Letter to the Editor

Clinical Peer Review: A Plea forFairness

Practically any cardiologist or endovascular interven-tionalist put through the rigors of an external peerreview is familiar with the term bad faith peer review.The latter may well be defined as peer review gonebad, with the ingredients of innuendo, rumors, andbias; with peer review being motivated by politics,economics, and greed. This process preys upon thesolo practitioner and upon those who wear the scarletletter of a previous bad faith peer review. In our field,the battle of control for endovascular interventionsbetween radiologists and cardiologists has been called‘‘the mother of all turf battles’’ with many vascularsurgeons also left with wounded wings. Immunityfrom BFPR is virtually always achieved by associatingwith a group of five or more cardiologists.An excellent model for peer review can be easily

drawn from several sources, including the ‘‘Massachu-setts Medical Society Model Principles for. . .PeerReview;’’ [1] ‘‘Guidelines for Internal Peer Review inthe Cardiac Catheterization Laboratory’’ [2] and cita-tions from ‘‘Safety in Interventional Radiology’’ [3].From these one will learn that blinding the reviewer tooutcome is often very helpful. A sentinel event shouldvirtually never be the initiating event for peer review,but an opportunity for improving the system. Inventorymay be the highest risk to the patient in the endovas-cular interventional laboratory and finally, multiplesources of bias contribute to bad faith peer review,including those biases from the foundation that hiresthe reviewer; the reviewers; the administration; thehospital attorneys; the physicians competitors; andprejudices from the reviewers regarding techniques andpreferences.However, the biggest concern is the ubiquity of this

process and what can be done to thwart the process. In

Tennessee alone, legal sources estimate 20–25 physi-

cians are undergoing bad faith peer review at any one

time. Many are cardiologists and virtually all are solo

practitioners. Virtually all are initiated by sentinel

events. Often the peer review is initiated from a multi-

disciplinary committee, e.g., peripheral endovascular

interventions, thereby, usurping the power from the

department of cardiology. The demand for action goes

directly to the Executive Committee of the hospital,

with no knowledge of interventional procedures. This

quickly evolves to an external review with the biases

listed earlier. Reviewers are hired by the hospital, of-

ten with the ‘‘right answer’’ expected. Whether real or

imagined, the reviewers are subjected to extreme pres-

sure. A significant amount of money is paid to the

external reviewer. If he does a ‘‘good job’’ he may

continue receiving multiple cases per year, supplement-

ing his income to six figures, and, perhaps adding to a

relatively low academic salary. In some cardiology

departments one will find every staff member affiliated

with a major firm that executes external reviews and

acts as a physician finder for external reviews and fair

hearings. The pressure gets even greater to render a

decision for a hospital at a fair hearing panel where he

must substantiate his completed review.As with the outside reviewers, the fair hearing panel

that decides the fate of the physician, his family, hisfinances and his future, is also chosen by the hospital.The hearing panel may often not include intervention-alists in appropriate cases and a common ploy is toadd a last minute substitute, who is in a different field,and works for a clinic that is an in-town competitor.The hearing panel is told that there may well not bean objective reason to take the physician’s privileges,but that is not why they have been chosen. They havebeen chosen to determine if external reviewers and thehospital and its physicians acted in a malicious andcapricious manner. This, of course, obviates all objec-tivity. A negative decision is again rendered to thephysician and he goes to appeal before a board ofdirectors where the administrator and hospital attorneystalk directly with the board and tell them what theyneed; how an adverse decision toward the hospitalcould have a negative affect on reputation and lead toa significant financial loss for the institution. Throughthis entire time the targeted physician may never havehad a conversation with anyone reviewing his case,including his own department, medical executive com-mittee, or the external review panel.

Received 18 January 2008; Revision accepted 26 January 2008

DOI 10.1002/ccd.21544

Published online 26 March 2008 in Wiley InterScience (www.

interscience.wiley.com).

' 2008 Wiley-Liss, Inc.

Catheterization and Cardiovascular Interventions 71:1000–1001 (2008)

In summary, the system bias and economic incen-tives are too great for a physician to win in this sys-tem. As stated by the past president of the Semmel-weis Society, C. William Hinnant, Jr., M.D., J.D.;‘‘Peer review is perhaps the last bastion of fundamentalunfairness and the only mechanism through which anindividual can be deprived of a recognized propertyright without Constitutional due process.’’ He goes onto say that ‘‘medical staffs are inherently political andinfluenced by power, money and alignment with hospi-tal administrations. Medical executive committees inthis day are virtually always populated by hospitalemployed physicians or private practice physicianswho are the beneficiaries of administrative servicescontracted with the hospitals.’’Perhaps it’s time to regulate expert witnesses partici-

pating in peer review, analogous to the regulation ofexpert witnesses in malpractice cases. The AmericanAssociation of Neurological Surgeons (AANS) requiresneurosurgeons acting as expert witnesses to present‘‘an accurate, current view of the standard of care inthe broad spectrum of acceptable practice,’’ making thecareful distinction among ‘‘personal preferences fromalternative but acceptable practices’’ [4]. Twenty-twostates have legislated minimum standards for physicianexperts in malpractice cases. The AANS may sanctionmember physicians with censure or expulsion frommembership, with these actions reportable to theNational Practitioner Data Bank. A federal court ofappeals upheld the actions of the AANS in one case.The American College of Obstetricians and Gynecolo-gists and the American College of Radiology are alsoactive in this arena [5].So, what can be done? I agree with William Parm-

ley, M.D., editor of The Journal of the American Col-lege of Cardiology. This will not change until reviewsare performed gratis, or for minimal reimbursement[6]; reviewers are allowed coach fare only, with noprivate jets; reviews are entirely done on site, with allmaterials available and the culprit physician inter-viewed before and after; with many times the wholedepartment reviewed as an element of fairness; theprocess of peer review at the hospital is reviewed, toinclude computer derived data, the process for han-dling sentinel events, and process improvement; allquality assurance performed by the individual’s depart-

ment with constant monitoring to prevent any blockvoting; and education of all members of the depart-ment on fair peer review on a yearly basis, with char-acter codes signed by each member. And, finally, apermanent committee should be established by boththe SCAI/ACC in a combined effort to address fairhospital peer review, with a forum offered at eachyearly meeting.All cath labs should be accredited as to the peer

review process. All cardiology departments that per-form angiography and interventions should be accred-ited through the SCAI/ACC in the area of fair peerreview. This will set a precedent for other nationalsocieties and should utilize the Massachusetts MedicalSociety Model for fair peer review. External reviewersin this process should be needed rarely, but when cho-sen they should come from a wide range of practi-tioners, to include private practitioners with a large ex-perience base and low complication rate. All reviewersshould be certified by the ACC/SCAI as havingattended a yearly peer review course, such as offeredby a consulting company or, perhaps, courses initiatedby the ACC/SCAI. Physicians abusing the peer reviewprocess should be subject to discipline from the SCAIand the ACC.

Wood Deming, M.D., FACC, FSCAI111 Stonebridge BoulevardJackson, TN

REFERENCES

1. Physician Practice Resources, Legal Resources page, Massachu-

setts Medical Society web site located at http://www.massmed.

org/AM/Template.cfm. (Accessed December 1, 2007).

2. Heupler F Jr, Chambers C, Dear W, et al. Guidelines for internal

peer review in the cardiac catheterization laboratory. Cathet Car-

diovasc Diagn 1997;40:21–32.

3. Miller D. Safety in interventional radiology. J Vasc Interv Radiol

2007;18:1–3.

4. American Academy of Neurological Surgeons. Rules for neuro-

surgical medical/legal expert opinion services. http://www.aans.

org/about/membership/Rules for_LegalExpertOpinionServices.pdf.

Updated March 2006. (accessed December 16, 2007).

5. Kesselheim A, Studdert D. Role of professional organizations in

regulating physician expert witness testimony. JAMA 2007;298:

2907–2909.

6. Parmley W. Clinical peer review or competitive hatchet Job.

J Am Coll Cardiol 2000;36:2347.

Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).

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