Talking to ourselves: does Peer Review in Medicine really work?
Posted by CEP America on Tue, Jun 22, 2010 @ 08:10 AM
By John Ruffner
If you're a physician, physician assistant, or nurse practitioner, you probably have a definite opinion on peer review. Personally, after 25 years of participating in peer reviews I'm convinced that there is definite practical /clinical value for these programs in medicine. That said, the question is: how can we maximize the benefits of the effort?
It's my viewthat organizations that can learn from within exhibit significantly higher levels of effectiveness. They are better at discovering error or opportunities for improvement - and translating that knowledge into action or changed behavior.
It seems obvious that organizational culture is key to successful efforts at improvement from within - where frank, specific and sometimes pointed discussions are encouraged
The literature is replete with examples of very sophisticated organizations where, notwithstanding a lot of very skilled individuals, the culture actually discourages accurate and open discussion of problems ("Skilled Incompetence", Harvard Business Review). NASA culture has been criticized on this point and the Shuttle accident was blamed on the organization's unwillingness to hear ‘bad news'.
While most medical peer review operations start by looking for ways to improve best practices, a number of factors often erode the effectiveness over time. These include:
- Medicine requires professional training and practice where complete information may not be available (Medicine is still an art)
- Professional behavior is often protective of its own
- Legal consequences are always a risk factor
- By definition, peer review is considered ‘Monday morning quarterbacking'
- Sociology of the Group or Group Think - what's ok to talk about and what's not
- Talking ourselves into the picture we want to see (related to the above item)
- The discussion focuses on how to shift blame self reinforcing thinking (sometimes appropriate)
- The discussion focuses on how to classify the case
- Focus on getting through the agenda
So, with these forces at work, what can be done to maximize the benefits (improve clinical care) of peer review? In my opinion, establishing a culture of openness and inquiry - one that encourages questions and scrutiny - is key. If a peer truly does not feel that the culture allows for honest comment, they will never speak up.
That's why it's imperative for a practice or healthcare organization to establish a mechanism for clearly stating and presenting ‘lessons learned' or the conclusion with differential explanations. This can most often be accomplished by a summary of findings at the end of each review and a clear statement of the conclusions with everyone's attention turned to this activity.
What are your thoughts on peer review? Do you have a system in place where you practice? Please share your thoughts.
Mr Ruffner has served in many roles both in acute care and physician organizations over the past 25 years. He holds a MPH degree from UC Berkeley and has served on the faculties of several universities.