Correcting the practice styles of errant physicians.

Eugene Margolis, MD, head of the catheterization laboratory at Garfield Medical Center, Monterey Park, Calif., has stated, "I have people who work at our lab that, if I had the power to say, 'You stop,' I'd do it. Either they are too nervous, they don't have the experience, or they don't do that good a job." He went on to say that, "Unless something is really gross, it's hard to get doctors to stop doing what they're doing, to take away their privileges. We don't have anybody that bad." [1]

Phillip Caper, MD, of Dartmouth Medical School describes this lack of professional accountability as an "epidemic timidity" characteristic of doctors and hospitals who "resist taking systematic responsibility for the social implications of their clinical decisions." [2] Physicians do what they feel comfortable with because of their training and experience.

But what about the physician who may not have kept up, or the physician whom others believe practices "bad medicine," but who denies the accusations? Some physicians may not have enough variety of cases to maintain invasive skills. How does the senior clinician learn newer technologies, and how does the rest of the staff deal with requests for privileges based on newly acquired skills? There is the problem of the physician who has been counseled about unsatisfactory practice methods and for whom no improvement has been noted. These are very difficult issues for a physician executive to deal with, and there isn't a great deal of information available on how to handle them. Adding to the difficulty is the clear lack of valid, scientific information on what constitutes appopriate, effective care. [2] Most physicians view any outside assessment of patient care as an affront to their training and credentials or as an attack on their very livelihood. Doctors are trained to think quickly and independently and to trust their judgement. They back away from quality assurrance (QA) systems because they view them as being high risk.

The birth of "peer review" as quality assurrance came from congressional interest in cost control for Medicare patients. At the same time that professional standards review organizations, the precursors of peer review organizations, were pressing "peer review" for cost control reasons, another form of "peer review" was gaining momentum--review of medical care in connection with unsatisfied patients who filed malpractice suits. Even the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has changed its rules and procedures frequently. In 15 years, it has promoted systems for medical staff evaluation varying from audits to focused audits to monitoring and evaluation--first a 9-step, then a 10-step process. And the task still isn't done! Dennis O'Leary, MD, President of JCAHO, maintains that the most visible part of his "Agenda for Change" is to devise methods to "gather meaningful data about clinical care and management." [3]

Finally, physicians have little understanding of due processes in the review of patient care apart from those that deal with privileges. Most simply do not know how to make the transition from a collegial discussion of cases to an appraisal of a physician's capability to practice medicine. There is confusion and hesitancy as to how exactly to proceed with the necessity of modifying another's practice style, technique, or capability. No wonder, with all these considerations, physicians don't want participation in or ownership of QA systems.

A major problem with the profession's stepping away from QA is that consumers are becoming more sophisticated and are demanding higher quality. They are pressing the profession toward attention to QA in uncomfortable ways: increasing demands for public accountability and/or the filing of malpractice suits. Physicians can no longer afford to be inactive in managing the practice patterns and the styles of their colleagues. There is tort law precedent that we are responsible for the practice of our colleagues. The medical staff must monitor that practice and evaluate it. [4] Also, the reporting requirements of the Health Care Quality Improvement Act demand filing of notification of any action on privileges in effect for more than 30 days to the National Practitioner Data Bank. [5]

What, then, is the process that should be in place to empower the staff to do what Dr. Margolis believes he cannot do?

* Quality assurance must have professional ownership.

* Standards of care must be established.

* A substantive process of patient care evaluation must be defined.

* Peer review must focus first on the best care possible to patients.

* Professional review has a procedural due process and is designed to consider privileges.

A clear separation between peer review and professional review has been urged. [5] Peer review is patient-specific, factual, positive, and nonthreatening (does not have sworn testimony). Professional review is physician-or privilege-specific, factual, confrontational, negative, and high-threat (may involve sworn testimony). With the above understood by the staff, any issue that arises regarding either patient care or physician privileges can be placed into the following process framework [5]:

1. Select peer by agreement. Each member of the medical staff should know in advance who will hold them accountable for practice style and competence issues and should agree to that person holding them accountable.

2. Establish the standard of care. It is only as physicians hold each other accountable that they add to the body of knowledge for medical quality and establish standards of care. It may not be easy, and there may be considerable room for opinion, but the staff must set the limits on what they are willing to live with, both prior to treatment (practice guidelines) and in retrospective review (standards of care).

3. Ensure that provider and peer agree. In the absence of agreement, the departnemt or the medical staff as a whole should decide, perhaps even by vote. There may be a need for outside consultants to render an opinion. However, there must be a decision; it is inappropriate to defer a decision because there is controversy. The bylaws of the hospital should state how controversy is resolved. Ultimately, the chief of the medical staff is responsible for the decision.

4. Perform oversight review by departmental QA committees and the executive committee of the medical staff. It is at this level that the legitimate function of the medical staff in monitoring, evaluatin, and ensuring the quality of care is documented. Here, too, the process of collegial patient assessment may move to professional review of privileges, and the credentials committee may be involved if privilege modification looms as possible.

5. Track and perform scientific method analysis of the outcome of the review. If there is no modification of privileges, the event must be noted and tracked so that it can be referred to in the reapplication for privileges. This is required by the JCAHO standard on "performance-based privileging." [6]

Had this five-step process been incorporated in the medical staff bylaws at Garfield Medical Center in the example at the beginning of this article, Dr. Margolis might not have had problems in the angioplasty lab. With a program such as this in place, Dr. Margolis would have the backing of the medical staff and some outcome-and process-oriented data with which to modify practice styles. He could then recommend to the executive committee or to the chief of staff that a provider may need more experience, more proctoring, more training, or even privilege modification (perhaps no angioplasty privileges). Should his recommendations not be concurred in by the committee or the credentials function, he would at least have done what the profession expects of him. The medical staff as a whole has accepted accountability and responsibility for the outcome from the cath lab. The provider in question has been monitored and evaluated by the medical staff and found acceptable to practice. Differences of opinion and judgment do not mean care failed to meet the standard.

Winkenwerder has noted that changes in U.S. health care are more significant now than at any previous time. [7] The physician-patient relationship has been transformed into a contractual one where the physician provides a specified, measurable service at a negotiated price. Our responsibility as physician members of this medical/industrial/governmental complex, Winkenwerder states, is to keep alive those parts of the profession and the system that should be retained. Peer review (personal accountability to the members of the profession) must be retained as patient-specific continuing education. It must not be given over to system analysts, auditors, and paraprofessional personnel. It is the essence of our accountability.

John R. Sharp, MD, FACP, USAF MC, is Chief of the Medical Staff (Director of Hospital Services) at the Air Force's largest hospital, Wilford Hall Medical Center, San Antonio, Texas. The opinions expressed in this article are those of the author and are not necessarily those of the Department of Defense or the United States Air Force.

References

[1] "Big Fees Draw Poorly Trained Doctors to Angioplasty." San Antonio Sunday Express News, July 23, 1989, p. 13-A.

[2] Caper, P. "Solving the Medical Care Dilemma." New England Journal of Medicine 318(23):1535-6, June 9, 1988.

[3] O;Leary, D. "The Need for Clinical Standards of Care." QRB 14(2):31-2, Feb. 1988.

[4] Corleto vs Shore Memorial Hospital, 138 N.J. Super 302, 350 A 2nd 534 (1975).

[5] Sharp, J. "Returning the Queen of the Professions to Eminence, an Enhancement of Peer Review." Journal of Quality Assurance 11(2);4-9, April-May 1989.

[6] Joint Commission on Accreditation of Healthcare Organizations. Accreditation Manual for Hospitals. Chicago, Ill.: Joint Commission, 1989.

[7] Winkenwerder, W., and Ball, J. "Transformation of American Health Care: The Role of the Medical Profession." New England Journal of Medicine 318(5):317-9, Feb. 4, 1988.

Further Reading

The following additional sources of information on peer and professional review were obtained through a computerized search of databases. Copies of the articles cited are available from the College for a nominal charge. For further information on citations, contact Gwen Zins, Director of Information Services, at College headquarters, 813/287-2000.

Berwick, D. "Peer Review and Quality Management: Are They Compatible?" QRB 16(7):246-51, July 1990.

Desch, J. "Qualit Assurance as an Information System for an Era of Increasing Accountability." Topics in Health Records Management 10(2):33-44, Dec. 1989.

Molinet, R., and Halpenny, C. "Peer Review and Quality Assurance." Journal of the Florida Medical Association 76(4):410, April 1989.

Warner, C. "Peer Review in Quality Assurance." HMO Practice 3(5):178-82, Sept.-Oct. 1989.