Perspectives on Peer Review, Medicolegal Cases and Judgment in Radiology

I don’t recall how early in my medical career it was that everybody started reviewing everyone else. The Internet tells me that “360-degree” evaluations didn’t get going by that name in health care until well after I was done with residency, but I know I saw the equivalent being done before I even got my MD.

That should have enabled me to slide right into the peer-review machine, but it didn’t. I resisted the notion that, as a complete newbie, I had any business rendering judgment. Aside from others fresh out of training, nobody was really my peer. Everyone was more experienced and senior to me.

The sentiment stuck around long after I could lay claim to newness. I was just an everyday radiologist without any particular genius or special credential. What business did I have saying whether I thought that some other rad had done a good or bad job? Even if another rad had obviously missed something, who was I to say whether it was a forgivable error or something worse?

That attitude changed for a couple of reasons.

First, “maintenance of certification” required participation in peer review, and that meant reviewing as well as being reviewed. Accordingly, I went ahead and did it, albeit reluctantly.

Second, some unpleasant episodes showed me that, while I wasn’t eager to ding other rads’ QA stats, they were not shy about doing it to me. Some were pretty petty about it. It is a small, competitive world that compares you against others in any way it can. Whitewashing their stats when they won’t return the favor only hurts you. I didn’t stoop to others’ level of sniping and nitpicking, but I stopped clinging to pacifism on the battlefield.

A third reason eventually percolated through my thick skull, and this was truer to the intent of peer review. There are some folks out there doing a truly lousy job. They need to either be woken up to do better or identified so they might be stopped from inflicting harm.

Paraphrasing the late, great George Carlin: Think of how often you have seen the average physician perform poorly and realize half of the other docs out there are worse than that. Assuming you are a completely middle-of-the-road radiologist, you are perfectly situated to call balls and strikes when seeing the work your colleagues have done.

Would you want super-duper brilliant, ivory tower rads doing all the reviews? They might consider the rest of us blithering idiots and give us QA stats that drum us out of the field. How about quacks in the bottom percentiles? They would either forgive all our mistakes as understandable or fail to recognize the errors in the first place.

I puttered along, doing my thing for a decade or so. Eventually, I stumbled sideways into what one might consider the “next level” of judgment: medicolegal stuff.

That might make it sound like a bigger deal than it is. I never dove into those waters. It was more like dabbling my feet. I haven’t set foot in a courtroom as an expert witness nor been cross-examined as one. I had heard about mercenary expert witness docs, willing to sell out their professional brethren and potentially scuttle careers for the right price. They purportedly said whatever lawyers wanted them to say. No matter the payoff, I would never go that far.

Still, the lawyers and insurance companies are going to hire physicians one way or another. If I have the chance and turn it down, whoever takes what would have been my spot might have less of a conscience than I. The thought also occurred that it might be good to get my foot in that door in case I ever want to do something other than clinical work.

When a former colleague had more “no-fault” cases than she knew what to do with, I started taking some of them off her hands. I was working 7-on, 7-off at the time (nights), and this gave me something productive for my off days. It paid much better than what the corporate telerad company was giving me. The job market was not yet in its current glorious state.

It was interesting work too. Seeing radiology from a non-clinical perspective was a novelty, and it gave me a chance to explain to non-docs what our nifty machinery does and what its images mean. That aspect expanded greatly when I occasionally received invitations to help defend rads who had gotten caught in the teeth of the malpractice industry.

As things have tumbled, I have never played offense, and I am not sure I would. The closest I have gotten to that side of things has been when defense attorneys need to know whether Dr. X’s actions are defensible or a “departure from the standard of care.” On occasion, I have had to indicate the latter.

It is not a happy task, but it is a useful one. If I went back to my old stance of not rendering judgment on a fellow doc and just said that everything is defensible, Dr. X would proceed into expensive court proceedings, the plaintiff’s expert witnesses would skewer me, and Dr. X would wind up with a far harsher result. If I advised his or her lawyer upfront that the case was a loser, he or she could aim for a less drawn-out resolution with a gentler settlement.