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COOKING BOOKS?
TRILLION DOLLAR COVER-UP?
HOSPITALS CALL IT PEER-REVIEW!
Are our hospitals any different from ENRON and WORLDCOM in their proclivity
to hide the truth? Doctors are supposed to keep the medicine clean by
performing "peer-review" on each other and taking actions where they find
problems. But in many hospitals, the power elite (administrators and
physicians acting in concert) simply use this system to hide the mistakes of
their friends.
For a long time, the medical establishment has argued that the doctors can
only review each other with honesty and candor if such reviews are protected
from the public eye. Most states have bought this argument in a gullible
fashion and have enacted laws that protect these reviews from being publicly
questioned for accuracy and effectiveness.
Politically powerful doctors can easily do unnecessary surgery or make
serious medical errors. They simply get reviewed by their colleagues in an
"understanding" manner. However, if you do not have the political clout but
simply practice good medicine, the same secretive process is used to
blackball and eliminate you.
Abuse of peer review is more prevalent than admitted by the medical
establishment. It has serious adverse effects on public health but nobody is
paying any attention to this problem. The Center for Peer Review Justice is
one of the concerned organizations (www.PeerReview.org).
This situation needs to be addressed quickly and effectively in order to
reduce medical errors, control malpractice costs and promote public health.
This nation can not afford to pay 1.4 trillion dollars per year and still
spiraling, medical price tag for long.
By RON A. VIRMANI; M.D., F.A.C.O.G.
"Reduce the medical errors", was the public outcry in the 1970's and 1980's.
Big malpractice awards were sounding alarm for public and politicians alike.
The medical establishment took the stand that there existed a few "bad
apples", who were causing most of the problem.
"Leave it to us", the establishment said, "We are going to establish a fine
system of 'peer-review'. We shall review our colleagues with utmost 'candor'
and throw out the bad apples". "But", they argued, "We can only do our work
with honesty and candor, if our decisions can not be challenged in a court of
law and the reviews are not open to the public. Otherwise these "bad apples"
will sue us."
With a strong leap of faith in the medical establishment (i.e. hospitals
and doctors entrenched in it), all states enacted stringent laws protecting
peer reviews from public disclosure and scrutiny. The Congress enacted the
Health Care Quality Improvement Act (HCQIA) of 1986, giving peer-reviewing
doctors and hospitals immunity from damages. Sen. Ron Wyden (D- Oregon)
authored the 1986 law that created the National Practitioner Data Bank
(NPDB), which was established to blacklist the "bad doctors" so that after
committing malpractice, they could simply not cross state lines and set up a
new practice.
But the medical errors have not gone down! Fifteen years have passed
since then! Institute of Medicine (IOM) reported in November 1999 that
98,000 patients die each year because of medical errors. St. Paul Insurance
Company reports that the rate of malpractice claims has remained steady over
between 1990 and 1999. In case you did not notice, we are in the middle of
malpractice crisis once again, right now. Malpractice premiums are rising.
The national medical bill is 1.4 trillion dollars and on the upswing. Where
did things go wrong? Does this peer-review driven system of catching errors,
educating and disciplining doctors and throwing out the "bad apples" really
work as promised by the establishment? Or is it merely a smoke-screen for
some doctors to maintain lucrative (but short on quality of care) practices
at the expense of their more conscientious colleagues who actually practice
good medicine? Is the stated objective of public good being seriously
compromised?
Let's see how the system is supposed to work. After any patient is
discharged from the hospital, the quality assurance (QA) nurses check the
chart to see if aberrations have occurred. If not, the chart is filed away.
Otherwise the chart is flagged and goes to the "peer-review" committee of
physicians. This committee checks to see if the physician attending the
patient met the standard of care. If not, the attending physician is
questioned, counseled, disciplined, suspended, terminated depending on the
seriousness of medical error. Largely, peer-review is meant to be a learning
process so that the medical errors are caught and all doctors are educated in
order for patients in future to get better care. But this is also where
doctors can play out their personal politics of favoritism, prejudices and
turf-wars!
First, who are these doctors that are reviewing their colleagues? Are
they somehow tested and proven to be better qualified than those they are
reviewing? Do they have the necessary integrity to judge others? Are they
dispassionate? Not really, in most cases, they are simply the "favorites" of
the administrators. Chances are that they are "stale, pale, male", who bring
in a lot of patients, surgery, and money to the hospital. They and the
hospital lie in the same economic bed. They and the hospital share strong
motive of profiting from keeping control of the medical practice in a given
community. They form the "inner sanctum" and closely guard against
"outsiders" using whatever means necessary. They may have a substantial
conflict of interest in doing a proper peer review.
Secondly, are these reviewers honest in reviewing their colleagues? Can they
objectively critique their friend who is simply a part of their everyday
professional and social life? Who often refers to them? Who they play golf
and dine with? On the other hand, can they be fair to one who just came into
town and who may be taking some of their patients away? An inadvertent
competitor? How about one who has this funny accent about him? Or different
shade of skin? Can these doctors rise above their personal and professional
ties, prejudices and insecurities to uphold the standards of medical
profession, as they assure the public?
The third factor is why should they expend time and effort on this
thankless job? The reviewers can simply gloss over the charts, do a
perfunctory review. In fact, the department of ob-gyn, of which I was a
member at that time, at Presbyterian Hospital, Charlotte, circulated a memo
in April 1995, admitting euphemistically:
Overall, our (peer-review) process has been very relaxed these past few
years.
Finally, the fact is that managed care has shrunk the size of the monetary
pie to be had, so it is a doc-eat-doc world out there! If I can review you
and eliminate you before you even get a chance to review me, I can be way
ahead in the game.
The manner in which many, if not most hospitals, set up their peer review
committees is by including those physicians who have maximum political clout,
not those who are better doctors. For these peer reviewers to criticize
other politically powerful physicians who are making medical errors would be
to commit professional hara-kiri. Of course, the reviewers can not afford to
do absolutely anything either. Citizen groups are watching, they have to do
something to "show" and make themselves look good in the public eye.
Given all these factors, it is very easy to see that the reviewers set up a
double standard of covering up the real mistakes of their friends and
exposing their politically vulnerable colleagues for non-substantial, flimsy,
clinically insignificant, bogus and fabricated reasons.
If they accept you or if you are part of the "inner circle", meaning
politically powerful, they simply look the other way if you make mistakes.
Chances are that your charts may never be peer-reviewed because the
administration, through the "understanding" quality assurance nurses, can
simply let these charts slide by. However, if you are a competitor but/or do
not belong to a powerful group, gender or race, full fury of the peer-review
system may be unleashed upon you.
Behind the smoke screen of every one physician targeted by sham peer-review,
there are a dozen physicians whose medical errors are quietly shoved under
the rug! Therein lies the real source of threat to public health as well as
injustice to those individual physicians, who become sacrificial lambs. The
system goes to great lengths to create an illusion of public protection,
while it is really protecting the establishment, by hiding medical errors of
the politically powerful physicians. The basic concept that an elite group
of physicians who depend on each other and the system for their bread and
butter, will demonstrate enough courage to criticize and discipline other
members of their elite group, is plain ludicrous. If they did, they would
threaten their own survival because their own medical errors would come to
surface. (I use the word "elite" here because of their social power not
because of their superior medical skills and judgment).
NATIONAL PRACTITIONER DATA BANK:
This data bank was created with much fanfare by the Congress in 1986.
Public perception was created and persists to date that somehow all the bad
doctors would end up in the data bank and all the good doctors outside. U.S.
congress Rep. Tom Bliley (R) has now introduced a bill to open up NPDB to the
public.
But as elucidated above, one's entry into the data bank simply depends on
his or her political connections. As with everything else in life, there is
an extreme double standard here. If you belong to the larger subset of
physicians who constitute the "country club", you will be protected by your
colleagues from being disciplined. Or that your penalty will be so chosen
that it does not get reported to data bank.
However, if you belong to the other subset of physicians, who are bright,
conscientious, good defender of public health but lack social connections,
you may be thrown into the bank as a scapegoat for minor and non-substantial
infarctions. Medical establishment has the power to make you look like a
monster lurking in the dark. They kill two birds with a stone, they
eliminate you for reasons of their whim as well as they get a "notch" in
their belt, show the public they are being guardians of public trust.
Nothing is more hypocritical than that.
I believe that the information entered into the data bank is so
incomplete and biased regarding physicians in general as to be of any help in
stating with much confidence whether a physician is competent or not. The
federal General Accounting Office reported in November 2000 that NPDB
contained information that is incomplete, inaccurate or both. It is
well-accepted that there is a low rate of reporting of "real" problem
physicians to the data bank. A report by the Inspector General of the
Department of Health and Human Services said that in the last decade, 84% of
HMO'S and 60% of hospitals never reported a single "adverse action" to the
government. It should therefore be obvious that, the bill introduced by Rep.
Bliley is not going to give the public any meaningful insight into a
physician's competence, rather a false sense of security when they do not
find a doctor's name in the bank.
The consumer groups continue to want more entries in the data bank. Sen.
Ron Wyden has said that the low level of reporting was unacceptable. While
they are rightfully concerned with the low number of the overall entries,
they should also be concerned with the fact that many of these entries are
"forced" upon good doctors! They should also be concerned with the
political, unjust and high-handed process by which these entries are
generated to appease the public demand. And with the fact that peer-review
process is controlled by the power elite in largely a mob fashion!
Here is an example. If 5 doctors assert that a woman should have a
hysterectomy for no medical reason but for their obvious financial reward and
one doctor disagrees, the lone doctor can be branded incompetent and cast
away into the data bank. From then on, he is falsely perceived by the public
as a bad doctor. He is headed for oblivion! There is no process of check or
balance against such a sham peer review.
The chance of finding good or bad doctors is about equal either inside or
outside the data bank! While I consider myself a well-trained, competent and
humanitarian physician, my paper trail in the data bank would convince any
potential patient to run away at the sight of me!
SUMMARY:
Effective medical peer review is (or rather can be) the ultimate
protector of public health! However, in its current secretive form, it
invites abuse. There is much reason, as elucidated above, to believe that
peer review is practiced more in its corrupt form rather than for its
original established purpose.
The Congress had devised peer review and NPDB as the way to reduce
medical errors and keep the medicine safe from the public. However, they
entrusted the establishment, the hospitals and the established doctors, with
the process. They thought that the system would catch its own errors and
reform itself. Well, as it turns out, the system is not such a saint! The
situation with medicine today is reminiscent of the days when scientists of
cigarette companies did their own research and declared that cigarettes did
not cause cancer!
By and large, the people sitting in the review-committees themselves are
interested in the bottom line- more surgery and more hospitalization. But to
make a showing that they are doing something in the direction of "reducing
errors", they hang their more conscientious colleagues and the ones who may
be better guardians of public health. The "bad apples" are thus throwing out
the "good apples". Dr. Charles Silver of Dallas, TX, has therefore said that
the "noble act" (HCQIA of 1986) originally intended to monitor problem
physicians, has gone totally in the opposite direction and, in many cases,
decimated fine careers.
Dr. Gerald Moss wrote in The American journal of Surgery" in 1994:
Our better (usually younger) surgeons increasingly are placed in jeopardy by
the unchecked ignorance and/or malice of their established colleagues.
The establishment has thus thwarted the intent of Congress. As columnist
James J. Kilpatrick points out in his column, their "candor" in review may be
a camouflage for "cover up". Once the hospital has thrown out the
conscientious and the competent physician/s under the false label of "bad
apple", the rest of the doctors can "play while the cat is away". They can
do unnecessary surgery with impunity, hide each other's mistakes, and
generally forget about the public good.
If patient care is to reign supreme, this problem must be tackled and solved.
AMA, state medical boards and societies, JCAHO and other concerned entities
need to look into this matter seriously. However, it may ultimately rest
with the Congress to do something about it.
In February 2000, President Clinton announced an initiative to improve
patient safety and reduce the number of medical errors by 50% over the next 5
years. I believe that the following needs to happen to meet that goal:
1. The hospitals need to stop playing favorites with some doctors at the
expense of others and public health. ALL members of the department
should review the medical charts on a round-robin basis. That would be more
democratic, would it not? No administration appointed group of physicians
should tower above the rest and abuse its power. The same should go for all
hospital committees that control various functions. The way some people have
all the power all the time, is the root of all corrupt practices.
2. Secondly, laws need to be put in place for independent and unbiased
"external review". The external reviewers, when employed, should have no
vested interested in the outcome of the review. This option should be
available to the reviewed physician. But, some of the so-called independent
"external" organizations are simply "guns for hire", we need to watch out for
them
3. American Medical Association envisions an "oversight committee" in each
state to prevent abuse of peer-review process. This will serve as a check
for sham peer reviews, avoiding local politics and conflict of interests.
Some states, such as New York, have an oversight mechanism needed for the
check. However, there is no mention of the "oversight committee" in the
recent report of AMA..
4. JCAHO and the medical boards should not just sit around in the face of
calamity of justice. Conspiracies like the one in my case are far too
common. They are not rare exceptions. Vital public health interests are at
stake. If the hospitals can force physicians to review others with complete
dishonesty, they can also force them to do more cesarean sections and
hysterectomies. The economic interests are so powerful, mere power of
suggestion from the administration will do.
5. The hospitals should be required to show that they have reviewed everybody
in a similar fashion and nobody is being doled out a disparate treatment.
6. Some measure of judicial scrutiny is necessary for the peer review process
to be honest, fair and beyond reproach. It is ludicrous to trust the
administrators of hospitals with the altruism of defending the public. The
job of the administrators is to make money. The strange concept of the need
of a process to be completely hidden from public eye in order to achieve
public good needs to be reexamined. Secretiveness invites abuse. The courts
need to abandon their "hands-off" approach of today, public health is not
just the realm of medical conglomerates, and the little man should be heard.
7. Finally, there is nothing in today's regulations that forces the hospital
to do effective (non-perfunctory) peer reviews. The hospital can merely make
a showing that they are doing something and get away with it. This situation
needs to be remedied.
With these measures in place, the peer-review and NPDB will have the
desired effect of reducing medical errors and protecting public health. By
bringing honesty into medical practice, they may well reduce unnecessary
surgery, reduce medical costs and save lives. The congress and states need
to take urgent steps to recognize this trillion dollar Enron and clean up the
peer review process. And to say the least, the media needs to promptly bring
this matter to public attention!
Ron A. Virmani, M.D., FACOG
Board Certified Obstetrician and Gynecologist
4626 Charlestown Manor Drive
Charlotte NC 28211
704-362-2240 (P)
Email: RVBABY1@YAHOO.COM
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