To the Editor:—
Edbril and Lagasse’s article 1tends to imply that their method of “structured peer review” is more accurate and reliable in detecting deviations from accepted standards of care than the legal system. Edbril and Lagasse offer their method to the legal system to assist it in its determinations:“If peer review could aid the legal system as a means of detecting deviations from the standard of care, it would offer the advantages of being more applicable to judging clinical competence and more justifiable in compensating injured patients.” Their assumption of the accuracy of such a system makes it appropriate to examine the basis for this assumption, and, in addition, makes it worthwhile to consider the purpose of peer review.
Their system categorizes each and every untoward event into one of a small number of categories of “error.” Is such a system truly accurate? Are we always able to categorize every event? Are not some events simply not able to be assigned to any category? A similar article by Liang 2suggests that there is more than one opinion on this subject. In Liang’s study, twelve clinical scenarios very similar to Edbril and Lagasse’s “narrative of the events” were reviewed and evaluated by 11 faculty members at a Harvard teaching hospital with an average of 15.4 yr of experience. Approximately, one in five of the evaluations was, “Can’t Tell.”
A “Can’t Tell” evaluation is not unexpected given the uncertainties present in all medical care and given the enormously reduced data sets being evaluated by the two groups of anesthesiologists. Recall that meetings of the peer review committee in Edbril and Lagasse’s are reviewing “abstracts,” sometimes prepared with the assistance of the anesthesiologist(s) involved, sometimes not.
The extraordinary element in Edbril and Lagasse’s article, however, is the misunderstanding of the peer review system that it promotes. Traditionally, the role of peer review has been the prevention of untoward events in the future. Anonymity is guaranteed the participants to permit them to freely discuss cases that they might otherwise feel inhibited in discussing for fear of accusation and blame: all in an effort to prevent future harm to patients. 3To change the emphasis in peer review to fault finding and calculating patient compensation will have a profound chilling effect on this process. How many patients will suffer in the future because potentially useful lessons derived from the peer review process are lost because of fear and dishonesty promoted by a draconian spirit of crime and punishment which would now enter this process?