Legitimate vs. sham peer review (SPR): Is there a difference?

For an introduction to SPR, click here. For a history of SPR, click here. 

When summoned for a peer review, how can you tell if it’s a sham? The biggest clue is whether the peer review process seems intended to help or harm you. If you feel sincerely supported by colleagues and the peer review proceedings are uniformly applied throughout your practice, you have less cause for concern. However, even practitioners who have never felt threatened by hospital administrators, medical staff, or colleagues can be targeted without precedent.

Here are some situations, circumstances, and personal qualities that make you more vulnerable to a bad-faith peer review:

• You are a woman, person of color, immigrant, or member of a marginalized group.
• You work in a highly competitive environment, like academia, or in a rivalrous community.
• Your department has a new chief or leader.
• Rumors of mergers, decreasing reimbursement, or declining patient load are circulating.
• You have a prestigious pedigree that could be seen as threatening to others, even though it likely led to your hiring.
• You are the only person being summoned.
• The meeting targets you for something routinely practiced by other physicians.
• The response seems out of proportion to the event cited.
• You have previously exposed unethical practices, patient safety issues, or financial fraud in your work environment.
• You have spoken up in defense of another colleague.
• When you request specifics, you receive responses like “The details aren’t important” or “We don’t have time for that now.”
• Someone recommends you undergo a neuropsychiatric evaluation or questions your mental stability.
• You have ideas that conflict with established medical beliefs in your setting.
• You mention contacting your lawyer and are told, “Oh, this is no big deal. Don’t bring a lawyer in,” or “We’re going to keep this local. A lawyer won’t be needed,” or “Lawyers aren’t allowed to be present.”
• You have worked in the setting for a long time and haven’t published in a while.
• People you consider friends or allies are now mute or seemingly against you.
• The word “disruptive” is used to describe your behavior.
• You feel paranoid or unsafe, sensing that something is awry or atypical.

Legitimate peer review seeks to uplift the health care system, including practitioners and patients. Sham peer review aims at character assassination of the practitioner. In a recent article, Arthur Lazarus, MD, MBA, explains: “Character assassination refers to the deliberate and sustained effort to damage someone’s reputation or credibility through false or misleading accusations, innuendo, or manipulation of information. This can be done through various means, including spreading rumors, exaggerating faults, or attributing malicious motives to someone’s actions. The goal is often to undermine the individual’s standing, influence, or career.”

Peer review has long been established to scrutinize professional conduct, promote professionalism, and maintain trust. Physicians are subjected to peer review when applying for a job, often as a regularly scheduled component of maintenance of certification, and as a standard part of The Joint Commission’s credentialing of health care centers.

In medicine, The Council on Ethical and Judicial Affairs (CEJA) has two primary responsibilities:

• Maintaining and updating the American Medical Association’s (AMA) Code of Medical Ethics.
• Promoting adherence to the Code’s professional ethical standards.

According to the AMA Principles of Medical Ethics: Fairness is essential in all disciplinary or other hearings where the reputation, professional status, or livelihood of the physician or medical student may be adversely affected. Individually, physicians and medical students who are involved in reviewing the conduct of fellow professionals, medical students, residents, or fellows should always adhere to principles of a fair and objective hearing, including:

The AMA Principles of Medical Ethics also assert that physicians should work together to ensure that medical societies and institutions with which they are affiliated provide procedural safeguards for due process in their constitutions, bylaws, and/or policies.

The problem is that medical staff bylaws, hospital policies, and institutions are not standardized. Today’s corporatized medical system functions to favor hospital administrators, boards of directors, and investors. Power structures are maintained under the guise of “quality patient care.” Although peer review is routinized, its methodology is not standardized–therefore, it is readily manipulable for abuse or personal gain.

Earlier this year, at an AMA meeting, Reference Committee G was dedicated to addressing peer review head-on, concluding: “Despite the attempts to make these systems safe and confidential, and the fact that employed physicians are protected from retaliation by state and federal laws, there are often still barriers that prevent physicians from reporting concerns without fear of retaliation in some form and/or seeking adequate recourse if a bad-faith peer review process is initiated against them. Peer reviews in medicine will continue to be a mainstay in ensuring safe and ethical patient care is provided by competent physicians. When conducted appropriately and according to acceptable standards, peer reviews are a valuable tool for the health care system. The conduct of bad-faith peer reviews, however, is morally, ethically, and professionally abhorrent and runs counter to everything that physicians and the practice of medicine stand for.”

This statement confirms the AMA’s recognition of the current lack of enforcement of state and federal laws meant to protect and support physicians subjected to SPR. However, the AMA also says it opposes any changes to current laws. These contradictory positions make it abundantly clear that the medical establishment is well aware of the prevalence and harm of SPR, is spinning webs to keep everyone confused, and is unwilling to change to actually protect physicians and prevent SPR from occurring.

Tracey O’Connell is an educator and coach who fosters positive self-worth, psychological safety, emotional intelligence, and shame resilience among physicians, teens, and LGBTQ+ individuals. She is a certified facilitator of expressive writing programs and Brené Brown’s research. Her change of direction came after many years of feeling “not enough” as a person, physician, parent, or partner. Tracey has found that expressive writing allows us to access our true selves, helps us gain self-trust and self-compassion, and ultimately leads to a more authentic and wholehearted way of belonging in the world. She is also an advocate for universal, affordable, fair, safe, and equitable medical access, education, and practice. Since 1992, she has lived in Durham/Chapel Hill, NC, where she began her medical career in radiology and musculoskeletal imaging, training at UNC-Chapel Hill and Duke University.

She can be reached on her website, LinkedIn, Facebook, Instagram @fertile__soul, and YouTube.