This is the first in a two-part series about how to provide constructive criticism to your hospitalist peers.
Part of improving your performance is learning from other hospitalists on a regular basis. You can do this through observation or discussion, and—when appropriate—by offering or receiving constructive criticism.
There are two types of physician-to-physician constructive criticism: When discussing perceived poor handling of a patient’s case, comments should take place within a formal peer review. Concerns about a physician’s non-clinical performance, such as communications problems or lack of availability, can be handled in a one-on-one conversation. Herein we’ll examine the peer review process; next month we’ll take a look at how and when to give constructive criticism to a peer informally.
Why Use Peer Review?
When a hospitalist notices a colleague’s clinical error or lack of judgment, it should be addressed in the program’s next peer review meeting, both for legal and procedural reasons.
“The key thing to understand is that ‘peer review’ offers certain protections for physicians and their colleagues,” explains Richard Rohr, MD, director, Hospitalist Service, Milford Hospital, Milford, Conn. “Ordinarily, if I discuss [another physician’s] case and render my opinion, then—in principle—if that patient were to file a lawsuit, they could subpoena me to testify about what I thought about their case. In the past, this had a chilling effect on peer review.”
Due to state laws passed years ago, peer review meetings now offer protection against subpoena. “Peer review meetings are protected,” says Dr. Rohr. “They can’t be used in court, and this makes it possible to have an organized peer review where you look at physicians’ work and provide an opinion about that work without fear of being drawn into a legal situation.”
The bottom line: “If you want to talk to another physician about their case, do so within [the peer review structure] so you’re legally protected,” says Dr. Rohr.
Focus on Improvement
When discussing a specific case or physician, remember that the reason for doing so is to improve quality of care. “Every practice should sit down, look at specific cases, and talk about possible areas of improvement,” says Dr. Rohr. “You need to take minutes of these meetings that are marked as confidential.”
The key to improvement is having an open discussion in each peer review meeting. “A good meeting is educational,” says Dr. Rohr. “The objective is to support each other and improve performance. A lot depends on the attitude that people bring to it. You have to not be afraid to say something; you must be willing to express opinions, or you’ll have a wasted meeting.”
Sometimes you may find that the problem goes beyond a single physician’s actions on a case. “If there is a problem with a case, find out whether it’s an aberration or if the problem needs to be addressed,” says Dr. Rohr. “Some things are not a physician’s fault, so much as [they are] signs that a medical system doesn’t work as effectively as it should or [that there is] a general lack of training. For example, an ER [emergency room] doctor misses a fracture. Was finding that fracture outside his competency? Does he need training reading X-rays, or can you manage to get radiologists in to check X-rays fast enough to become part of the process?”
Use a Set Structure
It’s up to the hospital medicine program director to set up a peer review process, which should be done within the structure established by the hospital. Peer review meetings “should be done on a regular basis,” advises Dr. Rohr. “How often depends on the volume of the program, but a typical group should meet monthly. You’ll probably look at three or four cases, which is a reasonable number to cover in one meeting. Look at unexpected mortalities or complications—you have a responsibility to the public to examine these.”
You might do best by bringing in an outside facilitator for the meetings. This creates an impartial atmosphere for discussions. “We bring in an external facilitator from a local teaching hospital,” says Dr. Rohr. “It’s good to have an educator lead the meeting; someone from academia will have a greater fund of knowledge and [a stronger] grasp of the medical literature, which helps bring the discussion to a more educational level. Everyone respects medical science.”
Note that the facilitator may need to be credentialed as a member of the medical staff in order for the proceedings to be protected from legal discovery.
“Peer review is difficult in smaller practices, because everyone knows everyone and they may be uncomfortable addressing problems,” explains Dr. Rohr. “Here, it’s especially helpful to have a leader from the outside who can render opinions and get everyone to chime in and render their own opinions.”
Remember that your peer review system is reportable. “As part of the hospital’s peer review structure, you’ll have to report findings from the meetings,” adds Dr. Rohr. “If someone is showing a pattern, these things have to be trended. Do they need training, or should they be dismissed?”
Giving Feedback through Peer Review
When you participate in a peer review discussion, don’t let your comments get too personal or subjective. “The most important thing is to keep it professional and make it educational to the greatest extent possible,” says Dr. Rohr. “Reference facts in the medical literature as often as possible. Point to something that’s been published to support your opinion. Base your comments on what’s known, and apply that to your analysis of the case.”
An evidence-based opinion doesn’t have to cite specific details; as long as you’re aware of major papers on the topic, you should have a grounded opinion.
Finally, as a physician participating in a peer review discussion, think before you speak. “Peer review works best when you have a basic respect for each other, as well as basic humility,” he says. TH
Jane Jerrard has written for The Hospitalist since 2005.