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A Peer by Any Other Name . . .

Patient Safety Quality Monthly, May 15, 2005

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Dear Colleague,

This month I have asked Dr. Mark Smith to address the critical issue of defining who is a peer for peer review. Dr. Smith is a practicing vascular surgeon in California who has been working as a consultant for the Greeley Company to help hospital medical staffs redesign their peer review programs.

Here are his thoughts:

Shakespeare was probably right, as usual-every day, people struggle with the practical definition of who represents a peer. In trial courts throughout the United States, the accused are tried by a jury of their peers. In this case, a peer is any registered voter living in the same jurisdiction that responds to the jury summons and answers the questions well enough to be accepted on the jury by both sides' lawyers. After observing some of the recent high profile legal cases, such as O. J. Simpson or even the present Michael Jackson trial, many wonder whether assembling a group of peers has the same likelihood as finding the end of the proverbial rainbow.

For physicians and medical staffs, this dilemma is especially real and poignant. Generally, medical staffs are delegated the responsibility of evaluating the performance of licensed independent practitioners in their facility. This process, known as peer review, requires physicians to rate the quality of care delivered by their fellow physicians. But who really constitutes a peer?

Recently, we were working with a Medical Staff Task Force in revising their peer review process. The definition of a "peer" for their peer review policy took center stage one day. Some physicians argued that all physicians went to medical school, took and passed a national examination and are licensed by the same State Medical Board, and therefore are all peers. This view would make filling vacancies on peer review committees much easier since there are unlimited candidates.

"Not so fast, my friend," replied an alternate-viewed doctor, a neurosurgeon. "No one who isn't trained and boarded in neurosurgery can possibly be able to evaluate my work competently."

So which side of this debate comes out the winner? The best answer is-they are both are equally right.

Perhaps the best way to think about a peer is that it is the person who practices in the same profession and has appropriate expertise in the subject matter-which is to say that peer identification is situational. There are many instances in evaluating physician performance where the subject matter expertise is the level of general medical practice. Anyone with an M.D. or D.O. has the knowledge level to function as a peer no matter the specialty or sub-specialty of either the evaluator or the evaluated. As an example, suppose a physician's case is being reviewed for failure to recognize and treat hypotension in a patient with gastrointestinal hemorrhage such that the patient sustained onset of acute renal failure. The case reviewer does not have to be a Board Certified Gastroenterologist to recognize this example of inappropriate care with subsequent complication. A peer in this case would be any physician.

Contrast that with the situation of a Cardiologist's case being reviewed for correctness of site placement and number of stints in a patient with multiple coronary artery stenoses. Probably, most would agree that a Gynecologist or a Family Practitioner really wouldn't be the appropriate person to render a peer evaluation. This situation does require the specialized knowledge of a Boarded Cardiologist or equivalent to function as the peer in this matter. Again, situational peer identification prevails.

The greatest number of instances of significant physician quality concerns from peer review committees fall into the first category. In my experience, approximately 75-80% of these cases can adequately be evaluated by any physician since they represent basic medical principles. The remainder will require to more narrow definition of a peer since specialty knowledge is necessary to render the opinion. If a Medical Staff can allow this flexibility in their definition of peer, then their peer review systems will achieve the greatest amount of efficiency. That is a lot of time saved for extremely busy physicians.

Perhaps some of the extra time will allow contemplation of Shakespeare's solution for the lawyers.

Regards,

Bob Marder, MD
Practice Director, Quality and Patient Safety
The Greeley Company

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