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2. 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.
3. Conducting the Review
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