Editor’s note: The American College of Surgeons (ACS) Board of Governors (B/G) conducts an annual survey of its domestic and international members. The purpose of the survey is to provide a means of communicating the concerns of the Governors to the College leadership. The 2020 ACS Governors Survey, conducted in June and July 2020 by the B/G Survey Workgroup, had a 96 percent (272/282) response rate. For the first time, the leadership of the ACS Young Fellows Association (YFA) of the College (Fellows younger than 45 years old), completed the survey. Several results from the YFA survey have been included in this article for comparison.
One of the survey’s topics was the peer review process. This article outlines the Governors’ and YFA leadership feedback on these issues.
According to the American Medical Association (AMA) Code of Medical Ethics, hospital medical staff typically assume duties and responsibilities to help ensure patient safety and quality of care. For surgeons, tenets of patient safety and quality were codified by Ernest A. Codman, MD, FACS, more than 100 years ago. Dr. Codman’s observations were the basis for the American College of Surgeons Hospital Standardization Program—the precursor to what is now known as The Joint Commission formed in 1951. Today, The Joint Commission accredits hospitals to improve and sustain good quality of care for patients. This effort has been codified by federal and state regulations and measures that The Joint Commission and other accrediting agencies develop and implement.
Today, a multifaceted approach helps achieve patient safety and quality, including the peer review process.
FIGURE 1. PHYSICIANS UNDER INVESTIGATION FOR POSSIBLE DISCIPLINARY ACTION
BY THE PEER REVIEW COMMITTEE ARE GIVEN DUE PROCESS
This article focuses on the peer review process used in hospital settings pertinent to surgeons. As surgical practice trends continue to evolve and more surgeons are involved in larger practice settings, the importance of fair, high-quality peer review further increases to promote professionalism, quality and safety, and the trust the public places in surgeons. These elements are embodied in the College’s motto, “omnibus per artem fidemque prodesse”—to serve all with skill and fidelity. Providing high-quality patient care often requires surgeons to make time-sensitive decisions that may increase their chances of being the subject of an external peer review.
The 2020 Governors Survey examined various aspects of the surgical peer review process; for example, Governors were queried about the frequency of due process being applied when physicians were under investigation for possible disciplinary action. Although 76 percent of the respondents affirmed that due process was usually or always used, 12 percent reported it was seldom or never used. The YFA leadership were polled similarly, with 75 percent agreeing that due process was used most of the time (see Figure 1).
FIGURE 2. PHYSICIANS UNDER INVESTIGATION BY THE PEER REVIEW COMMITTEE ARE INFORMED THAT THEY ARE BEING INVESTIGATED
Today’s physicians are more mobile and tend to move around more than their predecessors. These new practice patterns, along with the introduction of peer review, may result in some unintended consequences. For example, physicians who move to a new medical staff while under investigation may be unaware that switching location during the peer review process is reportable to the National Practitioner Data Bank (NPDB). While 78 percent of respondents indicated that physicians are usually or always informed that they are under investigation by the peer review committee, more than 12 percent said they were never or seldom informed (see Figure 2).
AMA Code of Medical Ethics
Regulatory agencies and accrediting institutions call for organized medicine to have processes in place for ongoing professional evaluation of its medical staff members, as well as mechanisms to evaluate its members for cases or situations involving complaints or outlier results. In the AMA Code of Medical Ethics Opinion 9.4.1, Peer Review and Due Process, the organization clearly defines parameters for these activities.
According to the AMA Opinion, “Fairness is essential in all disciplinary or other hearings where the reputation, professional status, or livelihood of the physician or medical student may be adversely affected.” Due process is mandatory, and each member must be treated equally. These points are delineated in the AMA Physician Guide to Medical Staff Organization Bylaws. If an activity is considered inappropriate for one health care professional, it is wrong for all. Robust peer review processes, when optimal, should emphasize fairness, diversity, and inclusion, while focusing on the pertinent medical and scientific variables of patient care.
FIGURE 3. PHYSICIANS UNDER INVESTIGATION BY THE PEER REVIEW COMMITTEE
ARE GIVEN ACCESS TO INFORMATION RELEVANT TO THEIR CASE
When members of the medical staff come under investigation, the peer review process must be objective. Staff members under review must receive a listing of specific charges under investigation and have the opportunity to present a defense. They must be given adequate notice of concerns, time to defend themselves, and the right to a hearing.
Governors were queried whether physicians under investigation are given access to information relevant to their case. Nearly 75 percent said they believe physicians usually or always receive appropriate information, whereas 15 percent found the information was seldom or never provided (see Figure 3). The ACS Optimal Resources for Surgical Quality and Safety (also known as the Red Book) stresses that physicians should be made aware that they are the subject of peer review proceedings and that peer review committee members should keep the identities of individuals involved confidential.
Physicians under review deserve to be evaluated by peers who have a “similar level of training,” such as specialists in their field. Members of the reviewing body must disclose relevant conflicts of interest, especially because peers of similar backgrounds may be competitors in the marketplace. External reviewers often are needed and should be used when conflicts occur. For example, on an ongoing basis, a major hospital in Ohio avoids these types of conflicts by partnering with a large hospital in another state to perform peer review activities. The survey revealed that most Governors (83 percent) believe that surgeons involved in the peer review process had adequate surgical expertise.
FIGURE 4. DO YOU BELIEVE THAT THE PEER REVIEW PROCESS IS FREE OF BIAS?
Although 36 percent of respondents did not believe the peer review process is free of bias, 64 percent believed it is unbiased. Nine percent of Governors indicated they usually or always witnessed abuse of the peer review process in the last five years, but 54 percent never saw any abuse; 45 percent of the YFA leadership believed bias was present in the peer review process (see Figure 4).
When comparing bias or abuse of the peer review on the basis of gender, 14 percent of women Governors reported usually or always witnessing abuse in the last five years, whereas 8 percent of Governors who are men witnessed it. In addition, women surgeons reported bias in the peer review process 44 percent of the time versus 34 percent among Governors who are men.
Examining the responses from different practice patterns revealed further insights. For example, Governors in military service reported that 100 percent of physicians under investigation for possible disciplinary action were granted due process. In contrast, surgeons in civilian private practice reported that 20−30 percent of the time due process is never or seldom observed. Civilian private practitioners also reported that 20−30 percent of the time physicians were not informed they were being investigated.
TABLE 1. PHYSICIANS UNDER INVESTIGATION BY THE PEER REVIEW COMMITTEE
ARE GIVEN ACCESS TO INFORMATION RELEVANT TO THEIR CASE
Thirty-three percent of Governors in private practice and 66 percent in government service noted problems receiving access to information relevant to their cases. In contrast, only 12 percent of academic Governors indicated this information was never or seldom shared (see Table 1).
Although most Governors (76 percent) believed that physicians under investigation for possible disciplinary action were given due process, 17 percent of Governors ages 61 to 65 believed due process was never or seldom followed. Most Governors (78 percent) believed that physicians under investigation were informed that they were under review, but 21 percent of Governors ages 61 to 65 reported this information was never or seldom shared, versus 68 percent of the YFA leadership who believed that physicians under investigation were informed.
Most Governors (83 percent) reported they never or seldom witnessed an abuse of the peer review process in the last five years, but Governors ages 46−50 years old and 66−70 years both usually reported this abuse 11 percent of the time (see Table 2). In comparison, 18 percent of the YFA leadership reported they had witnessed abuse.
Several interesting differences were noted when analyzing responses based on geographic location. For example, only 9 percent of both Canadian Governors and U.S. Governors reported that physicians under investigation for possible disciplinary action were never or seldom given due process, while 28 percent of international Governors reported this right was never or seldom granted. Another discrepancy was found when comparing access to information relevant to their case. Similarly, 25 percent of international Governors reported they were never or seldom provided access to relevant information versus only 9 percent of the Canadian Govenors and 13 percent of the U.S. Governors.
Other discrepancies were revealed when examining whether surgeons were involved in the peer review of other surgeons under investigation. For example, most Governors (86 percent) indicated surgeons were involved, but 25 percent of international Governors reported surgeons were excluded (see Figure 5.)
Governors recommended several ways the peer review process could be improved and how the ACS could assist in these enhancements. Popular ideas included offering more education modules and case presentations on the topic, as well as providing guidelines, templates, and best practices regarding the peer review process. More than 80 percent of Governors indicated they were moderately likely or extremely likely to use an education module of evidence-based peer review processes offered by the ACS.
TABLE 2. WITNESSED AN ABUSE OF THE PEER REVIEW PROCESS IN THE LAST FIVE YEARS
Additional recommendations focused on ensuring that a surgeon is a member of the peer review committee, especially when investigating another surgeon. Increased emphasis on the peer review process as outlined in the Red Book also would help to reduce bias by focusing on the case itself (as in single discipline case reviews or multidisciplinary case reviews) or the case as an outlier in the institution (that is, data registry reviews or educational reviews).
Strong peer review processes also capture positive outliers in habits, decisions, or actions to improve care. The trend toward larger group practices, health care delivery systems, and data sets may contribute to enhanced value-based care across patient populations. Although confidentiality should be maintained, opportunities for incremental improvement, innovation, and research should be captured as they occur and are promoted. When peer review of individual surgeons is needed, the following key points should be top of mind:
- The peer review process should be explicitly defined in the medical staff bylaws and in accordance with appropriate professional society guidelines.
- The peer review process should be completely transparent, including items subject to review, steps in the process, and delineation of the process.
- Due process is essential. The timeline of the peer review process should not be overly burdensome. Appropriate time must be provided to review the allegations, seek assistance and counsel, and provide a defense. Exceptions may occur for egregious actions.
- Peer review should involve appropriate colleagues. If peer review cannot be conducted locally and by individuals of similar specialties, external review is recommended.
- Ensuring fairness:
- Physicians should be notified promptly if referred for review.
- Physicians under review should be allowed access to appropriate personal counsel (professional, medical, scientific, legal, and so on).
- Physicians must be provided all relevant information pertinent to the review.
- The review should be independent.
- The results should be protected, confidential, and undisclosed.
Peer review is important to ensure patient safety and quality of care; however, misuse can occur if performed improperly. When peer review is unfairly performed, as in silencing whistleblowers or adversely forcing competitors out of business, the term “sham peer review” is applied. Sham peer reviews can be avoided if the recommendations described in this article are followed.
FIGURE 5. DOES THE PEER REVIEW COMMITTEE ALWAYS INVOLVE SURGEONS IN THE PROCESS
IF THEY ARE INVESTIGATING OTHER SURGEONS?
Clear and effective communication between the medical administrative staff and physicians is essential to conduct effective peer review. Any conflicts of interest must be recognized and dealt with fairly. The expected activities and behaviors of physicians must be clearly defined. When changes are planned and instituted, complete explanations are necessary.
Many professional organizations maintain that effective peer review is essential to improving patient care, but also assert that the process should be confidential, protected, and transparent and not subject to discovery. For example, at surgical morbidity and mortality conferences, information is both protected and transparent for educational purposes. Best practices should be implemented based on local needs and conditions. The review process also should be mindful of local resources, as well as the complexities of the cases under consideration.
Optimal peer reviews protect patients, improve care, and provide appropriate self-regulation. The Governors survey delineates that although many of these issues remain extremely complex, especially at the national professional society level, opportunities exist to improve peer review, although additional data may be necessary. Surgeons should lead these efforts via self-regulation and active introspection.
American Academy of Family Physicians. Peer review. Available at: www.aafp.org/about/policies/all/peer-review.html. Accessed March 1, 2021.
American College of Surgeons. Ernest A. Codman, MD, FACS (1869–1940). Available at: www.facs.org/About-ACS/Archives/pasthighlights/codmanhighlight. Accessed March 1, 2021.
American Medical Association Peer Review Committee. AMA peer review 101. Available at: www.albertadoctors.org/Member%20services%20Compensation/ama-peer-review-101.pdf. Accessed March 10, 2021.
American Medical Association. Peer Review & Due Process: AMA Code of Medical Ethics Opinion 9.4.1. Available at: www.ama-assn.org/delivering-care/ethics/peer-review-due-process. Accessed March 10, 2021.
Arkansas Medical Society. AMS and AMA seek intervention to support Review Fairness Act. Available at: www.arkmed.org/news/2014/07/ams-and-ama-seek-intervention-to-support-peer-review-fairness-act/. Accessed March 1, 2021.
Berman L, Berman L, Ottosen M, et al. Preventing patient harm via adverse event reviews: An APSA survey regarding the role of morbidity and mortality conference. J Pediatr Surg. 2019;54(9):1872-1877.
Freedman S. How 2007 Joint Commission standards expand hospital peer review. Patient Safety & Quality Healthcare. Available at: www.psqh.com/analysis/peer-review-how-2007-joint-commission-standards-expand-hospital-peer-review/. Accessed March 10, 2021.
Kitay A. Peer feedback. AMA Journal of Ethics. Available at: https://journalofethics.ama-assn.org/article/peer-feedback/2005-04. Accessed March 10, 2021.
Pennsylvania Medical Society. PAMED joins with the AMA to file amicus brief in peer review case. Available at: www.pamedsoc.org/list/articles—mvc/amicus-brief-peer-review. Accessed March 1, 2021.
Quest Diagnostics. Improving the peer review process through effective document management. Available at: https://blog.questdiagnostics.com/blog/2018/03/13/improving-peer-review-effective-document-management/. Accessed March 10, 2021.
Shemas H. The birth of modern peer review. Scientific American. April 19, 2014. Available at: https://blogs.scientificamerican.com/information-culture/the-birth-of-modern-peer-review/. Accessed March 10, 2021.
Vyas D, Hozain A. Clinical peer review in the United States: History, legal development and subsequent abuse. World J Gastroenterol. 2014;20(21):6357-6363.
Weber FK. The ACS motto: What does it really mean? Bull Am Coll Surg. 2015;100(3):32-34. Available at: https://bulletin.facs.org/2015/03/the-acs-motto-what-does-it-really-mean/. Accessed March 11, 2021.
Wikipedia. Clinical peer review. Available at: https://en.wikipedia.org/wiki/Clinical_peer_review. Accessed March 1, 2021.