Quality & Patient Safety

Peer Review & Conflict of Interest

Patient Safety Quality Monthly, April 15, 2005

Dear Colleague,

In performing peer review, many physicians have asked me about how to handle the issue of conflict of interest for the reviewers. In the United States, the Constitution guarantees us the right to trial by jury, but many people mistakenly believe that what we are guaranteed is the right to a jury of our peers. In reality, however, the Sixth Amendment grants us the right to an "impartial" jury. And the adjective "impartial" is the key to determining who should serve as a peer.

Like the members of a jury, a physician peer reviewer should be as objective and impartial as possible. In fact, one of the keys to getting physician buy-in to the peer review process is to select physician reviewers who are known to be fair-minded and objective individuals. Although a peer reviewer would ideally have no arguable bias in favor of or against the physician whose care is being evaluated, individual bias can never be completely eliminated in the context of a medical staff. This bias can however, be reduced by having the peer review committee-rather than any one physician peer reviewer-make all the ultimate decisions.

Conflict of interest is an important component of impartiality. 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 substantial enough that such peer reviewer should not be involved in their decision-making.

Most of these decisions are judgment calls; the only absolute conflict of interest is when the issues in the case directly involve the reviewer or a committee member. Just as judges who have a personal interest in a case must recuse 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 since 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.

Another question is what to do if a committee member was involved in the care after the event under review occurred-perhaps that physician was even the expert consultant who "rescued" the patient. Some might see that situation as a conflict; others might see that physician as being an excellent source of in-depth information.

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

First, all physicians who serve on the peer review committee must be scrupulously honest about disclosing potential conflicts, including relevant personal issues with other members of the committee.

Second, the peer review committee itself must use its judgment and wisdom when determining whether a particular physician can render a reasonably objective opinion. This judgment may be based both 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 safety and either assign a different reviewer or obtain an external review.

Peer review will never be without some type of bias, just as the individuals on a jury will have their individual biases. The reason the jury system generally works is that it depends on the group process overcoming individual biases. That is why using multi-specialty committees for peer review is gaining favor because they minimize the burden on the individual with the potential conflict of interest.

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

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