Peer review in medicine is the accepted standard for oversight and review of individual physician performance . The system is inherently flawed due to external factors, bias and human fallibility . With changing focus on ethical principles and process improvement techniques in the practice of medicine, we should be able to do better. We need to consider medical ethical principles and transparency with documentation of process improvement to develop and maintain the public trust.
Radiology has been the forerunner in the use of technology in everyday practice. Peer review in radiology has become easy to use with current software . Any time a radiologist reviews an old study, it can be marked with a peer review coding and submitted to any number of programs for indexing and analytics. As it is so easy, the peer review process is in full swing in most institutions. As such, the problems with peer review are also easily observed. In this article I discuss the current problems noted from the perspective of a radiologist and some ideas for improvements in the peer review system using radiology as an example.
Peer Review is the currently accepted best practice for oversight and improving physician related work product .
It is far from ideal. There are three major issues. At the top of the list is the loss of value due to lack of utility in process improvement. Bias is second and appears to be an insurmountable problem (reference). Lastly, forced participation without obvious beneficence is disingenuous. The radiologist has no reason to do anything more than protect their position in the institution. I believe that most radiologists are focused on the ideal of improving the system. However, it is easy to be jaded when the obvious goal is to punish offenders. In this way, the system encourages individuals to report only positive results.
Malpractice is out of control. The degree to which it affects our ability to improve healthcare is unclear. It is clear that malpractice litigation has a major effect on a physician’s ability to confront and correct errors due to routine gag orders during a claim and suit. From an ethical perspective, it is unclear about the real benefit to the patient. It enriches attorneys at the expense of patients and the system. The current justification is that the wronged individual (injured party) deserves their day in court and to be made whole. Yet, how do you make whole an individual that may have lost a limb or important organ? How do you bring back someone to life? Money is the tool we use to compensate someone for an injury or
loss. The legal system then adds extra money as punitive damages to satisfy the injured party that someone has been punished. The logic is wrong. Process improvement techniques are a well-established way to find and correct errors. Yet, how can we identify problems when the legal system demands that a physician in a legal case not discuss the case for fear of discovery? What does punitive damages do to help the next victim of a medical error? The medical community needs to have the freedom to identify errors without fear in order to come up with corrective actions so that the injury won’t be repeated. We may not be able to fix the injured party but we will fix countless others in the future.
The second major problem is that the peer review process is biased and misleading. Bias comes in many different ways. Bias is anything that influences a decision in a non-objective direction. It can be an individual bias toward a diagnosis . It can be an individual’s dislike of a test or a person. It can be fear of retribution from someone on the hospital staff or medical director. It can be fear loss of employment. It can be a tool to force someone to leave. It can be a tool to maintain a treatment protocol that an institution needs to be profitable (?Miller ref). Any of these reasons can be a source of bias in the peer review system. Individual bias is almost always present despite even the best individual’s efforts to be objective.
The real value of the peer review system is in its creation.
We now have a tool to examine the radiologist work product in
a microscopic way. How valuable is this if we can’t develop and
improve processes for patient care, it is a dead end. As we move
toward evidence based medicine, we need to keep in mind that
the evidence is in the knowing and understanding of the current
process. It is in our ability to analyze objective data and come up
with process improvements. It is this standard method that will
create the evidence based care practices to be used for future care.
To have a functioning peer review system, the system should
be transparent. Details of the deviations should be available
for review in order to identify good and bad decisions with an
emphasis on improving these decision nodes. Our current peer
review process hides details for fear of discovery.
The main function of the physician peer review system is
to provide the minimum needed data requirements to produce
reports for institutions to use to show they are meeting
institutional, federal and medical society standards. It is ethically
unsound as his process fails to improve patient care and reduce
Transparency is supported by respect for autonomy and
professional relations (Childress and Beauchamp). There are two
reasons for lack of transparency. One is to protect patient health
information and the other is to protect the physician’s reputation.
It is obvious that the physician reputation should not supersede
patient’s right to information about their health. As noted above,
the main factor blocking open discussion is the gag effect of
This is the primary problem and road block to developing a
process improvement. The ability to openly discuss errors without
reprisal is the environment needed to create a fix for the error.
This was shown to be a key tool for improving the airlines flight
failures . With the estimated number or medical errors well
into the 10’s of thousands, it is clear that our current system is not
working and more drastic steps are needed . Tort reform with
a focus on protecting physicians from punitive damages and loss
of reputation from individual events is the ultimate mechanism to
improve care and diminish errors.
The main value of peer review is to identify the worst
offenders in order to weed them out of the system or mark for
retraining. When the system is biased, the results cannot be
trusted. Additionally, without transparency, the data needed to
review and create a process improvement plan is lacking.
The value of removing bad physicians is high. However, the
peer review system fails to help the majority of physicians who
may need to minimal corrections in their performance. I put forth
that when we add up these small improvements, they will foster a
major reduction in errors.
The peer review system is not robust. A system with
transparency, attention to detail and open discussion could have
far greater value without losing the value of weeding out bad
actors. These affects would be a greater beneficence.
The inability to identify and create process improvement for
all players puts patient at risk. This delays creation or process improvement plans causing harm to patients. Sharing recurring
errors and process improvements is lost harming many more
patients. Indeed, bias may hide bad physicians.
Patient health information privacy is a concern in a transparent
system. Anonymization of data is not done well and remains
a concern (Sweeney). These concerns need further evaluation
and discussion. A continuing dispute over whether the rights
of society to medical improvement outweighs the right of the
individual to privacy needs to be answered. Many individuals are
willing to share their PHI in an effort to improve the system. This
volunteerism may be the key to success of a transparent system
without removing the right to privacy. The medical community
often balances maleficence and beneficence. Consider an operative
procedure to cure cancer. The patient is often disfigured and put
through a traumatic procedure for the possibility of a cure. We
should look at the loss of the malpractice liability as a surgical
cure for the system. This is not to say that individuals shouldn’t be
cared for or compensated due to the medical error. The individual
deserves compensation in a way to ease the error made. This
should be done so as to remove the financial gain of attorneys.
This will make more money available for compensation and allow
the system to accommodate and anticipate costs.
The ultimate goal is to improve patient care for as many as
possible and reduce the time for a process improvement to be
initiated. In a truly transparent system, peer review becomes
obsolete. All the data is available for review and analysis. True
patient centered care focuses on using whatever is at our disposal
to improve the patient’s health outcome without bias. Until such
time, that this is possible, we need to consider that the peer review
system is a necessary evil.
ii. Medical legal issues will force peer review to be
supportive of the individual in a group in order to safe guard
the groups standing in a hospital unless the error is so bad
that even a non-radiologist can identify the error.
iii. This limits the purpose of peer review to only big issues
when little issues are key to process improvement.
iv. Besides this, medical legal issues force silence of the
accused to protect their defense in a suit. In addition, the legal
bias of building a case will often force a physician to fight a
non-defensible position in order to lower a settlement. This
colors the issues and often obscures the real error and issues
surrounding the error.
v. Pressures on radiologists to do more (faster TAT’s and
increased volume) adds pressure on radiologists to take the
peer process less seriously and cut corners. The main way this
happens is by limiting the peer analysis to positive cases.
Keys issues of the patient centered ethical standard include
patient choice, satisfaction and safety. Patient choice is based
on patient’s preferences and need for knowledge creating an
environment where patients can make a choice. Patient satisfaction
is broad and often hidden in radiology as they are usually unaware
of the details of imaging practices. In general, they want access to
imaging services, affordable pricing, timely access and reporting,
confidences in the services and ability to seek second opinions.
Safety is non-descript for the patient. Radiation is the biggest fear
but the least important issue. The most important safety issues
are more mundane including the usual: wrong test ordered,
wrong patient, wrong side, incorrect diagnosis, missing report,
misunderstanding of the referring physician, etc. Of course, the
balance of benefit to risk must be in favor of the patient and
decided by the patient.
Radiology is failing to lead in this important area. The ACR
has made a great effort in creating appropriateness criteria and
practice guidelines. However, the amount of the information is
overwhelming for the individual radiologist; remember, a picture
is worth a thousand words. This is an underestimate of the
information in a radiology exam. Too often, we limit our report
to an overall interpretation. Change is inevitable. The radiologist
is image oriented whereas practice guidelines are in print. Image
based reporting systems need to be created to fill this void.
Currently a few are out there. Usual areas of problems in evidence
based medicine exist, mainly, one method doesn’t fit situations.
Most cases are straight forward. Consolidative pneumonia shows
as a white in an area that is usually dark grey and air bronchograms
can be seen in the white area. Major fractures can often be seen
from 10 feet away. Other findings can be more subtle. When do we
say bowel wall is thick due to disease or due to bowel contraction?
What is the proper anterior fat pad sign in the elbow? Why should
we take an image of the elbow when we see a fracture of the ulnar
with no other findings on the wide wrist view? These are specific
issues where a robust easy-to-use evidence database is needed.
Questions for building an evidence based system
1. How can we build an evidence based system for imaging
2. How can we make evidence based medicine easy to use
3. How would we create an evidence based system in
Radiology that can build on itself?
4. Can we show the value of this system and gain acceptance
by radiologists, referring physicians and the public?
What is the ideal? Should we use all available information
and tools at our disposal? These include: a modified peer review patient tracking and follow up, random case review and follow
up, AI guided case selection and analysis, and evidenced based
processes with analysis of outcomes.
We need to focus our efforts on what is practical and
achievable. We should continue our efforts in tort reform. A
growing movement to create single payer system for medical care
may supersede tort reform and force changes in medical liability
as the state becomes the major purveyor of health care.
Maintaining timeliness is key. Any system would have to have
a rapid response. AI is the only practical tool for rapid response.
Computer aided diagnosis is not practical or widely available.
Education is still a mainstay of maintaining quality. Any secondary
system should be predominantly a teaching tool (Morbidity and
mortality conferences) in which the cases are reviewed (where
secondary is any system that doesn’t use direct data analysis).
Use internal institutional data systems with creation of identifiers
as markers for errors or warning system. Creation of deep
learning systems to aid in early warning of errors or problems. +A
distributed patient record controlled by the patient with access
granted by the patient is being considered and promoted by some
1. Peer review, currently, is only succeeding in identifying
the worst offenders. Peer review can be improved by
focusing on removing as much bias as possible. This can be
accomplished by utilizing independent reviewers such as
individuals or groups outside of the of the reviewed practice
area and routine exclusion (friends, family and other known
relations). Independent reviewers can be a professional group
dedicated to peer review or a pool of independent groups
that are geographically separate and independently managed
possible by a professional medical society (the ACR could
serve this function for radiology).
2. Tort reform remains key to open discussion and
3. Development of a new gold standard which has access
to anonymized PHI. This would include AI and Deep Learning
tools. The goal being rapid identification of errors and
notification before a clinically significant error occurs.
4. Maintenance of health care teams made of physicians,
nurses, patients and others involved in patient care working
together offers the best current solution with its checks and
5. No impediments to having a review of any disputed case.
6. Continued use of morbidity and mortality conference as
an inhouse educational tool which should be a source of CME
or mandated as special CME with and protected as much as
possible from discovery.
7. Medical societies should actively promote to the public
and their legislators tort reform to create an environment
conducive to open discussions to improve patient care.
8. Transparent discussion and information so the public
will be able to see all issues related to their care openly which
will promote trust and improve care
The peer review system is far from perfect but remains
a necessary evil until the public can accept that malpractice
litigation is not the best way to improve patient care. True
process improvement will come when the medical community
can openly and transparently review the source of errors. With
tort reform and improvements in the information retrieval, data
analytics will be the main tool for process improvement utilizing
peer discussions. Peer review in health care delivery along with
morbidity and mortality conferences will continue to be an
important educational tool and a way to consider the method for