Legal risk associated with peer review / M&M processes

[seper]

Does anyone know of a case when a RadOnc physician was harmed by signing-off someone else's cases? A lot of people I know are very leery to be involved in uncompensated peer review process, but I doubt there is much risk.

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[RickyScott]

Does anyone know of a case when a RadOnc physician was harmed by signing-off someone else's cases? A lot of people I know are very leery to be involved in uncompensated peer review process, but I doubt there is much risk.

no, that kind of attitude is a bit toxic in my opinion. have seen it and not good at all for staff or patient care. You should be signing off routinely on partners/other doctors cases and writing sciprts and narcotics for their patients.

 

[GapCalc]

A lot of people I know are very leery to be involved in uncompensated peer review process, but I doubt there is much risk.

I’m glad my partners don’t feel this way.

 

[Mandelin Rain]

I'm not quite clear about the question. Is there legal risk to a peer review process, whereby one physician agrees that another physician's plan is reasonable? Probably, assuming it's documented, but I would agree that it's minimal as long as it is within a reasonable SOC or a case without a well defined SOC. I know no case law to support this, but I'm guessing they can't hold you to the same standard of the attending doc on the case.

I can see why you would want to be compensated for your time and this minimal risk associated with this if you and the other docs are not a single entity, like say two employed docs in 2 different cities or a contracted doc reviewing an employed doc's cases, etc.... But it is a worthwhile endeavor for all involved, not the least of which is the patients.

If it's about signing off other physician's plans while they're away, I definitely take much more time and thought to make sure I agree exactly with the overall plan of care, volumes are reasonable, and the dose distribution looks like I'd like. If not, I'll discuss with them and defer till they get back, but I won't sign off on anything I disagree with (even a little) just out of convenience because then you get all the associated legal risk. I often am looking at path, reviewing scans, reinventing the wheel in this process. Quite honestly, I find this to be a big pain in the butt that usually can just wait two more days until the guy who saw the patient, drew the contours, and will manage the rest of the case returns.

 

[medgator]

If it's about signing off other physician's plans while they're away, I definitely take much more time and thought to make sure I agree exactly with the overall plan of care, volumes are reasonable, and the dose distribution looks like I'd like. If not, I'll discuss with them and defer till they get back, but I won't sign off on anything I disagree with (even a little) just out of convenience because then you get all the associated legal risk. I often am looking at path, reviewing scans, reinventing the wheel in this process. Quite honestly, I find this to be a big pain in the butt that usually can just wait two more days until the guy who saw the patient, drew the contours, and will manage the rest of the case returns.

For better or worse, that's one advantage I've found with having the EMR and planning system in the cloud... Remote review and approval of plans

 

[thecarbonionangle]

no, that kind of attitude is a bit toxic in my opinion. have seen it and not good at all for staff or patient care. You should be signing off routinely on partners/other doctors cases and writing sciprts and narcotics for their patients.

rad Oncs who refuse to manage toxicity by not prescribing pain meds suck. They make us all look bad

 

[seper]

Thanks, the question was about "case law". Say, you filled out and signed a peer review form for a case that was riddled with malpractice, and the patient wound up suing.

 

[Mandelin Rain]

Thanks, the question was about "case law". Say, you filled out and signed a peer review form for a case that was riddled with malpractice, and the patient wound up suing.

Not sure. Interesting question though. I guess it may depend on the peer review process. If it's a typical, live chart rounds style process where you're completely reliant on the other doc presenting information, I guess your defense becomes you were presented with incomplete and/or inaccurate information. I hope you're not facing this issue currently, nor working with a complete bozo where you think this may become an issue.

 

[DukeNukem]

If it's about signing off other physician's plans while they're away, I definitely take much more time and thought to make sure I agree exactly with the overall plan of care, volumes are reasonable, and the dose distribution looks like I'd like. If not, I'll discuss with them and defer till they get back, but I won't sign off on anything I disagree with (even a little) just out of convenience because then you get all the associated legal risk. I often am looking at path, reviewing scans, reinventing the wheel in this process. Quite honestly, I find this to be a big pain in the butt that usually can just wait two more days until the guy who saw the patient, drew the contours, and will manage the rest of the case returns.

Edit: Sorry for the leftovers from my therapy sessions.

What I really meant to ask is, how much liability does one open themselves up to by signing plans of other docs? Is there pressure on you to do this from your colleagues or institutions to sign these things even if you don't feel comfortable? Am I being unreasonable if I refuse to sign off on things from other docs unless we review together or there's special circumstances? Should I just review everything closely regardless if I'm covering?

 

[BobbyHeenan]

Does anyone else find our case review process odd? We do it in our group (though we don't take a microscope to every DVH or contour), but it's not like surgeons are running their surgical plan by a colleague before they go and cut and med oncs aren't reviewing every case they're about to give chemo to. My local IR group doesn't run every new case by each other.

Why are we running by each new case? And why are we the only oncology specialty that does this?

I'm not saying we shouldn't, but it still strikes me as odd.

 

[seper]

It's a slightly different issue Duke, but a good point.
I too get "transfers" from the other sites, from docs of various seniority, but since I treat them, I see it is absolutely as my job to triple-check everything, modify prescriptions and re-plan if needed.
You need to make sure that care is not delayed, though.

I'm glad someone brought this up. It's our institutional policy that all documents, plans, prescriptions and such must be signed before the patient can start treatment.

When the big shots at the mothership send patients out to the satellites or I cover the mothership, the big shots almost never sign their own documents. When I started working here, the patients from certain attendings would arrive to start their treatment and I would almost always get called at the new start to "sign documents". Nobody told me about this when I started, so at first I was like ??? and would review every plan myself before signing, often with a patient waiting for treatment. Sometimes I would find stuff I thought was questionable. If I held up the treatment all hell broke loose when the big shots found out. The big shots would call my chair. A few times the chair reviewed the plans personally and at least twice sided with me for patient safety. Nobody thanked me or notified me that I had helped patient safety, just eventually word get back to me through therapy staff. Finally, I just refused to sign the documents unless someone contacted me first or there was extenuating circumstances like someone out sick, etc. I would have the therapy staff hound the big shots until they signed everything themselves or asked me to do it, which didn't make me any friends with the therapists.

I didn't realize what was coming. After some time into my job, I was brought into a meeting with several big shots and my chair to bitch me out. It was a total "lack of respect" that I refused to sign the documents. They have been doing this a lot longer than I have, they're "experts", and the other juniors have no problem with it so what is wrong with me. The therapists are mad at me because I'm holding up workflow, and it's important that I'm a team player. This was used to exemplify why I'm clearly not fitting in with the "culture", which is most important for a radiation oncologist in our center.

"Low energy" rad onc blasting off again.

 

[thecarbonionangle]

I'm glad someone brought this up. It's our institutional policy that all documents, plans, prescriptions and such must be signed before the patient can start treatment.

When the big shots at the mothership send patients out to the satellites or I cover the mothership, the big shots almost never sign their own documents. When I started working here, the patients from certain attendings would arrive to start their treatment and I would almost always get called at the new start to "sign documents". Nobody told me about this when I started, so at first I was like ??? and would review every plan myself before signing, often with a patient waiting for treatment. Sometimes I would find stuff I thought was questionable. If I held up the treatment all hell broke loose when the big shots found out. The big shots would call my chair. A few times the chair reviewed the plans personally and at least twice sided with me for patient safety. Nobody thanked me or notified me that I had helped patient safety, just eventually word get back to me through therapy staff. Finally, I just refused to sign the documents unless someone contacted me first or there was extenuating circumstances like someone out sick, etc. I would have the therapy staff hound the big shots until they signed everything themselves or asked me to do it, which didn't make me any friends with the therapists.

I didn't realize what was coming. After some time into my job, I was brought into a meeting with several big shots and my chair to bitch me out. It was a total "lack of respect" that I refused to sign the documents. They have been doing this a lot longer than I have, they're "experts", and the other juniors have no problem with it so what is wrong with me. The therapists are mad at me because I'm holding up workflow, and it's important that I'm a team player. This was used to exemplify why I'm clearly not fitting in with the "culture", which is most important for a radiation oncologist in our center.

"Low energy" rad onc blasting off again.

if you are doing so bad and so universally disliked, Why haven’t you been fired?

thankfully there are still plenty of high paying jobs out there for you brotha

 

[medgator]

Does anyone else find our case review process odd? We do it in our group (though we don't take a microscope to every DVH or contour), but it's not like surgeons are running their surgical plan by a colleague before they go and cut and med oncs aren't reviewing every case they're about to give chemo to. My local IR group doesn't run every new case by each other.

Why are we running by each new case? And why are we the only oncology specialty that does this?

I'm not saying we shouldn't, but it still strikes me as odd.

Radiology apparently does this as well, at least for ACR accreditation purposes, reviewing each other's reads etc

 

[Mandelin Rain]

Edit: Sorry for the leftovers from my therapy sessions.

What I really meant to ask is, how much liability does one open themselves up to by signing plans of other docs? Is there pressure on you to do this from your colleagues or institutions to sign these things even if you don't feel comfortable? Am I being unreasonable if I refuse to sign off on things from other docs unless we review together or there's special circumstances? Should I just review everything closely regardless if I'm covering?

Again, I can't cite case law but I imagine if you sign the plan it's on you. The staff just wants things signed and done so they can get the guy on beam. They don't care who or how or what. Just as long as it's done NOW. It's your job to make sure it's safe and reasonable. It shouldn't be like this, but often it is. They do the same for you. If you agree with the plan, sign it. If you don't, don't sign it and contact the doc to express your concerns and review him/herself. People hate this. And, I mean hate it. But it's your duty to act in a manner you feel is best for the patient.

 

[BobbyHeenan]

Radiology apparently does this as well, at least for ACR accreditation purposes, reviewing each other's reads etc

I guess path does this too.

Just so weird that you can take someone for a Whipple without a "case review" but heaven forbid you give 50.4 to the pancreas without that chart review.

I guess for solo rad oncs they don't often have case review, so there's precedent there.

 

[Krukenberg]

I guess path does this too.

Just so weird that you can take someone for a Whipple without a "case review" but heaven forbid you give 50.4 to the pancreas without that chart review.

I guess for solo rad oncs they don't often have case review, so there's precedent there.

they take them to the OR but really they shouldn’t in an ideal world without tumor board discussion beforehand. Our culture is for high quality QA while in surgery it’s more cavalier and each surgeon is his own kingdom.

 

[scarbrtj]

I will as usual be “that guy.” It’s is absolutely ludicrous to propose that a doctor’s treatment decisions *should* be signed off on by another doctor for the initially treating doctor’s treatments to be safe or valid. One reason this is done in rad onc is because it’s not completely impractical for us to do this. As pointed out it’s impractical in surgery e.g. Surgeons have M&M conferences where they pull out the retrospectoscope, but that’s different. What’s the purpose of residency? Of board certification? Of state licensure and CME etc? It’s a bit of a conceit to think you can show up a few days after a consult— and without having talked to and examined a patient, gone through the notes, scans, etc—impart some wisdom or cast some safety net on top of what another competent physician has already done. We can say it’s nice or pleasant or swanky to peer review. But it’s not a necessity for good care.

I generally am loathe to sign off on unapproved plans. I don’t mind signing off on the piddling minutiae like a sim note or something. But signing off on another rad onc’s plan is like being called in to take over another surgeon’s operation in the last 5 minutes of the case. You just pray and hope the dude did everything ok because as we all know eventually no good deed goes unpunished.

 

[scarbrtj]

they take them to the OR but really they shouldn’t in an ideal world without tumor board discussion beforehand. Our culture is for high quality QA while in surgery it’s more cavalier and each surgeon is his own kingdom.

Why not discuss all surgeries beforehand? If you’re going to tumor board to discuss removing a Krukenberg tumor, why not some “operating board” to discuss bilateral oopherectomy for cysts? Is it that in cancer the “stakes” are higher? Is the need for pretreatment peer review based on the emotional heft of a situation? Peer review in rad onc for gynecomastia RT as well as breast ca RT, or just for breast ca RT?

 

[BobbyHeenan]

I will as usual be “that guy.” It’s is absolutely ludicrous to propose that a doctor’s treatment decisions *should* be signed off on by another doctor for the initially treating doctor’s treatments to be safe or valid. One reason this is done in rad onc is because it’s not completely impractical for us to do this. As pointed out it’s impractical in surgery e.g. Surgeons have M&M conferences where they pull out the retrospectoscope, but that’s different. What’s the purpose of residency? Of board certification? Of state licensure and CME etc? It’s a bit of a conceit to think you can show up a few days after a consult— and without having talked to and examined a patient, gone through the notes, scans, etc—impart some wisdom or cast some safety net on top of what another competent physician has already done. We can say it’s nice or pleasant or swanky to peer review. But it’s not a necessity for good care.

I generally am loathe to sign off on unapproved plans. I don’t mind signing off on the piddling minutiae like a sim note or something. But signing off on another rad onc’s plan is like being called in to take over another surgeon’s operation in the last 5 minutes of the case. You just pray and hope the dude did everything ok because as we all know eventually no good deed goes unpunished.

Agree completely.

We do internal review but in over 6 y ears I can count on 1 hand the amount of times I've signed a partners plan. But each time I do make sure I actually look at the plan before signing it.

 

[Mandelin Rain]

It seems like my partners somehow always sim and contour some crazy re-treatment head and neck, or 4th chestwall recurrence taking the skin to 120+ Gy, or some such train wreck the day before their vacation and schedule the patient to start the next Wednesday while I'm covering. These are things you don't want to just blindly sign off on.

 

[scarbrtj]

It seems like my partners somehow always sim and contour some crazy re-treatment head and neck, or 4th chestwall recurrence taking the skin to 120+ Gy, or some such train wreck the day before their vacation and schedule the patient to start the next Wednesday while I'm covering. These are things you don't want to just blindly sign off on.

haha, if there are rad onc Murphy's Laws this would be #1. "1) When covering for another rad onc you will inevitably almost immediately be asked to sign off on something that from afar looks blatantly like malpractice" (And later, nearly 100% of time if/when you get a chance to speak to the other rad onc the approach looks reasonable/inescapable)

 

[medgator]

It seems like my partners somehow always sim and contour some crazy re-treatment head and neck, or 4th chestwall recurrence taking the skin to 120+ Gy, or some such train wreck the day before their vacation and schedule the patient to start the next Wednesday while I'm covering. These are things you don't want to just blindly sign off on.

As much as I hate the cloud, this is one aspect where being able to pull up the EMR and planning system out of the office is golden.

 

[FrostyHammer]

Why not discuss all surgeries beforehand? If you’re going to tumor board to discuss removing a Krukenberg tumor, why not some “operating board” to discuss bilateral oopherectomy for cysts? Is it that in cancer the “stakes” are higher? Is the need for pretreatment peer review based on the emotional heft of a situation? Peer review in rad onc for gynecomastia RT as well as breast ca RT, or just for breast ca RT?

It's because surgeons are sadists...as long as the plan is to cut, they're OK with it by default. No need for further questioning.

 

[PhotonBomb]

hold on - there is WAY more inherent oversight with what goes on in surgeries compared to the often hand-waving peer review with what a rad onc does.