Physicians fear being sued by patients, a well- known fact, but many also worry about being targeted by fellow doctors through the process of peer review. Allegations of poor care or other serious complaints against a doctor go to a panel, consisting mainly of physicians, that decides in secret whether the accused has done wrong. That system is too open to manipulation and needs reform, says the 4,000-member American Association of Physicians and Surgeons. The Semmelweis Society agrees; its 85 members are mostly doctors who claim to be victims of "malicious peer review," in which the process is used to damage competitors or punish whistle-blowers. Support for reform is also widespread among doctors who work in patient-safety policymaking, says Robert Wachter, co-author of Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. "We need as transparent and objective a system as possible," he says.
Dallas cardiologist Lawrence Poliner says his case shows how peer review can be abused. Last August a jury awarded him damages of $366 million from Presbyterian Hospital of Dallas and three colleagues who trumped up charges of substandard care against him to eliminate him as a competitor. Says Poliner: "It's unfathomable that a process that should be about healing could be used to attack doctors." Obstetrician John Raviotta, after reporting to state authorities dangerous obstetrics policies at the Community Memorial Health Center in South Hill, Va., lost privileges there as a result of a peer review that included doctors from the facility. "As contractors of that hospital, how can the doctors be objective?" he asks. The hospital said Raviotta "disrupted [its] efficient operation."
Not even critics of peer review want to abandon it. "Peer review is the process by which we say, What went wrong?" says orthopedic surgeon S. Jay Jayasankar, who helped devise the Massachusetts Medical Society's guidelines, which call for a ban on competitors of a doctor reviewing his case and on the common practice of registering confidential accusations in disciplinary proceedings. "There must be more openness," he says.
Semmelweis doctors went to Capitol Hill in May to lobby Congress to codify such principles. But they haven't managed to get even a hearing on the topic. Most reform advocates say it would be better for doctors to adopt new standards on their own. "Doctors already feel beleaguered" by regulation, says Wachter. More rules imposed by outsiders would be seen as "intrusion."
If doctors don't act, voters may do it for them. In November, Floridians approved a constitutional amendment giving patients access to records related to "adverse medical incidents," including peer-review reports. Several states are mulling similar laws. Some doctors fear exposing the process to the public will inhibit physicians from reporting and forcefully investigating problems and will ultimately hurt the quality of patient care. Publicity could also open hospitals to more malpractice claims, even when panels find no wrongdoing. Trial lawyers sponsored the Florida amendment. --By Jeff Chu