Jerrod Bailey 00:11
Welcome everyone to Reimagining Healthcare a New Dialogue Between Risk and Patient Safety Leaders, presented by Medplace. We're excited to bring you conversations with top risk and patient safety thought leaders from organizations across the country, please subscribe to get the latest news and content. And if you find this valuable this episode, please share it with your colleagues. We're trying to create meaningful dialogues here in your community and others. And if you're interested in participating as a guest, please email us anytime at speakers@Medplace.com. I'm Jerrod Bailey. I'm the CEO of Medplace I'll be playing host today. And today I'm joined by Dr. Hassan Vader, assistant professor at Rutgers University, and internal medicine faculty at Monmouth Medical Center in Long Branch New Jersey, Dr. Bader recently published an article very topical for us, titled clinical peer review a mandatory process with potential inherent bias in desperate need of reform. That is quite the title of Dr. Bader. Welcome. Thanks for joining me.
Dr. Husam Bader 01:16
Thank you, Jerrod, thank you for having me.
Jerrod Bailey 01:18
I have to say, we deal with this a lot here at Medplace, the companies that approach us to do things around peer review, or sort of already recognized some of the things that you that you brought up in, in this article. And, and so really appreciate you joining us and helping us kind of unpack, what is, what's the what's working, what isn't working? What are the current problems? And how can we sort of assess the peer review process? Looking forward? How does peer review 2.0 Look, to those of us who sort of recognize some of these things that you brought out? So, I'll just kind of start there. Right. So, what is the current state of peer review at most hospitals? What's working? What isn't working just based on your experience or your research?
Dr. Husam Bader 02:07
Yeah, absolutely. Jerrod? I think what's definitely working for peer review now, as we have it in every hospital, it exists. Yes. Mostly because it's a mandatory process. But it's almost like this expensive China, every household owns. It's there, it's sitting there, but I'm not sure how much use and benefit we're getting out of it. And that's the depressing part to clinical peer review is that we absolutely have them, we absolutely have to have them.
But it's really not living up to its potential. And that's what got me involved in that process is it truly need to maximize the benefit of clinical peer review? I think from my own experience, I think the areas where we really lack and clinical peer review, are two things are probably three things. One of them, ironically, is the lack of standardization, because clinical peer review was created to maintain and make sure that the standards of care are met, and that the care that patients receive as standardized, but as a process that is not it's really very loose, and it's up to the hospital, or to the clinical setting to decide how to come up with that process. The other thing that I really felt was a challenge as to how passive that that process is. A lot of times it does exist, we know it exists, but you don't really hear about it, you don't really get any feedback from it. And in that way, it does feel appear that the
Jerrod Bailey 04:01
no, go ahead. Yeah, that's interesting.
Dr. Husam Bader 04:02
I think something I found online is while I was doing my mind my manuscript, my article, it seems that 65% of the physicians felt that the clinical peer review process was not helpful. 30% did not know it existed in their hospital. And that's why I called it passive. Is it really not? It's not out there. It's not doing what it's supposed to be doing. And the reason why I call it punitive is when you have any contact with it. It doesn't feel that it's really doing what it's supposed to be doing and root cause analysis or quality improvement, but rather unfortunately, pointing fingers to what went wrong and who's at fault, which was never the intent of, of the process.
Jerrod Bailey 04:59
They're there to increase the quality of our delivery of care. And, when I talk to physicians that are in, hospital settings where, where it's done really well, it the culture embraces peer review, it's seen as like we're a team, improving ourselves and moving ourselves forward in there's a really deliberate and obvious state of feedback loop that comes back. And it's shared with everyone. And that's like, I've seen it done really well. That is definitely the exception to the rule, what you're saying, and we're all human, is, if I never get any positive feedback from if I don't see the data, actually improving any systems. And if I if I only ever feel it's punitive when it happens at all. And that's the majority of our experience, that's a system that really is begging for some sort of, reformation right.
Dr. Husam Bader 05:56
100%, I think what ends up happening as we have two ways of clinical peer review, we have the focus, and we have the ongoing peer review. And the focus is obviously when something when the bad outcome happens, and you have to look into it, we're really lacking when it comes to the ongoing which is evaluating the work without having to have a bad outcome. And this is a really strong source of feedback that doctors can take back and they can improve on their quality of work. But when it's only happening, when a bad outcome happens, that's when it feels punitive. And obviously, doctors will become defensive, they will become just unhappy with the process, because they feel like they're really being blamed. And I do feel like we've deviated from the, from really the purpose of that, that process.
Jerrod Bailey 06:52
I can see why it's a problem, especially when you don't get COVID. Everybody is has been redlining, everyone's got more work and more hours than they can, realistically handle anybody, this has all been happening even before COVID. But going to being proactive, just as a day to day and in taking, doing peer review across the going to every everything, not just when bad things happen, takes resources, it takes to your point earlier a system, and then standardization and process and a commitment to it. And it probably also takes a cultural shift. Right.
Dr. Husam Bader 07:33
Yeah.
Jerrod Bailey 07:36
We'll probably get into some potential solutions here in a second, too. But did you finish your list? I heard kind of three missing things. One was standardization. One was the process being passive and not proactive.
Dr. Husam Bader 07:49
Right. And then the last one was how physicians perceive it as punitive, rather than a utility of feedback. Yeah, and that really just circles back to how we're using it. Nowadays, yeah,
Jerrod Bailey 08:05
That's great. So what why is this topic even interesting to you? I mean, it sounds like you've been studying what
Dr. Husam Bader 08:11
I'm actually interested from. And honestly, that's something that I was thinking about, I do think it's part of this professional maturity that we go through as physicians, because as a medical student, really, most of your focus is on the human body, how it works, what can go wrong, how you fix it. But as we evolve, we get more involved in the more realistic aspect of healthcare you get, you become more familiar with insurance, what insurance can provide and cannot provide prior authorization. The economical aspect of healthcare, the medical legal aspect, and I think that's was just for me part of this maturity, because a lot of times you will, we've all encountered doctors being blamed for something that happened, whether it's my colleague, or sometimes even by a nurse, and the process to help evaluate that that event is really through clinical peer review. But when you find that, that process not to be up to par, that's when things get a little difficult.
Jerrod Bailey 09:30
What sorts of things have you seen in your practice? Or maybe you've seen other colleagues go through it that are sort of like obvious disconnects, right and in like, we had a conversation before about like, just being reviewed by someone who's not going to your peer level and or even a specialist in your in your specialty area, like what is that? What does that look like? Are there other sort of common sort of pitfalls that you see? Regional Hospital soon?
Dr. Husam Bader 09:58
Yeah. was one of the things that not only I saw in real life, but I also found that many physicians agree with that when I was doing my literature review, as I suggested, those committees, clinical peer review committees are available that every hospital because it's a mandate. But when you look into who is actually serving on those committees, a lot of times it's mostly the grand majority are not around physicians. And those are the ones who are evaluating the decision making of the physician.
So for example, when you have a hospitalist, and you're looking into an event that happened, but he's being reviewed by a nurse, whose expertise is in pediatrics, how much can you really trust that opinion. And when it comes to physicians versus nurses versus physician assistants, everyone really has a strong role in, in patient care, but the scope of practice, the depth of knowledge is really different. And even for me, as a physician, as an internal medicine physician, I can't really go and evaluate and OBGYN physicians work I, I can't tell you, I have enough expertise to judge on the standard of care. It's not that I have no knowledge, I graduated medical school, I rotated through OBGYN. I'm tested on it and exams, but I can't say I can truthfully judge on the standard of care. However, you still see, sometimes nurses or physician assistants or nurse practitioners, who part of that committee will tell you, this is what went wrong. However, they do lack the understanding and the depth of knowledge to evaluate that process.
Jerrod Bailey 12:01
If that's all in your response to something bad having happened, and we're already like, on our back heels, that this is, at best a punitive process, or maybe, worst opinion process, at best, it's a neutral move. And then, as a physician with years of study and expertise in a certain specialty to sort of be reviewed by someone that that isn't at parity with that. I mean, that's got to just sort of, be an automatic dysfunctional sort of, effort there. So, so, what's it like to be peer reviewed, by a peer? Like, how does that how's that received? I'm just curious, emotionally, if you've gone through both, and that's night and days type of thing.
Dr. Husam Bader 12:48
It's not easy Jerrod to be evaluated or to evaluate a colleague, especially when you're doing it within the same hospital. Because even if I'm evaluating a case, at the end of the day, I know, it's probably a colleague who was involved in that I might not know who exactly that colleague is. But it's going to be someone that I work with, that I see every day. And that gets tricky, because you always want to give an unbiased opinion. But if you know someone you're likely close with, or a colleague of yours, how much how unbiased can you be? We're all human. And that's, and that's difficult. And that's if you're the one who is evaluating if you're being evaluated or peer review. That's even more tricky, because now you're being critiqued, you're being criticized. And we're all human beings. And as physicians, we do take pride in what we do and how we do it. And just being told that you can improve upon something or being critiqued is not always taken positively.
Jerrod Bailey 14:03
Yeah. So that's even part of the system, right of how peer review can be improved is how, how can you remove that bias? How can you take out these sorts of very personal in difficult to untangle relationships? Because this might be my partner or my competitor that I'm being reviewed by or that I'm reviewing, right? How are we sort of knowing that and how can we how can we mitigate that, right? And that might mean doing more external or independent reviews, that also might mean training the reviewer on how to give constructive feedback, right versus something that because this is always going to be hard right, getting some kind of feedback. So I think these are all system changes that that could be considered and shifting percent.
Dr. Husam Bader 14:49
I definitely agree with you. There are multiple layers to this and there are multiple biases that we need to be working towards eliminating and One of them is knowing who is who you are evaluating or potentially knowing. And that can go either way, if it's a colleague of yours, you probably don't want to give in favor of an unfavorable opinion. But if it's a competitor of yours, you might be a little bit too harsh. So it goes both ways. And yeah, it's multi layered. And we need to be working towards this. But yes, one of them as, really, as you said, training and getting the environment that would facilitate the person not to be biased.
Jerrod Bailey 15:34
That's great. Well, bias is a really interesting word in you bring up some, you bring up bias specifically in in your article, and I'd love to unpack some of that, right. So, there's, there's multiple types of biases that you're using the right word that you're using, or that you're pointing to, what are those?
Dr. Husam Bader 15:58
So, honestly, Jerrod, there are so many types of biases, or let's call them cognitive biases. And the two that I was stressing upon in my article that I think are relevant to clinical peer review, are the outcome bias and the hindsight bias. And those two I think, are very common with gamstop process of clinical peer review, or even things that are related to this, like mortality and morbidity or root cause analysis. We have to be cognizant of those. And it's a very tricky topic, because just being aware of it or talking about it is not enough to eliminate it, we have to be really doing more. And that's why kind of came in the article and was connected to the, to the discussion of part of it.
Jerrod Bailey 16:53
Once Great. Well, so let's unpack some of these. What is hindsight bias just to kind of pick one? What is that? And for those who don't know? And
Dr. Husam Bader 17:01
yeah, yeah, and honestly, Jerrod, if, if you're talking about any cognitive bias, generally, the easiest way to describe it is a subjective reality. And if I'm going to talk about the hindsight bias let me actually give you an example that I go through almost every other week, that's the easiest way for me to, to just describe it. I have a cousin that I'm really close with, and these kinds of an IT marketing kind of guy, but really into stocks and cryptocurrency and every now and then I'm talking to him over the phone, he would say something you would like to mention the stock or like a coin and say, I think it's going to double is like Husam I think it's going to double. And you'll go on. And he's like, I looked at the company, and they looked at this, and they look at the chart, and he'll be talking about how he's very sure it's going to double. Granted, Jerrod, he doesn't buy or invest into the specific stock or the specific coin. Fast forward, like two or three weeks, it actually doubles. And he will always say the same thing to me. He would say “I knew it. I swear I knew it”. And in my head, I'm like, “you could not have truly known this. Because if you did, you would have invested” and it's such a tricky concept. Because really the way the way I would talk about hindsight bias is knowing the outcome, now that you know the outcome, it makes you exaggerate the likelihood of having known the events beforehand.
Jerrod Bailey 18:50
Okay, so something bad happened. Now I'm being reviewed, but they know the outcome. So knowing that as they're looking through the medical record, and what happened there, what does that what does that look like? So what's How's, how's that hindsight bias playing out there,
Dr. Husam Bader 19:05
Right, Let's say, a patient comes in, and you're doing a lot of tests or a lot of imaging, and in a day or two about the outcome happens. Then I'm reviewing this, and I look at the outcome, and I'm like, Wow, this patient passed away. And then I look back at the events. And now because I know that outcome, I know the outcome, I would probably exaggerate or I would have this delusion that I would have known that this happened. And I wouldn't be looking at the labs. I'm like, Oh, you see this was a little bit high. Had I seen this? I would have known that the outcome would be bad. And that's really easy, because I'm looking at things in retrospect. Yeah. But this is not how clinical practice happens. We don't look at things in retrospect. Phil looked at things in foresight. And that's the tricky aspect of it is, is this delusional? Clarity weekend, as we look at things in retrospect that yes, I would have known I would have expected that to happen.
Jerrod Bailey 20:19
Yeah. And I can see how that would then lead into reinforcing peer review process that feels punitive when there's a lot of, Monday morning quarterback, type of, hindsight bias. And this is really, related and tied to outcome bias as well, right, knowing what the outcome was? Sure, you kind of point to that as a as another type of bias.
Dr. Husam Bader 20:41
Yeah. And that's, as I said, it's really tricky, because the differences are a little bit subtle. But when we talk about outcome bias is the simple fact that you do know the outcome, it makes you judge the whole process. So instead of looking at the process, looking at how a lead to be lit, to seal it today, instead of evaluating that part, you would look at the outcome and say, Wow, I heard about outcome. So this process must have been really about. So you're not evaluating how you got to the outcome, objectively, but rather, looking back at it, and judging it solely by knowing the outcome. Interesting. And the point I really want to bring up, Jerrod, because this might not be very clear as those are really unconscious things that we do. It's, you don't go into a case and saying, I want to have outcome bias, or I want to have this type of bias. This is not how it happens. It's, it's really unconscious. And a lot of times, we're not aware of it.
Jerrod Bailey 21:55
It's a really hard thing to do is overcome our bias of knowing what happened, and then being able to change our approach. So what have you seen? Or are you suggesting any solutions, any of these things? How are our others approaching solutions? Or have you, do you have any suggested suggestions for those listening?
Dr. Husam Bader 22:18
Yeah, we, in that article, we really did not want to just bring up the problem, we really wanted to also brainstorm and think of solutions, some of the things that we came up with, and actually have been really supported in the literature is one of them is blinding the outcomes. And the way it happens is, you're given the case to evaluate. But you don't really know the outcome. So it could have been just a really good outcome, or nothing bad did happen. Or it could be a bad outcome, obviously. But as you blind the outcome, are you really forcing the person who's evaluating to go through the clinical scenario, the same way it happens, real life the step by step without knowing how things are going to pan out. And then every step for you actually evaluate, you see where you're at? Am I on the right track? Because that's how we practice. So planning, the outcome would force people to go into the foresight mode, rather than the hindsight mode.
Jerrod Bailey 23:30
It's interesting that you say that, because we do blind reviews here. And it absolutely plays out that way. Going to it's, the reviewers like, well, this, this all looks pretty good. There's nothing that sort of jumped out, right? And then all of a sudden, they'll find out oh, and then going to patient died at the end of this. And then it's like, Oh, okay. All right, well, now knowing that it's just really fascinating to watch the, the change in problem solving, posture and things like that once they know the outcome.
Dr. Husam Bader 24:03
And I honestly wish more people did it that way Jerrod, because it really changes things and it will help overall preserve that quality because if it becomes a process where we're just pointing fingers, nothing's going to happen. But if we're doing it for the quality improvement aspect of it, I think we will improve
Jerrod Bailey 24:28
so they might suggest to going to risk managers and others who are listening to this and patient safety quality people try peeling off a percentage of your peer reviews today if you're not doing it already and doing them as blind reviews, or take a percentage you've done in the last year and run those back through a peer review process maybe using completely different people or outside resources and just see if you're if you're getting different data points and different conclusions from that. That might help calibrate what kind of the how much of this, these different types of biases or arch affecting your system in general, right.
Dr. Husam Bader 25:07
And I think Jerrod, the other thing is just to kind of go off of that point as most of the institutions that I looked into, do clinical peer review only when a bad outcome happens. This is really dangerous. Because how many times do we, as physicians make a bad decision or an unwise decision, but we get lucky, and there's no bad outcome. And we just lucked out. Great point. And yeah, and if we're really not evaluating cases, without a bad outcome, we might miss those specific instances, that can later become a bad outcome in another case. And that's why I really hope organizations would get more engaged and not only focused on code peer review, but the ongoing part of it is take cases where nothing bad happened, where it was a good patient admitted that or went home, sometimes you might be able to pick up on something that could have potentially been dangerous, and avoid that happening. In other cases,
Jerrod Bailey 26:17
every malpractice carrier that's listening to this right now is beating this drum in a thrilled to hear this, because, they're, they're usually at the end of the line after bad things have happened right now that they're, running with claims and lawsuits and things like that. But what if there were better systems further upstream, that were really aimed at, not just not just when bad things happen, but, accounting for when they're not happening, and when there's just, we're just getting lucky. So really, really, really great points. Well, there's we talked about how, this, by the way, is there any other potential solutions that you want to highlight? Now, I obviously will link to your article for those folks who want to hear anything else top of mind for you.
Dr. Husam Bader 27:07
I mean, one other thing that I was also thinking about as just as we eliminate biases, I think the first step is getting an unbiased reviewer. And by unbiased, no personal connection, no financial advantages to, to reviewing, obviously, physicians will always be compensated when they review a case. But in certain cases, they are the way they are really reimbursed. Can push them in a certain direction. So just having this controlled environment, or the reviewer of the reimbursement can probably help the process overall, we have
Jerrod Bailey 27:57
You know, depending on the review type, we use standard language with our reviewers, that just helps catch them and what's really helpful here, right. And, for example, one of those language types is, is, this physician is not being indicted, there's this is not punitive. This, this process, and this particular review, the most helpful review is just what is, the actual, observational facts of what happened, what's the good, what's the bad, right, and in being able to create a balanced sort of view, not trying to sway one way or the other just did an actual honest clinical assessment. And because in our cases, at least, the reviewers don't know each other. And there's, that we don't have that bias component, it's a pretty liberating process to be able to come in and go, Okay, let me just look at this. And assess. And, and because it's two peers, that also helps to write making sure that, if you're being reviewed at somebody who would respect it's, it's like, if you were reviewing your peer, what would you what kind of helpful review would you provide to them? That's kind of what your expectation would be getting back. Right? And if you can make those things work, I think it's, I think it's a it's a pretty magical combination. We do a lot of technology here. I don't know if you have any opinions on what technology's role is in peer review, but have you considered it is
Dr. Husam Bader 29:25
there anything there? Slightly, I think I haven't really consider that till COVID. Hit us. And if I'm going to give COVID Any.
29:38
I'm going to give it any silver lining.
Dr. Husam Bader 29:41
The silver lining through the is how normalized using things like zoom or virtual meetings and even like us today, Jerrod, like you're somewhere on the West Coast, somewhere on the East Coast, and we're still having this conversation. I don't think this was as common for call Then the rest time we move towards solutions like this, because if we're going to limit ourselves within our own environment within our, like 10 mile radius, how much resources can we really get, versus when you can really reach anyone in the country and get the resources they have. So I think if we start utilizing those resources more, that would help eliminate bias, this would eliminate get a more objective sense of this process. And probably hospitals can really better benefit overall, because they're not having to limit it to their staff or to the availability of the committee that they have. But if they start utilizing other resources, I think we might get a better outcome.
Jerrod Bailey 30:50
I think that's right. I mean, technology now is, at least offered the ability to democratize access to, experience in specialty wherever it is in the world, right. And in knowing that, and knowing that, my current staff may be overloaded, and they've got all the things that we're requiring of them, and we've got no revenue, goals, and all of these other things, to burden them with a system that that otter already feels, either punitive or a waste of time is just not a great combination. But if we are democratizing access, and we really can get the best minds on our peer reviews, and that mine happens to be on the other side of the country. Uh, but they have the capacity and the willingness and the ability to engage in, in thoughtfully engage that that presents all kinds of interesting opportunities for us, right. So I do think you're right, I think COVID If it has a silver lining, it normalized. This, this virtual sort of ability, but going to we'll have to see as time goes on how much it continues to help, I'm seeing AI come in and finally becoming viable and, and capable in certain areas as far as just like streamlining processes, and, organizing records for, sort of quick consumption and things like that. But I think as going to technology matures, we're going to see some of these things continue to come into the workflows to, to make this general concept of the democratization of experience, start to start to help us for any closing thoughts you got, I mean, what happens if peer review doesn't change?
Dr. Husam Bader 32:39
That's a really sad thought. It's, I totally wish it does change, if it remains the same, I think we'll be just losing a really precious resource for physicians for patients for the overall healthcare system. Because if we keep waiting on a bad outcome to happen, and once it happens, we have no good way and really eliminating the biases to judge. What does that say about our ability to prevent those from happening again? What does this say about doctors who end up getting caught up in litigation and medical malpractice suits? How about residents who are still learning, and they really need the valuable feedback, so they can improve their practice and become the best doctors they can become. And all of those things we're not going to get if we're getting committees that are not efficient, that they're not living up to their potential. And they're only slightly involved in that process. So I really hope that this change because we there's no other better way of changing those things.
Jerrod Bailey 33:59
If it doesn't, it's the biggest missed opportunity. at our fingertips, I will say this, we do a lot of hearing in place, and we do a lot of peer reviews, but we do a lot of like case reviews for a medical malpractice team. So something bad happened right now, it's turned into a claim. And now, this claim or the suit is, is hanging over the head of a physician who really did everything right, had the best intentions, but this is medicine, and bad things are going to happen. And now, I'm under this existential threat of these things going on. And it's a really hard place to be. And what I've noticed is that our reviewers who are also just peers of these individuals, they're practicing physicians and nurses doing it a long time. And they'll do these reviews and then I'll kind of assess these cases. And every single one of them says, because I've done that I practice better medicine myself, right, because I'm, I'm looking critically but fairly at my peers and we're, really looking at each other. Inevitably they Go back to practicing better medicine documenting in better ways, right? And going to and so it's just it's a great environment, if you can create the environment in the culture for it for, for, for providers of all kinds to level up and continue to level up by learning from each other.
Dr. Husam Bader 35:16
Ya know, 100% I think, in medicine, if you practice medicine, you never stop learning. And that's, it's a continuous learning curve and reviewing someone else's work does make you reflect on your own practice and how you judge things, how your documents agree with your child. I think that sounds really exciting and exciting opportunity to be part of.
Jerrod Bailey 35:43
It's great. Well, Dr. Brady, I want to thank you for joining me, is there any way that I will link to, to your article here in the show notes? Is there any thing that you want to mention as far as how people might want to find you if they want to reach out to you on LinkedIn or you on other places?
Dr. Husam Bader 36:01
I definitely like then I can send you my LinkedIn profile was updated, because it's I think I'll have to update it a little math, but I will send it to you.
Jerrod Bailey 36:14
Perfect. Well, we'll make sure that we put anything any way that you'd like to be contacted into the into the show notes for people to reach you. And in the meantime, appreciate you joining us and for everyone else, thank you for listening to reimagine healthcare, a new dialogue with risk and patient safety leaders podcast. Again, subscribe and share if you found this valuable in this episode, if you'd like to participate in the guest Hey, maybe this is a call to arms, anyone who's particularly proud of their peer review process. That's been listening to this and thinking going to what we've really been intentional about these issues and others, reach out. I'd love to hear your story and tell your story here because it this is really if we're going to change these systems for the better. It's really who's at the vanguard of pushing for these changes. That's important. So again, if you're interested in speaking on the subject, you can reach out to us at speakers at Medplace.com And of course, we'll share the link and everything else for Dr. baiters peer review article as well. But get a doctor. It was a pleasure. This was just such a such a great session. Thank you for unpacking this for us.
Dr. Husam Bader 37:19
Likewise. Thank you for having me, John.
Jerrod Bailey 37:22
Fantastic. All right. Well,
Dr. Husam Bader 37:23
we'll talk soon. Absolutely. Have a good day. Bye.
