Army Peer Reviewed by NPs

[DD214_DOC]

Is this common elsewhere? It seems very odd to me that our PMHNP's are in our peer review pool, and sometimes review the psychiatrists. It's especially odd considering their respective state licenses actually require a written, "collaborative", agreement with a supervising psychiatrist/physician -- which none of them have.

So this begs a couple questions that maybe others can clarify with a regulation I have not yet been able to find: Why do none of them have this required agreement? Why am I being peer reviewed by someone whose state license requires to be supervised by me?

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[Monty Python]

Is this common elsewhere? It seems very odd to me that our PMHNP's are in our peer review pool, and sometimes review the psychiatrists. It's especially odd considering their respective state licenses actually require a written, "collaborative", agreement with a supervising psychiatrist/physician -- which none of them have.

So this begs a couple questions that maybe others can clarify with a regulation I have not yet been able to find: Why do none of them have this required agreement? Why am I being peer reviewed by someone whose state license requires to be supervised by me?

An RN, with a nursing degree and license, is *peer-reviewing* a physician who graduated medical school ?? That's sheer insanity. I don't care about their advanced practice nursing degree; they are still NOT your peer. Not even close.

If their state licensing scope of practice mandates a collaborative agreement and there is no such agreement, a quick phone call to their BON would have immediate repercussions for them.

If you are their supervisor, one could easily argue conflict-of-interest if they're assigned to peer review you.

Do the RN/PA/NP surgical first assistants peer review the board-certified surgeon who is FACS or FACOG? I would hope not.

 

[HighPriest]

If I overheard you mention this in a bar, I would automatically assume you were in the military.

The answer is: because in the eyes of the DoD, you are all "providers." You're all square pegs that fit a square hole. It should never surprise anyone that the DoD, their service branch, and frankly even their direct chain-of-command has no idea what they do or how they do it or what it actually requires to do what they do. Maybe your immediate command is a provider, or even your hospital commander, but they don't make the regulations. People with no knowledge of medicine or medical systems - and absolutely no incentive to learn about those things - make the rules. And, frankly, as long as all providers are considered equal in the eyes of the DoD, it would be hard to make a rule specific enough to dictate who can peer review who without making it 100 pages long.

They only reason they don't have first-assists doing surgery is because someone would report it and they'd get their OR shut down. Otherwise that wouldn't surprise me either.

At my first station, I was peer reviewed by an optometrist and a physical therapist. They were both real nice guys, but they wouldn't know if what I was doing was correct no matter how off I was.

 

[Gastrapathy]

Your medical staff bylaws should not permit this (even in the military).

 

[HighPriest]

Your medical staff bylaws should not permit this (even in the military).

and yet....

 

[Monty Python]

Is this common elsewhere? It seems very odd to me that our PMHNP's are in our peer review pool, and sometimes review the psychiatrists. It's especially odd considering their respective state licenses actually require a written, "collaborative", agreement with a supervising psychiatrist/physician -- which none of them have.

So this begs a couple questions that maybe others can clarify with a regulation I have not yet been able to find: Why do none of them have this required agreement? Why am I being peer reviewed by someone whose state license requires to be supervised by me?

One more thought: are the non-physicians peer reviewing you just for clerical compliance with various documentation requirements, especially those required by Joint Commission? If that's their purpose I could probably tolerate it. If, on the other hand, the non-physicians were peer reviewing your physician clinical decisions and rationales then I would have severe difficulty with it.

 

[TurtleDO2012]

A non physician should not be reviewing you. If they are it’s because someone doesn’t understand the differences between an NP and a physician or credentials in general. If you needed you can have a another person with you’re level of credentials review your documentation and you review theirs remotely. This commonly occurred with our facilities dermatologist who was a clinic of 1 doc and 1 midlevel. The doc could review the midlevels info but not the other way around. The derm had to send records to a derm at another facility.

 

[Monty Python]

AR 40-68's definition. In my mind this lacks adequate precision.

"Peer: An individual from the same professional discipline/specialty to whom comparative reference is being made."

 

[DD214_DOC]

One more thought: are the non-physicians peer reviewing you just for clerical compliance with various documentation requirements, especially those required by Joint Commission? If that's their purpose I could probably tolerate it. If, on the other hand, the non-physicians were peer reviewing your physician clinical decisions and rationales then I would have severe difficulty with it.

They are reviewing clinical decisions and rationales. It’s as fun as you imagine it would be, because I frequently have to explain why THEY are wrong when they try to, “correct”, something.

 

[DD214_DOC]

AR 40-68's definition. In my mind this lacks adequate precision.

"Peer: An individual from the same professional discipline/specialty to whom comparative reference is being made."

Yeah, I’ve read this. The situation is made even better when you throw in the fact that I’m actually a sub specialist, and literally the ONLY sub specialist in my field. So general psych NP’s are peer reviewing a psychiatric sub specialist. Makes total sense.

 

[155HE]

Absolutely ridiculous. Non physicians should not be doing peer review on physicians...this is a false equivalence. You should address this with your Dept Head. If that doesn't work, go to the Credentials Committee Chair, or higher to the MEC Chair. This could run afoul with TJC...maybe that could help change some minds.

 

[HighPriest]

AR 40-68's definition. In my mind this lacks adequate precision.

"Peer: An individual from the same professional discipline/specialty to whom comparative reference is being made."

This is exactly what I meant.

 

[militaryPHYS]

If you are 1 of 1 subspecialist and you have no other peers somebody still needs to review you... Who would be your recommended peer to do the reviewing? All you have to do is tell the person assigning the peer reviews and they can change it.

For purposes of OPPE peer reviews I often involve our Ortho PA, Podiatrists etc. in the peer review of our ortho surgeons because we all have the same requirements when it comes to the workup, evaluation and documentation of our ortho patients. I always double check their review and do a bit of my own review on top of the non-surgeons, but they are still qualified to review AHLTA notes for completeness. If the surgeons are only peer reviewing themselves I usually only get a copy and pasted "good to go" from everybody. Never any comments and never any question about anything.

 

[militaryPHYS]

Plus, the requirements of peer review are that you have all the checkboxes documented to make the clinical decision. It isn't evaluating whether you made a good clinical decision or not. That comes at your own departmental CME conferences, PREOP/POSTOP conferences, M&M's etc. Poor clinical decision issues are sorted out with SOC FPPEs and such.

There are good mid-levels and there are bad mid-levels. Whether or not you trust them to fit in to AR 40-68's definition or not is completely based on you and the individual mid-level provider. But, realistically, a mid-level provider IS within the same professional discipline as a physician and there is some comparison. Not exact...but some.

It is frightening how put off we are in this thread to be practicing in the same field with others who are not exactly like us.

 

[SirGecko]

If you are 1 of 1 subspecialist and you have no other peers somebody still needs to review you... Who would be your recommended peer to do the reviewing? All you have to do is tell the person assigning the peer reviews and they can change it.

Pretty sure that some places they will have someone from a different MTF do the peer review when you are 1 of 1. So that might be an option?

 

[deleted480308]

Plus, the requirements of peer review are that you have all the checkboxes documented to make the clinical decision. It isn't evaluating whether you made a good clinical decision or not. That comes at your own departmental CME conferences, PREOP/POSTOP conferences, M&M's etc. Poor clinical decision issues are sorted out with SOC FPPEs and such.

There are good mid-levels and there are bad mid-levels. Whether or not you trust them to fit in to AR 40-68's definition or not is completely based on you and the individual mid-level provider. But, realistically, a mid-level provider IS within the same professional discipline as a physician and there is some comparison. Not exact...but some.

It is frightening how put off we are in this thread to be practicing in the same field with others who are not exactly like us.

I’m not sold on the premise that we are in the same professional discipline

 

[militaryPHYS]

Same field (profession) but not necessarily the same level of competence or experience. Still very capable of reviewing someone’s ahlta notes though...


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[pgg]

For my specialty (anesthesiology), 1 of 1 people send their records to another hospital for peer review by an actual peer. We don't get peer reviewed by CRNAs. Even when I was a 1 of 1 MD at a small hospital, with 3 CRNAs, one of whom was my dept head, they didn't peer review me. I bundled up some charts in a PDF every 3 months and emailed them to someone at another MTF.

Plus, the requirements of peer review are that you have all the checkboxes documented to make the clinical decision. It isn't evaluating whether you made a good clinical decision or not.

That's not peer review.

We incorporate that box checking stuff in our peer review process
- is there an exam documented
- were the SCIP criteria met
- is the chart signed
- etc
but the core of a peer review OPPE is an examination of the chart and a determination of whether or not the care was within the standard. If not, THEN the move is made to do a FPPE, plan of supervision, etc.

M&Ms and CME conferences are a separate parallel phenomenon, with an educational and process improvement slant. Important, but NOT peer review.

It is never OK for a non physician to peer review a physician. Subspecialists should have their subspecialty case load reviewed by another subspecialist. Email works. No one is truly 1 of 1 DOD-wide.

 

[Perrotfish]

We incorporate that box checking stuff in our peer review process
- is there an exam documented
- were the SCIP criteria met
- is the chart signed
- etc.

There is also almost certainly another, parallel records review process that your nurses and corpsmen are doing to make sure that those boxes are checked. Physicians generally aren't aware that it exists unless they either get a lot of negative reviews or get voluntold to oversee it.

 

[militaryPHYS]

It is never OK for a non physician to peer review a physician.

My fault. At my current MTF we do have a check box for "Is there an appropriate and clinically pertinent plan?"

IMO this can still be answered by a trusted mid-level provider in our specialty (ortho). It allows different perspectives and cross examination of all our members in the clinic. As I mentioned, I re-review all of my surgeons documentation anyway. The peer review encourages interaction, discussion and accountability at all levels. Such a system may not work for Anesthesia, or psych but it works for us here.

Realistically this is all specialty, MTF and department specific. Ultimately the DH signs off on the OPPEs and Renewal PARs which means they trust the peer review process. Set it up however you'd like (within restrictions of local MEC/credentials) so long as the provider is being properly reviewed to ensure patient safety.

 

[narcusprince]

For my specialty (anesthesiology), 1 of 1 people send their records to another hospital for peer review by an actual peer. We don't get peer reviewed by CRNAs. Even when I was a 1 of 1 MD at a small hospital, with 3 CRNAs, one of whom was my dept head, they didn't peer review me. I bundled up some charts in a PDF every 3 months and emailed them to someone at another MTF.


That's not peer review.

We incorporate that box checking stuff in our peer review process
- is there an exam documented
- were the SCIP criteria met
- is the chart signed
- etc
but the core of a peer review OPPE is an examination of the chart and a determination of whether or not the care was within the standard. If not, THEN the move is made to do a FPPE, plan of supervision, etc.

M&Ms and CME conferences are a separate parallel phenomenon, with an educational and process improvement slant. Important, but NOT peer review.

It is never OK for a non physician to peer review a physician. Subspecialists should have their subspecialty case load reviewed by another subspecialist. Email works. No one is truly 1 of 1 DOD-wide.

I agree this is the ideal system. One can argue if it ever became an issue to have their peer review done by a true physician peer.

 

[Gastrapathy]

There is no way there is validity to a peer review process that allows a midlevel to be your peer. That is a typical military medicine response to fake it rather than do the right thing. If you only ask another MD to get involved if there is a problem, that assumes that 1) someone unqualified can figure out that there is a problem and 2) that this wouldn’t only be used to retaliate against a good doctor who tried to do the right thing.

The semantic argument about the instruction is irrelevant. This is fundamental to who we are as physicians.

 

[militaryPHYS]

Be careful with the direct personal attacks. To suggest I am gundecking my peer review process is quite the accusation.

Interesting how you chose to go down the false accusation route despite me explaining the 2 layer review process I described, one of which incorporates our trusted peers in medicine, the other is a direct peer if layer 1 ends up being a mid-level or podiatrist.


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[Gastrapathy]

You aren’t gundecking, you are using an approved process that is deeply flawed. That’s not a personal insult. There is simply no way a midlevel can provide meaningful feedback to a surgeon. It’s box checking and not the purpose of peer review but it meets the .mil version of the requirement. You don’t even have an equivalent standard of care. The fact that there is a second level of review doesn’t change how that first level biases the process. I also was talking about the OPs experience. I hadn’t read your defense of midlevels as peers.

I actually know a little bit about this topic. TJC says “it is important for a practitioner to be judged by a “true peer”, someone working...in the exact same medical specialty.” This means that midlevels have two types of reviews, the physician supervision review requirements and a peer review process involving another similarly trained midlevel. Obviously, if you can’t peer review them, they certainly can’t peer review you. TJC also discusses the problems with small departments “i review you, you review me, etc” that are obviously the case in the .mil system. You really should read in the subject if you have such strong opinions. A peer review process where you are reviewed by a PA or a Podiatrist isn’t going to provide you with meaningful feedback (which is actually the entire point). There’s a wealth of literature.

As for “be careful”, I find the threat to punish a voice that happens to disagree with a new moderator for a perceived personal attack to be highly objectionable. I’ve been skipping your posts because I disagree so often, now I have to read them to make sure I don’t accidentally disagree?

 

[militaryPHYS]

Perhaps I am just used to you going out of your way to reply directly to posts in which I offer an opinion different than the typical posts of milmed SDN of the last 10 years. Forgive me if your post was no intended for me, but it came at the end of an already developed discussion I was involved in, provides no direct response to OP or recent responses and your most recent response even contradicts you claiming it was not personal.

Regardless, your assumptions that opinions which differ from yours must be rooted in poor research or experience by the person involved really detracts from a meaningful discussion.

Rotating ongoing peer reviewers every 3 months while including trusted peers who ARE working along side us in the exact same specialty allows us to mitigate some of the small department concerns while providing useful feedback that prevents the “you do me, I do you” standard review. Therefore, over the course of a year a surgeon is reviewed by 3 other surgeons and once by a trusted peer not necessarily with exact same credentials but who works along side us in the same discipline.

I am open to differing opinions, but I don’t accept a blanket statement that midlevels can’t provide meaningful ongoing review of physicians when incorporated smartly. I think it increases collaboration and provides additional data to make a final determination on OPPEs.


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[HighPriest]

They could. If the review is limited to things like: interacts well with patients, notes contain the following mandatory parts (with a checkbox list), behaves in a professional manner.

If or when it comes to commenting on appropriateness of medical or surgical care? I don't think midlevels can provide meaningful review. Yes, that's a blanket statement. Does it mean there's not midlevel out there who could teach a physician anything? No, not at all. But that scenario is uncommon enough that there's simply no point to creating a peer review system for those circumstances. A much more common scenario is that the midlevel doesn't have the same breadth of knowledge, and that they might mistake something with which they are unfamiliar as something that doesn't meet standard of care.

 

[Gastrapathy]

@HooahDOc

Bottom line: you are getting out soon and will never encounter this anywhere else.

 

[HighPriest]

@HooahDOc

Bottom line: you are getting out soon and will never encounter this anywhere else.

This should be the milmed motto.

 

[backrow]

. I’ve been skipping your posts because I disagree so often

You’re not the only one....


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[Atlas Shrugged]

It is insane that an attending surgeon is approving of a midlevel reviewing them.

 

[militaryPHYS]

It is insane that an attending surgeon is approving of a midlevel reviewing them.

Are we so far above midlevels that they can't look at our AHLTA notes every once in a while to help them learn and give us a different perspective? Sad to hear so many people feel this way

 

[deleted480308]

Are we so far above midlevels that they can't look at our AHLTA notes every once in a while to help them learn and give us a different perspective? Sad to hear so many people feel this way

To help them learn? Absolutely, read my notes all day. I’d even love to have some paid time for them the ask questions for their learning

To officially judge my clinical performance on my permanent work record as a peer? A physician in my specialty is the only one qualified

 

[militaryPHYS]

As you know, your department head signs your OPPE. To have a mid level contribute 1/4th of the data that said DH signs off on is not a final judgement of your work. Additionally, your CAF file stays local and does not transfer to next work location.

Besides, what we are all refusing to acknowledge is that the OPPES are ultimately signed off by MEC chair and credentialing chair who are more often NOT in our specialty. Many times they are nurses.

But whatever. Further defense and discussion of such a minor thing is not worth any more of our time


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[backrow]

The false equivalency provided by allowing them to do “peer review” is what let’s midlevels continue to argue at the State Legislative level that they are equivalent or “just as good” as physicians and therefore should be able to expand their scope of practice/practice independently.

Call it a 360 degree review, call it a non-physician review, call it a non-peer review or whatever, but it is most certainly not a peer review. And yes, one might find some use in that, but it should not be misconstrued as peer review for credentialing purposes. I would bet your QI/CMO shop would actually love that idea and could even create a method for one to do it.

As to MEC/Credentials....typically Medical Staff voting membership and ability to hold office within the MEC is limited to those who hold licenses to practice independent medicine (physicians, dentists, oral surgeons, podiatrists, etc). This is because even the ACHE in their 2015 text regarding Redesign of the Medical Staff recognizes that “physicians need to lead physicians....not even member of the C-suite can lead Staff physicians where they do not want to go”


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[pgg]

Are we so far above midlevels that they can't look at our AHLTA notes every once in a while to help them learn and give us a different perspective? Sad to hear so many people feel this way

One more perspective. I was 1 of 1 at a small command where it was me and three CRNAs, one of whom was my department head. It's easy and expedient to blur lines in such circumstances.

I live in a world and practice a specialty where the midlevels have had substantial political success in arguing that their training and competencies are equivalent to mine. To the point where they practice pseudo-independently or actually-independently in many locations, with a deleterious impact on quality of care, pay, and employment.

Be careful with how closely you invite the the camel into your tent. Most midlevels are decent enough people, and friendly. They also resent you, think they don't need you (except when they do), promote policies and laws to minimize your role, and won't hesitate to deflect blame in your direction when it's convenient. They do. They will. Look. See behind the smile.

Involving them in your peer review is not in your best interest. And when you do it, and normalize it, it becomes harder for the rest of us to resist their encroachment.

 

[Perrotfish]

As you know, your department head signs your OPPE. To have a mid level contribute 1/4th of the data that said DH signs off on is not a final judgement of your work. Additionally, your CAF file stays local and does not transfer to next work location.

Is your peer review process drastically different from mine? At my command any peer reviewer has the ability to refer you to the MEC for a review of your credentials, either because they think your overall care is substandard (average score of < 2.5/4 on all reviewed cases) or because they think a single case is particularly egregious (score of 1/4 on any case). At that point you are hiring a lawyer and defending your credentials before a committee that is not made up of members of your specialty. The department head can't short circuit that process. I thought that was standardized across the Navy.

 

[DD214_DOC]

The false equivalency provided by allowing them to do “peer review” is what let’s midlevels continue to argue at the State Legislative level that they are equivalent or “just as good” as physicians and therefore should be able to expand their scope of practice/practice independently.

Call it a 360 degree review, call it a non-physician review, call it a non-peer review or whatever, but it is most certainly not a peer review. And yes, one might find some use in that, but it should not be misconstrued as peer review for credentialing purposes. I would bet your QI/CMO shop would actually love that idea and could even create a method for one to do it.

As to MEC/Credentials....typically Medical Staff voting membership and ability to hold office within the MEC is limited to those who hold licenses to practice independent medicine (physicians, dentists, oral surgeons, podiatrists, etc). This is because even the ACHE in their 2015 text regarding Redesign of the Medical Staff recognizes that “physicians need to lead physicians....not even member of the C-suite can lead Staff physicians where they do not want to go”


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Our department head and representative/voting member on the hospital credentials committee is not a physician.

I know I'm leaving soon enough that I really shouldn't care, but how jacked up this system really is annoys me beyond belief. I'm particularly annoyed with how mid-levels play this game of claiming they, "practice nursing, not medicine", when convenient, despite everyone knowing they're practicing medicine. Anyone who doesn't, "practice medicine", has no business reviewing anyone who actually does and claims to do so.

They're also not required to follow the rules of their state licenses. Many here do not have written supervisory agreements with a physician, despite being a requirement of the state that licenses them to practice as a NP.

It has been an enormous source of frustration, especially in an environment where ALL of the department leadership are NOT physicians.

 

[HighPriest]

Are we so far above midlevels that they can't look at our AHLTA notes every once in a while to help them learn and give us a different perspective? Sad to hear so many people feel this way

I'd be happy if more of them paid attention to their own notes.

 

[Cooperd0g]

As a medical student I was working a rural clinic with a NP and a PA. I diagnosed a guy with peripheral artery disease. It took 30 minutes to explain to them I needed a Doppler, why was taking the guy’s blood pressure at his ankle, and what claudication was.

As an intern two NPs ran circles around me in the ICU. Of course, they were ICU nurses for years before becoming NPs and had done nothing but ICU as NPs.

The point is there are good and bad at all levels, including physicians. But there needs to be standardization for things such as peer review. In a professional sense, NP does not equal PA which does not equal MD/DO.

 

[militaryPHYS]

The point is there are good and bad at all levels, including physicians. But there needs to be standardization for things such as peer review. In a professional sense, NP does not equal PA which does not equal MD/DO.

There is standardization but they leave it open for interpretation. I do appreciate you at least acknowledging there is more to the discussion.

...
Apparently I am not on the front lines of the MD/DO vs. Mid-level war in the world. That's good considering I'm in PACOM worrying about other potential battles. I've had issues that you all are discussing related to mid-levels but that doesn't mean I assume all are incompetent or out to get me.

Fear not, I will do my part to prevent NP's and PA's from taking over the world. But it will be secondary to us all working together over here to keep the active duty guys full duty.

 

[Perrotfish]

There is standardization but they leave it open for interpretation. I do appreciate you at least acknowledging there is more to the discussion.

...
Apparently I am not on the front lines of the MD/DO vs. Mid-level war in the world. That's good considering I'm in PACOM worrying about other potential battles. I've had issues that you all are discussing related to mid-levels but that doesn't mean I assume all are incompetent or out to get me.

Fear not, I will do my part to prevent NP's and PA's from taking over the world. But it will be secondary to us all working together over here to keep the active duty guys full duty.

Have you ever changed your practice based on the feedback you get from this site?

 

[militaryPHYS]

Clinical practice? Of course not.

Personal approach to pitfalls/admin tasks/etc. of Milmed? Maybe. The cynicism and sarcasm does help temper my optimism. But then again, maybe it has just changed my approach to discussions on SDN, not really anything about how I function as a day-to-day Stapler or Office Chair within the system.

 

[HighPriest]

I call it pragmatic realism.