Letting Your Hair Down After Reviewing Your Peers

   I entered a room in the bowels of the hospital marked “administrative conference room.” It was 7 a.m. on a Friday. I usually have a cup of coffee and read a book at that hour. There was a coffee pot and some bagels but the reading material was patient charts stacked at one end of the table.    All physicians are invited to participate in chart review but it is a tedious and often unpleasant task generally known as peer review. Three of us showed up on this day. One was a young OB-GYN who has been with us for a year. One was a urologist who has been here about eight years and is known for his serious, no-nonsense approach to peer review. I had to be there as chief of surgery in order to sign off on the group’s decisions. Two quality management nurses presented the cases.    We reviewed charts of cases with adverse outcomes or where the standard of care may have been breeched. Our job was to determine if the outcome were unavoidable or if it was due to poor standard of care. Our findings and recommendations could seriously impact a colleague’s medical career. That is why few physicians respond to the call for volunteers for peer review activity.    The nurses began presenting cases. Questions came up about which test or X-ray physicians should have ordered and whether physicians should have sought a consultation. The physicians scoured the chart notes to try to determine the thought process of the attending surgeons. This is where poor handwriting and scant documentation can get a doctor in trouble.    In the end, we established a critique of the case based on the standard of care and the outcome. We also made recommendations for further corrective action if needed. In the worst case, temporary suspension of privileges could occur. In most cases the doctor explained his or her rationale for management of the case and no action was necessary. In some cases, we requested further written explanation. Most physicians cooperate with this process but some take it as a personal insult to their skills. Two hours of chart review is more physically and mentally taxing than a day of clinic. I was glad to head back to work where I only had myself to judge.    I couldn’t help but reflect on the cases I had reviewed and the surgeons I had evaluated and judged that morning. I wondered how some of my care plans would be perceived in a peer review setting. I admired the urologist for his clear insights and objectivity in judging his peers. I also wondered if he had a wild side where he could cut loose and shout out subjective comments and critique. It turned out that he does.    The local medical society has a yearly summer picnic for doctors and their families. Since we are a small community, podiatrists are welcome to become members of the group. Our summer picnic was that Friday after work. The members of the society and their families boarded a chartered bus, and we went to Seattle to see the Baltimore Orioles beat our beloved Mariners.    I sat next to the urologist at the game. He had subjective value judgments about every player on either team. He stood and shouted his concerns about a Baltimore player’s broken bat. “Check it for cork!” he screamed as his wife tried to calm him down. “That guy’s batting average will never equal his weight,” he screamed about a Seattle player who struck out in three pitches.    I was seeing a whole other side of my peer review colleague. The outbursts were punctuated with trips to the refreshment stands for beer, deep fried chicken nuggets and garlic French fries. The usually docile Presbyterian internist who sat in front of us was eating a barbecued beef concoction with fries and the required $8 pint of beer. He didn’t stand and scream but would occasionally remove his iPod earphones to acknowledge an event on the field. He was listening to classical music.    The combined smell of the garlic fries, deep fried chicken nuggets, beer and barbecued beef was all too similar to puppy vomit. More importantly, my seemingly too serious colleagues were having fun. I enjoyed seeing the wild side of the physicians who conduct themselves in such a serious and professional manner in the hospital setting.    Most of the doctors happily snored on the two-hour bus ride back to Centralia. The urologist still wore his ball cap inside out and sideways, which he always does when the Mariners lose. Dr. McCord (pictured) is a Diplomate with the American Board of Podiatric Surgery. He practices at the Centralia Medical Center in Centralia, Wash.