Restoring the Commons Institutions

                A few months ago I mentioned that institutions can help maintain a shared commons like a hospital even in the face of individual self-interest. In our time, though, we seem to have an instinctive distrust of institutions. I have followed with sadness the controversy embroiling the Roman Catholic Church over its handling of sexual abuse cases. I heard an interview on television with an Irish lay ombudsman, who commented that the Church in Ireland had instituted wide-spread reform of the way it handled these cases ten or fifteen years ago. The controversy now seems to be what senior members of the hierarchy did, or did not do, thirty years ago. It seems clear from published accounts that at least some of the bishops placed protecting the Church ahead of protecting past and future victims. Why do I bring this up?

                The Medical Executive Committee occasionally has to consider a course of action when a physician’s practice has been found unsatisfactory.  The majority opinion is focused on the need to prevent harm to future patients, but a minority is focused on the need to protect the physician. Now I do not mean to suggest that we should eliminate the procedural protections that are written into our bylaws, but I could not help noting that our bylaws are focused on protecting us as the institutional medical staff, not on protecting the patient from doctors who deviate from standard practice. Over the past ten years, we have been “cleaning up our act,” but are we not in danger of being in the same place as the Roman Catholic Church? After all, patients in our hospital are in a state of child-like dependency for at least a little while. I think we need to be able to assure our public that we won’t abide “bad” doctors, or bad practice. What do you think?

                If you agree there may be an object lesson here, what can we do to avoid the same trap? I suggest that each of us approach our peer review responsibilities with a simple question: would I want my (wife/husband/father/mother/child) to be treated by this physician this way? Clearly there are often multiple ways to address various problems, but we do operate by consensus in the absence of clear data, and we do have good data for many common issues. Peer review that is respectful of honest differences of opinion is important, but peer review that sees all differences as just opinion is hypocritical.

                Another common excuse is the so-called “economic” argument. It basically says that if you are doing peer review of someone who is in your practice group, or of someone who is in a “competing” group, that the process is not fair. While we have all seen examples of biased reviews and “tit for tat” critiques, I do not believe that this issue precludes a fair review. After all, if we are doing it correctly, the reference standard should be the literature, or the “standard of care” in our local community. Using the literature is obvious, although not done as much as I personally would like to see. One of our urgent tasks is to formally establish our “standard of care” by consensus, and use it to guide our ongoing peer evaluation process, and to improve the care we deliver to our patients. I urge all of you to participate.

Written 28 April 2010, revised 3 May 2014.

Further Reading

The Public Looks at Healthcare Reform

The Tragedy of the Commons
Recognizing the Commons is critical for success in an era of rapid change.

Trust in Physicians and Healthcare Reform
Public trust in physicians as a group is quite low, despite the high regard patients have for their personal doctor. The implications for the physician's role in the health care reform debate are considered.

What Business Are We In? 
All healthcare organizations have both a clinical and a business function.  The proper balance is crucial for success.

What Do I Owe? 
A discussion of unexamined assumptions about what physicians owe their hospitals.