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Handling conflicts of interest in peer review

Medical Staff Leader Connection, July 5, 2006

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A physician peer reviewer with a potential conflict of interest is ethically obligated to disclose it to the rest of the peer review committee. The committee will then determine whether the conflict is susbstantial enough that the peer reviewer in question should not be involved in their decision making. Most of these decisions are judgment call; the only absolute conflict of interest is when the issues in the case directly involve the reviewer or a committee meber. Just as judges who have a personal interest in cases must remove themselves to avoid even the appearance of impropriety, peer reviewers should recuse themselves in such situations.

Most conflict-of-interest situations, however, are not that clear because they are usually relative. For example, some people have argued that being a partner or a competitor should be considered an absolute conflict. But if it were, then internal peer review on technical quality of care issues would be virtually impossible.

The economic competitioon issue is particularly difficult, especially for smaller medical staffs. There is no absolute prohibition against an economic competitor serving as a peer reviewer and, in fact, the traditional organization model of peer review--the departmental model--often had apparent competitors serving as peer reviewers. Although this is not necessarily fatal to the process, it is one reason why a multi-disciplinary committee model, rather than a departmental model, is superior for peer review.

Two actions are necessary in order to resolve these relative conflicts of interest so that, should a judge or jury examine the situation from the outside, there will be no question that the peer review was conducted in good faith:

• All physicians who serve on the peer review committee must be scrupulously honest about disclosing potential conflicts, including relevant personal issues (E.g., the physician under review is also engaged in a child custody fight with a committee member).
• The peer review committee itself must use its judgment and wisdom when determining whether a particular physician can render a reasonably unbiased opinion. This judgment may be based on the physician's reputation for fairness and on the nature and intensity of the conflict. If the committee has doubts, it should always err on the side of caution and either assign a different reviewer or obtain an external review.  

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