Peer Review: The Mandate for Physician Leadership

By Timothy E. Paterick, MD, JD, MBA
February 10, 2022

Physicians working in hospitals face challenges when it comes to understanding and meeting the medical, legal, and ethical subjects outlined in the hospital bylaws. Hospital staff physicians and the hospital administration both aspire for high quality medical care and the assurance of patient safety. Unfortunately, when quality concerns surface, there can be reasonable differences of opinion as to whether a physician’s practice pattern met the accepted threshold of the standard of care. Such differences of opinion can lead to conflict that fuels a physician review.


One complication for physicians is that many of the issues that surface at peer reviews is veiled in legal concepts and underpinnings for which physicians lack education, training, and familiarity. It would be prudent for all physicians working in hospitals to become familiar with the hospital bylaws and regulations.

Physicians must take a leadership role in assuring fair and equitable peer review. Physicians are thrust into the world of peer review without the education and training in the legal and ethical principles that are inherent to a fair and trusted peer review process. Physicians must comprehend that the purpose of peer review is to “evaluate professionally a colleague’s work.”

In medicine, colleagues define peer review.” An honest and fair peer review process is the staple of an excellent medical staff. During a peer review, the reviewing physicians must pursue all the relevant facts and determine their veracity. Typical allegations against physicians are practice patterns that do not meet the standard of care or behavioral patterns that do not meet the accepted behavioral standards of the hospital. Medical staff members reviewing a colleague must proceed in a fair and honest manner. A fair and equitable peer review process is essential for a hospital that wants high quality medical care and a safeguard for patient safety.

Organized medicine employs the peer review process as a methodology to gauge professional activities and conduct. Physicians have an ethical and moral responsibility to each other and to patients to assure all hospital practice patterns meet the standard of care. The peer review committee must allow physicians the right to exercise freedom in their medical judgment but ensure that the medical judgment is accepted and consistent with the national standards of care. Disciplinary hearings where a physician’s reputation, professional status, or livelihood is at risk must be objective and fair. To be objective and fair, the hearings must include the following:

  • A list of alleged wrongdoings.

  • Adequate notice of the right to a hearing.

  • The right to defend one’s actions.

Reviewing physicians that have a similar scope of practice as the physician under review. All reviewing physicians must disclose any conflicts of interest and recuse themselves when conflicted for any reason. The hospital bylaws and administration must ensure safeguards that guarantee all physicians due process when enduring a peer review.


The importance of a fair and equitable peer review process is never so self-evident until a physician is the subject of one. The birth of peer review conceptually started with Ernest Amory Codman. He was an extraordinary surgeon at Massachusetts General Hospital who was ahead of his time. His true passion was the science of quality improvement. Codman was a surgeon who believed that by prospectively tracking outcomes, we could learn from patient results and advance the field of medicine. He helped develop the concepts integral to present-day morbidity and mortality conferences and started the first national registry in American healthcare.

Given the challenges of medicine today with ever increasing rates of errors and wide variability in quality, many physicians are requesting that Codman’s basic tenants be revisited and applied. Codman described patient tracking in a publicly circulated pamphlet in 1914: “Every hospital should monitor every patient it treats long enough to determine whether the treatment has been successful, and then inquire ‘if not, why not’ with a review to identify root causes of failure with a view to preventing similar failures in the future.” The approach to peer review today had its seeds germinate in the early 1990s when the American College of Surgeons implemented peer review to define the standard of care requirements to be met by medical staff physicians. The peer review process today includes a peer review committee composed of staff physicians who report to a board of directors. The crucial decision-making authority is the board of directors after an examination of the peer review committee’s judgment regarding the charged allegations. As envisioned by Dr. Codman, this peer review process is required by JCAHO for hospital accreditation.


Peer reviews may be instigated in US hospitals for several reasons. It is expected that hospitals will initiate a peer review of physicians requesting hospital privileges to determine whether the physicians have the necessary education and training to perform the requested privileges. A second basis for peer review is the allegation that a physician is practicing below the standard of care. A third reason is that a physician is acting outside the boundaries of normally accepted hospital behavior. A fourth reason for a peer review is the random selection of cases to improve the overall quality of patient care. Lastly, a peer review may be prompted by adverse outcomes to determine the root causes of errors and develop processes to prevent future adverse events. Across the United States, the lack of a standardized peer review process has allowed varying decisions for similar alleged wrongdoings. This lack of standardization is a major issue that must be confronted by physician leaders.



Excerpted from: Physicians and the Law: The Intersection of Medicine, Business, and Medical Malpractice, by Timothy E. Paterick, MD, JD, MBA, MS





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