The Problem of Bias
Until recently, the definition of a peer for peer review purpose was based on the historical notion of a peer. A “jury of one’s peers” once meant a jury composed of persons who personally knew both the defendant and the community. These peers were assumed to be better able to determine the truth of the case than persons who did not know the participants and their history. The legal system gradually rejected the use of knowledgeable peers because of the problem of bias. The courts shifted their concern with the jurors’ knowing the facts of the case to a concern that the jurors would let their prejudices for or against the defendant affect their ruling. Contemporary court rules allow the exclusion of jurors who know the parties or any facts of the case. Concern for bias is forcing peer review committees to make the same move to the uninvolved peer.
Bias has always been an issue in peer review. Until the Congress passed the Civil Rights and the Equal Employment Opportunity Acts, women and blacks were routinely excluded from medical staffs. It would be naive to assume that such forbidden criteria have been eliminated from all peer review decisions. Physicians with unconventional practice styles or uncollegial personalities pose a difficult problem of balance. Whereas it is unreasonable to expect every physician to behave in the same way, unconventional practice styles or personality problems may be evidence of substance abuse or psychological impairment. Peer review activities should not be conducted by physicians with outspoken biases against either the individual being reviewed or the aspects of the individual’s practice that are being reviewed.
Peer review has always had an economic component. Hospital medical staffs tried to balance the needs of the community with the economic interests of the existing staff. Sometimes this meant preventing new physicians from starting practice in the community, but as often it resulted in efforts to encourage physicians in needed specialties to set up practice in the community. As physicians and hospitals have been forced into competition, economic biases have become a major confounding factor in peer review activities.
In most communities, physicians practicing the same specialty are either in business together or are competitors. In large cities, physicians and hospitals compete with their geographic neighbors. This competition is exacerbated by the blurring of specialty lines. As the number of physicians in a community increases, subspecialists often practice general medicine to supplement their incomes. General medicine physicians and others cross specialty lines to offer lucrative procedures such as liposuction. The act’s requirement that hearing officers and panels must not be in “direct economic competition with the physician involved” seems to preclude traditional peer review committees composed of physicians in the same specialty or practice area who practice in the same community as the physician under review.