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- William W Parmley, MD, MACC*
- ↵*Send correspondence to: William W. Parmley, MD, MACC, Editor-in-Chief, Journal of the American College of Cardiology, 415 Judah St., San Francisco, California 94122
Peer review is the “hallowed” bedrock for review of grant applications. Although it is not perfect, it appears to be the best system available. It requires reviewers who 1) are unbiased experts in their field, 2) have no relationship to the applicant, and 3) have no conflict of interest. Potential conflicts of interest might occur if the reviewers are from the same institution(s), working in a similar area, or have conflicting views on a research topic. In this case, they might absent themselves from a review or discussion of a given application.
When we consider manuscripts for JACC, the same considerations apply. We want reviewers who are expert, unbiased, and have no conflict of interest. We ask reviewers to declare any potential conflict of interest, which helps us judge their reviews. Sometimes, authors will point out the potential conflicts that some reviewers have and ask that they not be used.
Generally, in the above two circumstances there is no financial conflict of interest. That is, the reviewer will not lose or gain money depending on the results of the review. There is another circumstance, however, where peer review involves big financial stakes. This is peer review of clinical performance, which can potentially lead to loss of income or job, depending on the outcome.
As chairman of the ethics committee of the College, I have recently received detailed notes, depositions, and case reviews from hearings in which a charge of clinical incompetence was raised against three different members of the College. The three circumstances are eerily similar. The accused are either solo practitioners or in a small group working in a private hospital. A large cardiology group at the hospital appears to be the moving force behind the accusations. Furthermore, one member of the accusing group is the chief of cardiology, and others have positions on the hospital executive board or committees. In reviewing all of the materials, it is unclear to me whether this is unbiased peer review or an attempt to eliminate some of the competition.
Each of the accused has had clinical privileges suspended during the investigation, and is required not only to have expensive legal counsel but also to find other peer reviewers around the country who would be willing to provide independent review. In general, the charges are for doing too many catheterizations, interventions, or echocardiograms. Sometimes the allegations relate to misinterpretation of tests or to poor clinical judgment.
Two examples are worth noting here. In one, a physician is accused of doing too many caths in a given patient. In the hearing the accuser and reviewer of the clinical material is questioned by the accused physician. Despite the accusation, it is clear that two of the alleged catheterizations were, in fact, NEVER DONE. Thus the physician was accused of doing catheterizations that did not exist. There is a strong sense as one reads this material that this was NOT careful peer review but a competitive hatchet job.
Another example is informative. A cardiologist is accused of misinterpreting caths and echocardiograms and performing too many, etc. in 37 patients. The hospital reviewers conclude that the standard of care was not met in 26 of the patients. An outside reviewer brought in by the hospital concludes that 18 patients did not meet the standard of care. Four outside expert reviewers from around the country, who were contacted by the accused cardiologist, found that the standard of care was met in all 37 patients. After reviewing the cases, I would concur with the latter view. Unbiased peer review or competitive hatchet job? The human tragedy in all this is that two of the three cardiologists lost their privileges and had to move. The third was cleared of wrongdoing but still suffered tremendous financial losses.
Are these isolated cases? As I have explored these cases and talked to different individuals, it seems probable that this scenario is far more common than is appreciated.
What can we do to prevent a miscarriage of justice? First of all, we must appreciate that peer review may uncover physicians who are practicing below the standard of care, and may thus help protect the public. On the other hand, how do we protect a physician who is accused primarily to reduce the competition? In the past, the College has wisely stayed out of local issues and politics. There are neither the resources, personnel, nor time to carry out such reviews. Maybe, however, it is time for the College to create ways to help. Perhaps a list of qualified physicians who would do this for free (1) or for minimal reimbursement is needed. This may be the only way to get peer reviewers who are qualified, unbiased, and free from conflict of interest. One thing is certain, this problem will not go away, and it is likely to get worse. I am interested in your comments and suggestions.
- American College of Cardiology