Robert Marder's Peer Review Monthly: 13 Angry Men

Some of the most dramatic movie scenes involve a jury deliberating the fate of a defendant. In fact, the 1957 film “12 Angry Men” was set almost entirely in the jury room. But what if the screenwriter had decided to place the defendant in the jury box and allowed him to comment while the jury argued about the case and determined his fate? We would think that something is terribly wrong with the script.

I pose this scenario because I recently received the following question regarding how to handle a potential conflict of interest during a peer review evaluation: If a case comes before the peer review committee to discuss and assign a rating, and the case involves a member of the peer review committee, does that member:

1. Remain in the room to discuss the details of the case?
2. Get asked to leave the room when it is time to assign a rating?
3. Take part in the entire process, including discussion and rating?

That’s a trick question because the best answer is none of the above. Any practitioner, not just a member of the committee, should not be present during either the discussion or the rating of his or her case. This would be akin to a defendant sitting in a jury room. And yet, The Greeley Company consultants see this occurring in many peer review committees. Why do some medical staffs consider this a reasonable approach, but any layperson would be surprised—if not aghast—with this script?

This misconception most likely has its roots in the evolution of peer review, which started as morbidity and mortality (M&M) conferences. During these conferences, the basis for learning required the practitioner to be present so that he or she could explain the case and receive feedback. But, as we discussed in the December 2008 issue of Medical Staff Leader Connection, M&M conferences are no substitute for peer review. Peer review committees must eliminate, or at least minimize, conflicts of interest through clear polices that are always adhered to even if it seems inconvenient or not collegial because the practitioner happens to be a committee member.

How should committee members respond when a member’s performance is under review? The first step to inform the practitioner in advance when the committee will discuss the case so that he or she is not caught off-guard and embarrassed. The committee chair should do this (rather than by support staff) out of courtesy and respect. The chair should also remind the member of the committee’s policy that requires any members who are under review to be absent from the decision. During that discussion, the chair should also ask whether it would be more convenient for the member if the committee discussed the case toward the beginning or end of the meeting.

The peer review committee should approach cases involving members the same as they would for non-members. If your policy states that the peer review committee will write a letter to a practitioner under review asking for an explanation, then it should use the same approach for the member. When the committee discusses the response, again, the member cannot be present.

By the way, if your policy allows for a practitioner to attend the meeting to provide a response, then the policy should limit the practitioner (or the member) to responding only to the committee’s questions; the committee should ask the individual to leave during its discussion of the response.

If your medical staff policies allow practitioners to be involved in the review of their own cases, perhaps it is time to re-write that script. One of the most important ways the peer review committee can maintain the credibility of the peer review process is to effectively manage conflicts of interest.

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