01 June 2009

A Review of Peer Review

Bob Wachter, who I generally like and admire, takes on the topic of hospital peer review, stimulated by a report issued by Public Citizen's Health, that hospitals rarely report physicians to the National Practitioner Data Bank:

Wachter's World : Is Hospital Peer Review a Sham? Well, Mostly Yes
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?
And on the merits of the matter, it's hard to dispute that the NPDB has been an abject failure as far as its original goal went: it is not an effective data bank collecting data on suspect and problematic physicians. I think that Public Citizen and Dr Wachter transpose cause and effect, though, when they attribute the blame to the peer review process. The fault, I think lies in the NPBD itself.

The goal may have been laudable and simple -- get in trouble, get a file, and keep bad doctors from hurting patients. Wow. Who could oppose something like that? But that's not how it worked out in the real world. Perhaps it's a consequence of the fact that it is so infrequently used, but the reality is that being in the NPDB is incredibly stigmatizing, which is not a matter limited to the ego of the reported physician, but also is an essential death sentence to his or her career. This is not a "Oh dear, now I'll never be Chief of Staff," sort of career disruption -- being in the data bank makes a physician essentially unemployable.

And that's why it's shunned: it often seems 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 judgement 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 suprise that medical staffs are loathe to invoke it.

And it's expensive. Since a physician at risk of a medical staff action usually knows how high the stakes are, they will commonly lawyer up and fight tooth and nail to prevent any blot on their record. The legal bills for these cases can run into the hundreds of thousands of dollars, and even if the hospital "wins," all they've done is spend a ton of money to get rid of a problem. If they can get rid of him or her for free with a negotiated sham resolution, why would they go through all the expense to persecute the poor bastard as well?

Much of the same can be said for the state licensing boards, to which medical staff committees are also responsible for reporting of suspensions and revocations of privileges.

So, I think it should be noted that this is not a simple "docs are too softhearted to police themselves" issue. It's that the legal and regulatory tools we have been given are too blunt and indiscriminate for those of us weilding them to feel that they are useful and fair in the vast majority of cases.

Because the true case of the dangerous/incompetent/morally unfit physician is relatively uncommon. Dr Wachter falls right into the false "Good doc/bad doc" dichotomy and buys into the assumption that there is a large cohort of "Bad Doctors" out there that we need to drum out of the profession. There are some, I am sure, but I've rarely seen one at our hospitals, and they're actually quite easy to deal with when you come across them. It's the gray cases, which comprise the majority of the head-scratchers that we have to deal with in the hospital. It's the surgeon whose patients love him but just seem to have a lot of complications. It's the doc who manages to pick a fight with every other member of the medical staff but never quite crosses any bright lines. It's the creepy male doc who makes all the nurses uncomfortable but never really touches where he shouldn't. The "incompetent" doc who you wouldn't let care for your family member but seems to muddle by just well enough to keep from killing anyone.

You all know the one I'm talking about, right? But it can be tough to identify an incompetent doc. I've never yet met one whose ID badge or diploma listed them as "incompetent." In many cases, there's a legitimate defense to the care provided, even if it's a weak defense. In many cases an error or errors may have been genuine and severe, but not characteristic of the doc's general level of quality. The cut and dried "you suck" level of incompetence is rare and far overshadowed by the many cases of borderline physician skills.

The "Bad Doc" approach to this matter also makes the error of assuming that a problem doc is irredeemable and must be expelled from the order. I've seen docs who rose and fell and rose again over the long arcs of a career. Some of them needed to go through a formal, sanctioned process involving chemical dependency treatment, most often. Others, however, simply needed attention and managerial support: focused redirection, re-education, sensitivity training or the like, and with appropriate supervision they are able to continue practice. Reporting them to the NPDB is not a solution, at least not a defensible one in the "typical" borderline case. Sometimes you can counsel them or devise a practice plan that works to keep patients safe and the hospital harmonious. But the adversarial relationship makes this hard enough, and the need to carefully work around this death threat of the NPDB is a burden and an impediment to working collaboratively with the "challenged" physicians.

None of this is intended to be a defense for the truly impaired, incompetent, or sociopathic docs out there, or the medical staffs who have enabled them. I'm sure that the problem exists to some degree. But the idea that the NPDB is a valuable or even a positive tool in the vast majority of cases is itself laughable. It was a great idea but as implemented it has been an abject failure. The high-handed folks over at Public Citizen will never admit to it, will never modify it in ways that might make it more functional. They will, rather, rail against the scofflaw docs and hospitals who do not deign to use this blunt and ineffective instrument which has been thrust upon us. And we, working away on Medical Exec and Credentials Committees will be left with ad hoc and jury-rigged apporaches to the borderline physicians who represent the more common and more challenging dilemmas in the industry.

9 comments:

  1. Do you think a component of sensible tort reform would include a better system for monitoring performance?

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  2. The same mind set can be found with so called zero tolerance policies. Bring in aspirin or heroin and you get treated the same.

    We simply don't allow folks to use judgement anymore.

    You must have screwed up pretty bad, pissed off your hospitals board of directors, or not been smart enough to lawyer up to even get put on the list. Even the bad docs have more than a couple of brain cells to rub together to make a thought and could have seen the consequences for getting on this database.

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  3. My understanding is that every malpractice settlement (no matter how small) shows up on the NPDB list, and that certainly does not make one unemployable. Maybe there are degrees of unemployability depending on the type of listing.

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  4. I think the settlement limit that gets reported is 30k. Correct me if I am wrong. So a lot of nuisance suits get settled for 29,999.

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  5. It's all about unintended consequences. Telling a dirty joke is not and should not be classified the same as unwanted hands-on groping. It sure sounds like the process needs sufficient revision to weed out those who really shouldn't be practicing while avoiding sullying the reputations of good docs who had barely-justifiable settlements for dubious malpractice cases.

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  6. To Anon8:16 -
    ANY payment/settlement to a patient is reportable, whether a suit is filed or not.

    Which means a decent proportion of OB-Gyns have his or her name on the NPDB. :)

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  7. Scalpel,

    Yes, malpractice cases do go in the NPDB, but that's not the same thing. It's the reports that say your license or hospital privileges were revoked/suspended that are so harmful to your career.

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  8. Kudos for a fabulous post.

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  9. "being in the data bank makes a physician essentially unemployable."

    How many physicians are truly unemployable as a result of this? Literally cannot find work?

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