The Many Guises of Peer Review
Dr Alper is a practicing internist in Burlingame,Calif, and a Robert Wesson Fellow in Scientific Philosophy and Public Policy, Hoover Institution, Stanford University, Palo Alto, Calif.
My first encounter with peer review dates back to the surgical death and complications conferences that took place during my internship at Mt. Sinai Hospital in New York City. These sessions were famous; attending physicians actually traveled from neighboring states to attend. Case presentations were followed by interrogations that were often brutal, creating high drama whose underlying rationale was to improve patient care. All was done with almost religious fervor and in perfect safety. No lawyers or insurers were in the wings—only doctors were relevant.
The first variation on this peer-review theme occurred shortly after I entered into medical practice. A rogue anesthesiologist fought restrictions on his privileges that were proposed after a series of clinical blunders. He made the review committee and others on the medical staff miserable with legalities that dragged on for years and put the reviewers at personal risk due to accusations of malice and violation of antitrust laws. This kind of case is far from rare. Counter accusations are a standard legal tactic and poorly performing physicians always have more at stake than their peer critics. Still, it is our duty to police ourselves.
Over the years, peer review has gone from clinical performance to extend into almost every aspect of medical care. In the process, I believe it has often become tainted by misuse. The original purpose of peer review was the protection of patients and enhancement of the quality of care. Scrupulous implementation has served as the basis for both public trust and trust among colleagues. Properly done, honesty and fairness are assumed and elaborate mechanisms of redress assure that all get a fair hearing.
That is the ideal. Where peer review has taken a turn for the worse is in the co-opting of the peer-review process by numerous third partie—government, insurers, hospitals, and even medical journals, to name just a few—in service of other, often hidden, agendas. For example, Medicare uses peer review with dual motives, no doubt to seek the best care for the dollars it pays out, but also to serve as a moral and scientific basis with which to enforce dubious fraud and abuse laws that leave physicians in a perpetual state of debilitating uncertainty. Differences of opinion regarding coding and treatment alternatives are sometimes transformed into issues of crime and punishment. While this is difficult to explain to nonphysicians without seeming overly self-serving, it is intuitively understood by anyone practicing medicine today.
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Medical journals, including the very best of them, are another sacred cow that provides grounds for misgivings. “Scientific” peer-reviewed journals now include socioeconomic as well as scientific content with legal, political, and investment implications. We now hear complaints about bias that includes commercial and political motivation. Thus the lead editorial in the (November 16, 2005), which was titled “New England Journal of Politics.” The article condemned using the credibility conferred by the status of a “peer-reviewed journal” to advance what the journal considered to be a variety of left-leaning political agendas as well as self-insertion into the rofecoxib (Vioxx) drug litigation. Environmental issue bias in other journals is also cited.
Is this criticism credible? I think so. A personal wake-up call came when a prominent Stanford colleague would not let me cite my Hoover affiliation on a paper we wrote together. “Hoover’s right-wing reputation would lower the odds of acceptance,” he said. (Actually, in the only analysis ever done, Hoover’s voting pattern in a presidential election exactly replicated the national average.) It is unknown how much similar self-censorship exists.
The complex relationships among academics and industry and the inclusion of medical socioeconomic articles and commentaries in major medical journals have raised numerous issues of conflict of interest and political and financial bias. Needless to say, leading universities, corporations, and journals have become embroiled in controversy.
Self-promotion that was once considered anathema has been replaced by hospital promotion of individual physicians, procedures, and equipment with the undisguised goal of revenue enhancement. Continuing controversies over the safety of minimally invasive procedures, whether orthopedic or cardiac, are glossed over. As the radio and television ads are broadcast, issues of visibility, credit, and money make the difficult job of assessing professional excellence even harder than before. Surgical departments were being given monthly status reports detailing their relative place as revenue-generators, at least until one department rebelled. “It’s as if the indications and outcomes weren’t even relevant,” said an orthopedic colleague.
As for who should judge whom, should primary physicians, most of whom no longer see their own patients in the hospital, vote on requiring other specialties to take night call? Indeed, what do our own hospital credentials attest to in the absence of ongoing inpatient experience?
A word about insurers. Every one of them is developing surveillance programs to assess physician performance and “increase compliance.” Meticulously-detailed literature sources and recognized clinical guidelines based on the peer-review process mix the science and the money in such inscrutable ways that they are difficult to argue against. Blue Shield of California has gone to the head of the class with its Relative Efficiency Scores that rate individual physicians on a Resource Utilization Grid. The scores aggregate the physician’s use of resources (a euphemism for cost) in treating selected diagnoses. Clinical outcomes are not relevant.
Nowhere is it said that employers and insurers employ standards that are quick and dirty for commercial reasons while scientific standards, which always involve doubt, serve different masters and may not be compatible. Not only is the peer-review process subject to its own distortions, but the uses to which peer review is put may be more pseudoscientific than scientific.
To summarize: Peer review has been compromised in mny ways—by politicization, introduction of other agendas, hidden financial considerations, and misuse of the “peer reviewed” imprimatur to promote dubious practices. Maybe it is time that this process, one to which all doctors could automatically subscribe to in the past, should now be given a fresh look.
e-mail: philipa@itsa.ucsf.edu
