Peer Review: Why Doctors Can Get Away With Unnecessary Surgery

Astonishing news about the latest allegations of fraud in heart operations raises some troubling questions about the time-hallowed process of medical peer review in hospitals. If physicians decide which cases to review and what to do about them, and if hospitals stand to lose millions if any doctors are found guilty of wrongdoing, who's looking out for the patient? The short answer: no one.

Mark Midei, former head of the cardiac lab at St. Joseph's Hospital in Towson, Md., and former head of the hospital's cardiology department, has been accused of placing stents in 600 patients unnecessarily and falsifying records. He denies wrongdoing, but the hospital has contacted the patients to tell them that they might have had the stents inserted without a medical justification. A class-action suit has been filed against the hospital, nevertheless.

Why didn't the peer review committee at the hospital discover what was going on before an employee lodged a complaint? An investigation by Maryland regulators found that "the hospital's peer review process permitted Dr. Medei, as chair of the cardiology department, to select cases, including his own, for peer review." While St. Joseph's has since changed that process, a similar policy is most likely in effect at many other hospitals across the country.

Over-use of cardiac procedures, including stents, is also common at many institutions -- and in some cases, fraud is suspected. The Maryland Health Department is investigating a second, unnamed hospital, according to the Baltimore Sun, which also fingers two hospitals that have stent volume that's 20 to 30 percent above the state average. Meanwhile, another Maryland cardiologist, John R. McLean, was recently indicted for allegedly placing stents unnecessarily in hundreds of patients. Last year, a Louisiana cardiologist was sent to jail in a similar case.

Healthcare observers will also recall that several years ago, a brace of cardiac surgeons in Redding, Calif., were charged with performing unnecessary heart operations. Tenet Healthcare (THCO), the big for-profit chain that operates Redding Medical Center, ended up paying nearly half a billion dollars to settle federal and civil lawuits, and the surgeons also paid hefty fines. But while they were barred from performing surgery on Medicare, Medicaid, or Tricare (military) patients, they didn't lose their medical licenses. In a settlement with the California Medical Board in 2009, heart surgeon Fidel Realyvasquez was placed on probation for three years but was allowed to keep practicing medicine.

What lies at the heart of these disheartening developments is peer review -- or the lack thereof. Even when physicians find fault with a colleague, they're reluctant to take action against him for at least three reasons: First, they're afraid he might retaliate against them; second, the hospital doesn't want to discipline the doctor for fear of a lawsuit; and third, many doctors feel that they themselves could make the same error that the physician under review made. Midei, for example, has supporters who say that his aggressive use of stenting might have reflected judgment calls or personal differences with the guidelines.

But in fact, we can't have every physician deciding how he or she wants to practice, regardless of the evidence or the consensus of peers about what is medically justified and what isn't. To the extent that the deficient peer review process allows that to happen, all hospitalized patients are in jeopardy. As for office-based care, that's largely left up to state medical boards to police. As the low number of sanctions against doctors shows, they aren't doing a very effective job, either.

There's no easy solution, because doctors insist on being judged by their peers, rather than non-physicians who don't understand medicine. But once again, changing how doctors are paid could be part of the solution. If expensive surgical procedures were a cost center, rather than a profit center, they might be performed more judiciously.

Image supplied courtesy of Flickr.
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