Medical Director Corner – Audra Thomas, MD

A Strong Argument for Peer Review
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​Why do peer review?  Why are there organizations that exist just for peer review?  These are questions we should know the answers to because we are practicing physicians and we review our fellow physicians. Here at CIMRO, we do reviews for a few different reasons, including:
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• A hospital may request peer review of a case that had a bad outcome.
• A hospital is interested in the performance of an individual provider.
• A hospital is looking for systems issues that can be fixed to provide the best, evidence-based care.
• A facility may ask us to review routine care to establish a pattern of quality: EKGs, mammograms and x-ray interpretation are part of what we review.
• Patients may request reviews when their insurance companies deny payment for services or medications. In these cases, peer review acts as a mediator between two contracted individuals or entities. These decisions are binding. In general, they cannot be appealed or changed.
  

Part of being a good peer reviewer is understanding your role. You are the expert. You are the judge. You are being asked to confidentially evaluate another practitioner’s care in regard to quality. We should think of ourselves as trusted colleagues who will openly and honestly evaluate other colleagues’ care. This can be intimidating for all parties involved. No one wants to be judged and found lacking. We are a competitive lot. We strive for perfection. However, we all make mistakes. Usually, those mistakes are errors of bias such as anchoring bias or, sometimes, group think. Other times, there are system failures that lead to error. However, there also are incompetent providers who need focused education to improve their practices.

​How you answer the questions posed to you about each individual case will affect ongoing medical care. Will the provider continue to practice in the same way? Is further education needed? Are there systems that need to be changed in the hospital or clinic? Perhaps your decision will support the current practices of the physician or insurance company.

Your answers also will lead and shape insurance policy and decision making, help a patient get the care needed, or force a particular practitioner or facility to change their practice. We have an important job at CIMRO because each and every review could affect not only local practices, but regional practices through insurance company policy. This is a good thing. We can help hospitals, physicians and insurance companies provide the best evidence-based and accepted practices.

Hopefully, we are doing our homework, too, basing our decisions upon evidence-based studies and guidelines. CIMRO asks you to provide literature and data to support your argument for any case. This support should also be directly cited within the body of your report. Simply directing the reader to an article is not good enough. Pulling direct quotes or statistics from the articles you cited is helpful to give your review power of persuasion as well as truly educate your reader, whether the reader is the insurance company, the hospital quality-control officer or the physician herself.

Quotes instill trust in the quality of your review. They show it is not just your opinion; rather, the opinion is widely held within the specialty of medicine and supported by data. The quotes do not need to be long. They can be from UpToDate, a textbook or a recent article you read. They do need to be current, relevant and educational to the subject of the review.