Smoke

It has been hard for me to find the heat in all the smoke surrounding this one. I expected to have an advantage understanding this, but maybe I am seeing too many subtleties.

Peer review is a medical staff process that I am quite familiar with. When doctors criticize each other it is supposed to be a healthy collegial process that leads to reflection and improved care. We all should reflect on our decisions and actions with the intent to do better (or the same) next time.  Doctors are supposed to do this in the “peer review” process in hospital committees and meetings. Since the 1970’s the state of Idaho has considered professional peer review important enough for the public welfare that the state has declared the process immune from discovery by a third party in a lawsuit. So a patient who considers himself wronged by a physician’s care cannot troll through the peer review minutes for support. It is protected from such discovery.

Two years ago the Idaho Supreme Court decided that a patient who was injured by a physician’s care could sue the hospital for negligent credentialing. That is, the peer review was still immune, but the actions that the hospital took based on peer review are not. So we have before us a bill [HB162] that extends the immunity for peer review decisions outward to include the actions of the hospital that are based on peer review.

In my experience the peer review process has been very frustrating. I always wanted more collegial and critical discussions about patient care decisions. I spent a lot of time encouraging doctors to change their behavior. I wanted input on my own. Collegial criticism has always been difficult to bring about for many reasons. Most people, not just doctors, do not chose to reflect. Few are comfortable with criticism. I considered these to be essential elements in medical training and thus in the practice of medicine. Yet in the hospital and the clinic I found resistance and denial were the norm when I tried to promote these practices. And the excuse most often offered for why to not be involved in critical peer review had to do with the fear of litigation. Like admitting one’s mistakes or examining another’s begged a lawsuit.

Disgruntled patients are not the only source of this fear, because patient care peer review is protected. Sometimes,  physicians fear their colleagues. This is the uncomfortable secret of peer review: sometimes doctors do not get along or do not agree on what is the best course of treatment, and sometimes they can even be downright vindictive. Who would want to try to promote reflection in such a colleague? Worse, if these character flaws spill over into clinical judgment, can one keep to the issue of patient care when there are personality conflicts? And finally, add to this that medicine is a business, and we physicians have our financial futures tied to reputation and affiliation. Consider this swamp of conflicts in which a profession is granted immunity from discovery to better itself and the care it provides. It is amazing there is no brown ooze coming out from under the door closed on the peer review panel.

We heard HB162 last week in Senate Health and Welfare committee. Representatives of the Idaho Hospital Association and the Idaho Medical Association both spoke in favor of the bill. There were lawyers who spoke in opposition and doctors who spoke on both sides. What most impressed me was that there were five doctors from a Boise specialty hospital that thought this bill was going to allow competing hospitals or physicians to limit their practice;“economic credentialing”. The decision to allow a physician to practice in a hospital or to limit their scope of practice can be quite subjective. If these decisions are made for the purpose of promoting the business interests of one party over another then the spirit of peer review is not met. There are many stories of this happening. I have seen it myself. One doctor with a certain kind of training may not think other doctors with a different kind of training should do a certain procedure. The more lucrative the procedure, the stronger is the defense of “the right way” to do things. And there is no clear evidence on “the right way”, despite the advertisements one sees in the papers or television.

I honestly had not decided how I would vote before the testimony. I had received emails and heard conversations on both sides.  I wondered if there was a problem in Boise that did not apply to rural Idaho hospitals. In the end, I was most influenced by the repeated and heated overstatements by the opponents who feared economic credentialing. In my careful reading of the bill I did not think such a fear was warranted. I want there to be good peer review. I hope this promotes it. So I voted yes, to pass the bill to the floor.

But I will pay attention if it passes into law. I am not sure if this will keep smoldering, burst into a decent fire that might shed some light, or just go out.

The bill was just defeated on the Senate floor 14-21, not even close. I’ll still pay attention.

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