Question: One of our dentists recently experienced a number of unusual complications/outcomes with patients on whom he had performed minor surgical procedures, so we sent several of his cases for external review.  The report we received showed that each case was reviewed by two individuals:  a dentist and an oro-maxillofacial surgeon.  While we appreciate that the review agency was trying to be thorough, the reviewers unfortunately came to vastly different conclusions regarding the dentist’s care.  The dentist recognized only minor issues, finding most of the care to be appropriate or consistent with general dentistry practice.  The oro-maxillofacial surgeon, on the other hand, identified a number of lapses in judgment and clinical skill.  With conflicting opinions such as this, how do we proceed?

Answer: Your situation sounds like quite a pickle!  Most organizations use external reviews to help them resolve internal uncertainty or conflict regarding whether or what concerns exist with a practitioner whose care has been questionable.  It is no wonder, then, that you find yourselves without a clear path, in light of conflicting external reviews.  It seems that given your current situation, you have a couple of options available to you:

• The first option is to contact the review agency and ask for the reviewers to clarify the inconsistencies in their expert reviews.  While dentists and oro?maxillofacial surgeons are trained differently, the standard of care for any services provided by such practitioners is the same.  In other words, there is one standard of care for tooth extraction – regardless of whether that extraction is performed by a dentist or an oro-maxillofacial surgeon.

Since there is only one standard of care, it is quite unusual that two reviewers would come to such different conclusions regarding the care provided by your dentist.  If you ask for clarification, you may explain the problem and request that the reviewers, when responding, define more objectively the standard against which they are measuring the dentist’s care (rather than merely subjectively concluding that a problem did or did not exist in the care provided).

• A second option is to obtain another external review, this time specifying for the review agency the exact qualifications of the expert who will perform the review – and requiring hospital approval of the chosen expert in advance of any review.  Essentially, you are then “breaking the tie” with a third external review.

Of course, if things ultimately do not work out well for the dentist, nothing will prevent him from claiming at some future date that the singular favorable review was accurate while the others were misguided.  But no peer review will ever be enveloped in 100% certainty and, therefore, the hospital and medical staff leadership should feel comfortable proceeding once any inconsistencies have been worked out to their reasonable satisfaction.

• A third option is for the Medical Staff leadership to consider the external reviewers’ reports and then use their medical expertise, judgment, and discretion to determine which make more sense and/or are worthy of greater weight.

Of course, there are risks to this approach.  If an adverse professional review action is recommended for the dentist, the dentist may claim that the leadership should have given more weight to the dentist’s review.  On the other hand, if the leadership gives more weight to the dentist’s review and, in turn, takes minimal peer review action, any patient who is harmed during a future surgery of the dentist’s could potentially make a negligent credentialing claim (arguing that the leadership should have given more weight to the oro-maxillofacial surgeon’s opinion or taken further steps to assure patient safety before allowing the dentist to return to practice).

• Finally, a fourth option is for the leadership to determine that they simply cannot resolve the inconsistencies between the experts’ reviews – and to proceed in light of that uncertainty.  This could mean, for example, allowing the dentist to practice in the hospital, but implementing some form of focused professional practice evaluation (FPPE) to make sure that patients are safe and, at the same time, gather more information about the dentist’s practice.  Perhaps a period of proctoring or required consultations, followed by a period of 100% chart review?

Peer review can be complicated.  It’s not just a matter of going step-by-step through routine procedures.  Sometimes, even when you follow all of the rules, you end up with a conundrum!  We hope this Q&A helps.  If you are looking for even more detail on how to refine your peer review process, please join us at The Peer Review Clinic in New Orleans, May 2-4.