Call ’em like you see ’em: Should physicians be allowed to appeal case reviews?

Have you ever see what happens during a baseball game if the batter disagrees with the umpire? Although umpires aren't always right, to keep the game moving, players are not allowed to contest every call. If the player persists, he or she is thrown out of the game.  However, if there’s a close call on a home run, players have the opportunity to hash it out with the umpires and even ask for a video review of the play.

In my experience as a consultant, the peer review committee’s scoring of individual cases should be like the umpire’s ball and strike calls. A client recently asked me, “What steps should the peer review committee take if a physician questions a decision or wants a second review because he or she strongly disagrees with it?” Many physicians feel that unless they have the right to appeal a decision, the medical staff is not treating them fairly. So what is the fairest way to handle this issue?

While to some, the answer is to allow physicians to appeal peer review findings, like in baseball, allowing physicians to appeal without limits could undermine the credibility and usefulness of a good peer review committee. Thus, the peer review committee should set limits as to when a physician can appeal.

The first thing to consider is whether the peer review committee solicited the physician’s input before making a decision. If the peer review committee, by policy, is allowed to make a decision without physician input, then an appeal mechanism should always be available to physicians. However, The Greeley Company strongly recommends that peer review committees do not make any decisions without receiving the physician's input first, so long as the physician provides it promptly.

The second thing to consider is the nature of the committee's decision. If the committee simply decides whether the care a physician provided was appropriate, but it takes no action against the physician's membership or privileges, then the physician should not be allowed to appeal. This approach is consistent with the philosophy that peer review should be an opportunity for improvement rather than punishment. If the committee feels that the physician could have handled the case better based on the available documentation and the physician's response to their concerns, the learning opportunity should not be ignored based on the physician’s appeal. However, if the finding causes the peer review committee to restrict the physician’s membership or privileges, then the physician should be allowed to appeal based on the due process rights outlined in the medical staff bylaws.

Oftentimes, physicians choose to appeal a peer review committee decision, not because they disagree with the specific finding, but because they do not want an adverse finding on record. (Have you ever appealed a traffic ticket to avoid a scar on your record?) Unfortunately, allowing physicians to appeal a peer review committee’s decision to avoid marks on their records undermines the principle of peer review. It obviates the practice improvement opportunity and hinders the peer review committee’s ability to track physician practice trends. Physicians should not be concerned that a single peer review finding appears in their records because the medical staff did not take action against their membership or privileges.

Physicians should have the right to request additional review if he or she believes that the committee did not have enough expertise to make a decision regarding his or her performance, or if the physician feels that a member of the committee had a conflict of interest.  However, this should not be an automatic. Rather, the medical staff body that oversees peer review, typically the MEC, should seriously consider such circumstances. If the MEC comes to the conclusion that the physician’s concern is legitimate, then it should either assign additional reviewers or obtain external peer review. The Greeley Company does not recommend that the MEC review cases unless the peer review committee has recommended corrective action because it politicizes the peer review process.

Robert Marder, MD, CMSL, is vice president of The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.