis. Dr. David Wong in Denver surveyed Ortho Doc’s a few months ago and found that 53% admitted cauing harm in the past year thus on the average every two years every doctor is harming one of his/her patients. Wachter’s final bottom line question is accurate the very definition of “Patient Centeredness” should be putting patients ahead of provider reputations.

  4. blackwhitereadallover June 3, 2009 at 3:20 pm - Reply

    DZA has a good point about industry policing in general. However, while a lawyer or banker and the others mentioned may RUIN a life, he or she can’t actually kill someone with bad practice…usually.

  5. Bob Wachter June 3, 2009 at 3:51 pm - Reply

    I just wanted to point out a very thoughtful post reacting to mine, on the blog “Movin’ Meat” (“The Accidental Blog of a Semi-Accidental ER Doc Living in the Pacific Northwest”).

    After saying some nice things about me (thanks!), the blogger goes on to disagree with my assessment of peer review and the NPDB, accusing me of falling into a “false ‘Good doc/bad doc’ dichotomy” trap. While he acknowledges that there are some truly bad docs out there, he sees the bigger problem as being with the NPDB itself, which he calls “unjust.”

    There’s no proportionality, no way to indicate the gravity of the transgression, because the full details behind a report are screened from view. Molesting a patient and telling dirty jokes in the OR both show up as ‘sexual impropriety.’ An isolated mistake or an episode of poor judgment is impossible to distinguish from incompetence, as both are filed as ‘quality of care deficiencies.’ When the only punishment is the ultimate one, it’s no surprise that medical staffs are loathe to invoke it.

    I appreciate the feedback and agree that a) this is a sticky problem; b) the threshold for a NPDB report should be high; and c) there need to be other tools to deal with the much more common cases of imperfect docs who aren’t truly dangerous (I’d argue that more robust and credible board certification — and maintenance thereof — is a key part of the solution here).

    But the problem of truly bad docs remains, and averting our eyes doesn’t help. If we don’t take peer review seriously even in unambiguous cases, the public and its advocates have no way of knowing whether we are rebelling against an unjust punishment system or simply protecting members of our tribe. And they’re likely to assume the latter. You would.

    So let’s agree that aggressive peer review and NPDB reports are the wrong tool for the physician who isn’t quite keeping up with the literature or who tells an off-color joke. But if we react by never pulling the trigger on disciplinary action, we should not be surprised when patient advocates accuse us of being asleep at the patient safety switch, and respond by taking matters into their own hands.

    When self-governance fails, outside intervention is inevitable, and we are witnessing the beginnings of that painful transition. Yes, some of it is the fault of “the system” (in this case, the medico-legal system and the NPDB), but much of it lies with us.

  6. DZA June 4, 2009 at 12:48 am - Reply

    @Kerry O’Connell-good point yourself.

    now for the less cynical POV. i have not observed a doctor who smokes in over a decade. not one. way over a decade. there are no rules or laws against it. how did it happen? peer pressure. it is powerful and it works. and it is the function that serves to rein in the near dangerous. the truly dangerous already have laws for them…malpractice, assault, fraud, neglect, harassment, etc. don’t really need more policing or more overseeing authorities or more meetings or more paper shuffling. just transparency and professional peer pressure. and finally, with the web, there are no more secrets. the truth will out.

    /sneakers fan

  7. Annie June 4, 2009 at 10:50 am - Reply

    At least in hospital settings, there is usually knowledge of physicians’ suboptimal performance by registered nurses, who are charged by ethics and statute with safeguarding patients. But because nurses work overwhelmingly as employees, they are placed in a double bind. Employers don’t want to rock the boat, and nurses respond in passive aggressive ways often suggesting physician problems but not taking any direct action to halt, prevent or address acts which are unacceptable. Nurses don’t want to be in physicians’ andemployers’ cross hairs, and patients mostly don’t hold nurses accountable for problems which they aren’t likely fully aware.

    More than 50% of hospital based nurses report being threatened, intimidated or assaulted by physicians on an annual basis. Having been the target of many physicians over the years, including stalking and physical assaults, I cannot stress to you the importance of creating reporting and performance improvement mechanisms which protect nurses in particular. While the number of physicians who practice in an unacceptable manner is definitely a minority,their acts create an outsized impact on patients,nurses and healthcare institutions.

    Physicians quite effectively retaliate against nurses or other employees who do take action, and so employees remain inhibited and intimidated. Employers find it less expensive to churn dissatisfied employees than to lose the patient reimbursement and volumes from problem physicians.

    The points you raise about the limits of the extant peer review process are important.

    Perhaps a more effective alternative for providing more effective peer review and timely intervention to address targeted behaviors might include investigating the use of physician/nurse owned and directed professional practice groups, where the structure is such that the PPG performs its own credentialing, chooses/recruits its own members, establishes its own criteria for minimum accepted practice which of course meets or exceeds state board practice requirements, and which provides incentives for members to demand acceptable practice from all of its members.

    This model might also allow for a salary model, in which the playing field might be leveled somewhat between physicians in primary care and those in clinical specialties. PPGs would also provide for clinical career satisfaction and advancement for nurses, which is the major driver of the shortage (unsafe and unsatisfactory practice conditions with concomitant unmanageable patient case loads).

    By practicing in an interdisciplinary group structure, nurses and physicians would be in better positions to collaborate instead of to further competition and resentment.

    I’ve long suspected that the nurse practitioner movement is more a response to unsatisfactory practice conditions for nurses more than a desire to practice in a look alike narrow subset of medicine.

    This model would also promote physicians who are already practicing as employees to convert to a peer corporate/professional partnership model, and I believe that physicians would like this for the professional autonomy and authority it preserves without employer loyalty and compliance conflicts.

    But until nurses are added to the physician and patient equation, and incentives to hold clinicians accountable for their patients’ care and outcomes are built in to practice structures, fundamental change will not be achieved in any significant way, in my view.

  8. DZA June 4, 2009 at 11:25 am - Reply


    have to agree on the unacceptable level of abuse nursing and ancillary take from both intentional and oblivious nitwit MDs. which brings me to my next pitch, which is somewhat more generic and simpler than Annie’s (sounds like a well rehearsed business pitch?). hospitalists have more in common with nursing than they do with medical staff. employees, shift workers, team management, communication, covering each other (ideally), etc. i think hospitalist medicine should break off from medicine departments and assimilate with nursing. given the state of medical staff affairs these days, i’ll take my chances with the VP Nursing over the VP Medical Practices any day. sends a message, elevates the status of nursing to it’s rightful place, sets a new precedent, and allows a fresh look at administrative structure. just a thought…

  9. jcmdkumc June 5, 2009 at 6:25 am - Reply

    Greetings from the shelter of South Dakota. It is always interesting to see your state in print…even more so to find out that it is because we have never had a bad physician.

    That being said, as a junior member of a group that had to let a physician go, I wondered what “officially” could have been reported. After reading this I am beginning to understand that our profession will become subject to “outside intervention” as we will likely continue to be too slow to pull the trigger on our own.

    As Kerry mentioned above, if all of us feel like we could at some point cause harm to our patients, we will continue to have difficulty pointing fingers at others within our profession.

  10. DrMaryJohnson June 5, 2009 at 6:15 pm - Reply

    I came here by way of Kevin where I posted a comment.

    Thought I’d post one here too.

    As a Pediatrician in public service, I “pulled the trigger”/”blew the whistle” on a clueless colleague/bad care ELEVEN YEARS ago (reporting a case to peer review), and for my trouble, was pushed into a never-ending medico-legal black hole.

    I’ve only been in the blogosphere for over four years trying to get someone somewhere to care/help.

    Special duties and privileges should be PROTECTED. They are not. The medical establishment KNOWS that there are BIG problems with peer review (not to mention employment laws as they pertain to physicians), but has done NOTHING.

    The answer to your question is easy. It is more important to protect patients. But in protecting patients, we CAN act fairly. Little things like due process matter. In the abscence of that, it’s just a witchhunt.

    And that’s so 1692.

    My experience (a short version):

  11. Dantes June 17, 2009 at 10:10 pm - Reply

    Not a word about sham peer review for economic or competitive reasons. The definition of disruptive behavior has been applied to whisteblowers and physicians who speak up about poor patient care practices as well. I myself have been subjected to a sham peer review action by a hospital adminstrator and physicians who embarked upon a costly, and now failed, joint venture. They needed me out of the picture. Imaging this…many people, including hospital lawyers, lied.

    Hospitals and medical staffs should not be in the business of deciding physician competency, etc. Too many conflicts of interest and not enough protections. HCQIA and peer review laws have been appropriated by unscrupulous hospitals for abuse. The presumption for a physician is guilty until proven innocent, and a report to the data bank can be made with virtually no way to contest it, because the information is “protected.”

    Medical boards should investigate issues of competence. Create a system where reports go to a medical board, with a uniform process of appeals, etc. This would require states to give boards more money, and is not without its dangers…see what has happened in texas, for example. But as someone who has successfully beat an illegitimate peer review action, and who has talked to other good doctors who have not, the system is fundamentally flawed.

    As for nitwits in hospitals, doctors do not have a corner on the market. Nurses, especially in administrative positions, can be vindictive and vicious. Hospital administrators, the same. But there are no rules or processes for dealing with them, and none which have the potential consequences doctors face if tagged with a disruptive physician label. What is disruptive??? Hospital bar lawyers have a list…includes things like making rounds at unusual hours….its a label to apply to troublesome physicians to coerce them into keeping silent.

  12. Dr. Greek Girl July 2, 2009 at 2:43 am - Reply

    As President of Medical Staff, I have been involved in several peer reviews. Since I often spent a lot of time investigating and agonizing before the presentation, I have to admit I would preside with a good idea of how I wished the outcome would be. I have never ceased to be amazed how my otherwise reasonable colleagues seem to be unable to commit to a decision that would result in a physcian being reported to the data bank. It is much easier to get the physician in question to voluntarily leave the medical staff, thus circumventing the data bank report. What really amazes me, is the hospital down the street then eagerly scoops up the doc in question. There are plenty of places to read between the lines, but the friendly neighbor is just too willing to take all the derogatory comments from the maligned doc at face value. The real place to scrutinize the doc is before you ever let him or her on staff.

  13. BBeck August 17, 2009 at 1:30 am - Reply

    Kerrry O’Connell started out right, but then turned slightly. Having been in most of the leadership roles in our Medical Staff and having spent most of the last 25 years on the Credentials Committee, I think I can sum up physicians reluctance to discipline other members of their staff by the phrase: “There, but for the Grace of God, go I.” Not because we are making mistakes right and left, but because, as Dantes points out, we have also witnessed abuse of the peer review process for personal or economic reasons, and realize that some nurse, administrative supervisor or competitor can make charges which are difficult, time consuming and expensive to refute.

    That said, the quality of peer review depends on the culture of the hospital and especially the medical staff. Placing the patient’s need for quality care first, before the self interest of the physician(s) needs to take place. Unfortunately, changing the culture takes a while, but it is possible to do. For it to happen, there are a few things which need to be adopted as medical staff policy and stated overtly and repetitively at the Medical Executive Committee meetings, Credentials Committee meetings, and any peer review meetings:

    1. Quality patient care is the standard. “Would you allow this kind of care for a member of your family?”
    2. You cannot base your judgement or decision on “There, but for the grace of God, go I.” Deal with the facts, not the potential consequences.
    3. Whether or not the disciplinary action will result in a NPDB or state licensing organization report has absolutely no place in any discussion or decision about the action and the chair of the committee should not let it come up. Whether the event is reportable is only to be decided and dealt with after a decision has been made, and then by another body. (Yes, I know, this will not be easy.)
    4. Disruptive behavior (especially acting out) will not be tolerated by the medical staff or the board of directors of the hospital (i.e. peer pressure with teeth).

    What has worked well at my hospital (a not-for-profit full service community hospital) has been to give the Credential Committee and MEC the ability to impose a “Conditional Reappointment” for physicians who are having problems which do not warrant removal of privileges. This reappointment is for a specified period of time, up to one year, and states the behaviors which must change in order for the physician to be reappointed again at the end of the 1 year term. The physician has to sign the Conditional Reappointment letter and return it to the medical staff to be granted reappointment. This, along with some counseling, has proven to be very effective for most physicians. If the physician refuses to cooperate, you don’t really want him or her as a medical staff member as they will be much more trouble in the future and, as mentioned above, physician leaders don’t really like dealing with these problems, especially repetitively.

    As Dr. Greek Girl identifies, allowing the physician to resign and go somewhere else, solves your problem, but only foists it on patients and staff elsewhere. It is, however, cheap, expeditious and avoids having to agonize over disciplining a colleague, so it will continue to be the favored solution.

    Her last sentence is key: Don’t let them on you staff in the first place (if you can identify them up front). This takes due diligence. It’s a lot easier to keep them off the staff than it is to get them off (it costs our hospital $250K to $400K per physician to jump thru all the review and quasi judicial and judicial hoops to expel a member). Still, it is extremely difficult to deny medical staff membership to an individual physician without good objective reasons and a fair, good -faith evaluation.

  14. Shammed September 6, 2009 at 7:17 pm - Reply

    Dantes’ comments are exactly right. Peer review is usually used as a weapon by average or below average doctors and nurses in the position of power. The immunity should be for fair and evidence based for the educational purposes, whereas it is used to get rid of and make the life difficult for some excellent physicians. The bad physicians are still practicing and everyone looks away as noted. Take out immunity and make the evidence the cornerstone, not just the opinions of a few in power.

  15. Robert Oshel October 9, 2009 at 5:53 pm - Reply

    I’m the retired Associate Director for Research and Disputes of the Division of Practitioner Data Banks, the Department of Health and Human Services that runs the NPDB. The following comments are my own, not the Department’s.

    The original article and several comments above reflect misinformation about the NPDB. First, if a practitioner resigns while under investigation or resigns to avoid an investigation, a report must be filed. A hospital cannot legally evade its responsibility to file a report by working out some sort of unofficial deal to have the practitioner resign and go away.

    Second, There are effective ways to challenge an NPDB report which is erroneous or not required to be filed. Practitioners can (and do) request Secretarial Review. About 20 percent of the time Secretarial Review cases result in an outcome favorable to the the practitioner either because the Secretary voids the report or the reporting entity files a correction or voids the report at the suggestion of the Secretary.

    Third, only about 1/3 of queries to the NPDB are from hospitals. Managed care organizations, licensing boards, and other authorized queriers are responsible for about 2/3 of queries.

    Fourth, it is easy to indicate the gravity of a transgression in a Data Bank report. In fact, reporters are instructed to do so. The narrative in each report should contain enough information so that an uninformed observer can get a reasonable idea of what led to the action that was taken and understand the nature of the action. The narrative shouldn’t simply repeat the codes; it should explain. Often narratives do not do this well, and the Secretarial Review staff often request improved narratives during the course of reviews. The problem here isn’t that you can’t indicate the gravity of a transgression; the problem is that reporters are often reluctant to do so.

    Lastly, another comment. One person above said it wasn’t the job of hospital peer reviews to decide physician competency and that it was the job of the licensing boards to do so. To me, this is professional irresponsibility. Peers know a physician’s competency much better than a licensing board ever can, and licensing boards typically are as reluctant to act or are even more reluctant to act than are peer review panels. If the public is to be protected, the first line of defense has to be the hospital peer review committees.

  16. Bob Wachter October 14, 2009 at 3:50 pm - Reply

    I really appreciate all these thoughtful comments, especially the clarifications by Dr. Oshel. I couldn’t agree more regarding his last point — we can’t punt this one to a licensing board.

    On the other hand, I really wonder whether the inherent conflicts embedded in local, hospital or clinic-based peer review (which I’ve characterized as either “peer review by your golfing buddy” or “peer review by your to-the-death competitor”) make it virtually impossible to get it right. I don’t think we’ve stumbled on the right model yet — it’ll probably be not quite as local as being peer reviewed by a member of your own medical staff, and not quite as distant as being reviewed by your state’s licensing board. I don’t have the answer here; seems like a problem that would benefit from pilot studies and high quality research.

    Re: Dr. Oshel’s point that “A hospital cannot legally evade its responsibility to file a report by working out some sort of unofficial deal to have the practitioner resign and go away” — perhaps not, but it is my sense that this happens all the time. If it is to be stopped, there’ll have to be far more aggressive enforcement/auditing of this process.

  17. The conscious of a nurse November 28, 2010 at 3:09 am - Reply

    As a nurse in a large affluent community hospital, I can attest to the failure of physician peer review process. It is a sham in most institutions. The director of peer review is a physician and hospital employee. I have wittnessed negligent and sometimes incompetent physician practice, which has had devasting outcomes and death for patients. The nurses are forced to complete incident reports, for “documentation.” However, the physician may ocassionally be brought before his “buddies” on the peer review board. They assure their friend that this will pass and they look the other way. Business proceeds as usual. This is a closed club and they protect their own, even if they know the truth. They fear, it could be themselves next and they would want to know that they can count on their “peers” to support them. The function of peer review is not to improve physician performance standards. It is not an objective learning experience. It is ocassionally a documentation for future liability for a hospital, however, these records are sealed. The fact is, we nurses work very closely with our physicians and we don’t want to see anyone fail either. We however, are the patient’s advocate. We are also at will employees of the hospital and we are intimidated and frequently threatened by hospital administration, if we dare talk. The fact is; medicine is not a perfect science, and patients accept risks and physicians make mistakes-period. Peer review must become an independent 3rd party enitity. The conflict of interest in the current model is obscene. I watch in silence, as a particular well trained physician repeatedly blunders and causes harm and death. I am silenced.

  18. KDC February 10, 2011 at 1:54 pm - Reply

    The issue I face regarding physician behavior reviews is “lack of solid evidence.” An occurrence report by a hospital staff member is viewed as “he said, she said” and cannot be used, as the physician always has an acceptable response regarding his/her behavior. It may be well known throughout the organization that a physician’s behavior is inappropriate, but all fear for their jobs if they report it and they know nothing has been done about it for years. A physician may be “counseled” if there are additional complaints filed within a defined time period, but no “teeth” are used for these unproved complaints. That brings us back to the initial statement: lack of solid evidence!

  19. pedro tondo December 9, 2014 at 5:20 pm - Reply

    You forgot to mention that peer review is also abused by hospitals administrators to eliminate or threaten independent doctors who have hospital privileges to sell the hospital their practice to the hospital or not use a competing surgi-center else peer review proceedings will be started against them and the reviewers are immune from litigation by the victimized physician, because of the immunity provisions in the peer review laws. THAT’s the real issue, not the authors points about there being too little reviews.

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About the Author: Bob Wachter

Robert M. Wachter, MD is Professor and Interim Chairman of the Department of Medicine at the University of California, San Francisco, where he holds the Lynne and Marc Benioff Endowed Chair in Hospital Medicine. He is also Chief of the Division of Hospital Medicine. He has published 250 articles and 6 books in the fields of quality, safety, and health policy. He coined the term hospitalist” in a 1996 New England Journal of Medicine article and is past-president of the Society of Hospital Medicine. He is generally considered the academic leader of the hospitalist movement, the fastest growing specialty in the history of modern medicine. He is also a national leader in the fields of patient safety and healthcare quality. He is editor of AHRQ WebM&M, a case-based patient safety journal on the Web, and AHRQ Patient Safety Network, the leading federal patient safety portal. Together, the sites receive nearly one million unique visits each year. He received one of the 2004 John M. Eisenberg Awards, the nation’s top honor in patient safety and quality. He has been selected as one of the 50 most influential physician-executives in the U.S. by Modern Healthcare magazine for the past eight years, the only academic physician to achieve this distinction; in 2015 he was #1 on the list. He is a former chair of the American Board of Internal Medicine, and has served on the healthcare advisory boards of several companies, including Google. His 2015 book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, was a New York Times science bestseller.


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