By RON A. VIRMANI, M.D.

"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. National Practitioner Data Bank (NPDB) 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. 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?

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 and vendetta!

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 "buddies" 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 surgery, admissions and keeping control of the medical practice in a given community. They form the "inner sanctum" and closely guard against "outsiders" using whatever means necessary.

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 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.

Of course, the reviewers can not afford to do absolutely anything either. Citizen groups are watching, they have to show some places where care was not optimal.