:dropcap_open:M:dropcap_close:edical peer review is a process whereby doctors evaluate the quality of work done by their colleagues, in order to determine compliance with accepted health care standards. This self-regulatory procedure provides quality assurance for the medical community by fostering standardization of appropriate medical procedures and by policing caregivers who could pose risks to patients. The rationale for the process is efficiency: working doctors are best situated to judge the competence of other working doctors because they regularly see each others’ work and possess the relevant expertise to evaluate it” (New Jersey Law Revision Commission, 2004, http://www.lawrev.state.nj.us/medicalpeerreview/mprM083004.pdf).1
In a perfect world, the peer review doctor would render an opinion on the paperwork that certifies necessary care and covered issues for injured patients. Peer review differs from an IME in that there is no face-to-face meeting with the patient and no examination. The peer review doctor reviews the paperwork of the treating doctor to see if that doctor practiced within the standards of his/her license and renders an opinion about the necessity for care. Like IME abuse, peer review abuse has gone relatively unchecked for decades, as doctors and lawyers have not focused on the solution to neutralize those reports that border on fraud or licensure misconduct language. To render a fair and balanced opinion, there are many doctors nationally who conduct very fair and ethical IMEs and peer reviews. This article is not focused on those ethical doctors who perform a necessary function in the healthcare environment.
In August of 2011, I was given a peer review report written by a chiropractor in New York who was hired by Alternative Consulting & Examination located in Fulton, New York to render an opinion on the immediate ordering of an MRI by a chiropractor, although the MRI wasn’t performed until 9 weeks post-care. The lawyer representing his client wanted my opinion on the report. The peer review doctor stated, “Because MRI’s reveal so many herniations in pain-free people, and HNP’s respond to most conservative treatments anyway, MRI findings have little if any use in determining early therapy options.” He quotes this snippet from The Journal of Family Practice. He then goes on to take various quotes from various other research journals. First, he uses The Journal of Family Practice for his lead quote in his opinion. He cites 2 authors incorrectly, as there is only one author with another rendering a commentary. The peer review doctor uses that “very limited” 1 & 1/2 page study and quotes one person’s opinion, but conveniently omits the following from the same author in the same paper: “Unfortunately there are too few studies to guide clinicians in the appropriate use of MRI in the evaluation of low back pain. Higher quality evidence is needed before firm guidance can be made for the use of MRI in the evaluation of low back pain” (Grover, 2003, p. 232).2
The same paper offers a clinical commentary by a family practitioner that states, “I find MRI useful to help tailor therapy and make decisions regarding appropriate referrals” (Grover, 2003, p. 232). The peer review doctor also omitted this in order to make one believe that his conclusion was a supported standard of care. This irresponsible type of action reminds me of the tobacco companies who attempted to defend themselves in lawsuits by quoting snippets from research and attempting to produce a global decision that cigarette smoking was safe. Although irresponsible and bordering on misconduct, it is easy for anyone to “dig up” snippets from various research articles to win an argument using limited portions of the scientific research data. The peer review doctor went on to quote many research articles of disc findings in asymptomatic patients, none of which had any bearing on the case at hand, but were all just “fluff” in an attempt to misdirect the reader. In spite of the peer review doctor’s attempt to discredit the treating doctor, this issue is a standard of care issue and goes well beyond the necessity of one patient.
The standard of care currently taught at the doctoral and post-doctoral levels is with the presence of significant radicular or myelopathic findings that corroborate with the patient’s clinical presentation of signs and symptoms, an immediate MRI is warranted in order to determine an accurate diagnosis. In the absence of either, conservative care is warranted for 6-8 weeks. Should the pain pattern persist in the absence of either a radiculopathic or myelopathic presentation, then an MRI could be considered to determine the etiology of the unexplained persistent pain. A radiculopathic or myelopathic finding may indicate a significant space occupying lesion that could signify disc issues, tumors, varices, tethered cord issues and many more co-morbidities. Without advanced imaging, the practitioner is treating an undiagnosed condition blindly in the presence of positive clinical findings and treatment may end up with the opposite effect, hurting the patient, in many cases, irreparably.
It was reported by Fish, Hisashi, Chang and Pham (2009) that “Perhaps the more meaningful portion of our study was the one in which we limited positive-MRI findings to those with major severity because lower-grade radiologic findings can be common and clinically insignificant. Disk protrusions are particularly common findings in cervical MRIs of asymptomatic patients. Mild cervical stenosis are very common, as well. Also, only significant nerve root compromises are generally expected to exert associated symptoms. It has been reported in a lumbar study that a mere contact of nerve root by disk material is usually not associated with neurogenic symptoms, whereas a compression does seem to be important in this regard. To evaluate MRIs ability to predict treatment outcome, it would be more valid to limit positive MRI findings to only those that will likely have symptomatic effects” (p. 243).3 This statement reflects the clinical standard stated previously, which is to limit an immediate MRI to a significant radiculopathy or a myelopathy.
The peer review doctor further went on to discuss studies of disappearing herniations with language that is very misleading. It is a physiological “truism” that discs shrink over time in a process called desiccation and a physiological phenomenon that begins as soon as 2-3 days post trauma. The peer review doctor’s statement, a form of misdirection and misuse of physiological facts, still does not answer the direct question clinicians have to answer, “What is the underlying pathology (co-morbidity) creating the clinical signs and symptoms?” A practitioner will not be able to conclude an accurate diagnosis, prognosis and treatment plan without an MRI in the presence of significant radiculopathic or myelopathic findings. The peer review doctor’s opinion, should it be adhered to by practitioners, will be the cause of many innocent injured patients being hurt further and possibly experiencing a delay in necessary proper treatment, surgery or proper and timely triaging in potential cancer patients. In addition, should his opinion be adhered to, it could be the cause of many doctors facing licensure misconduct issues.
Although this doctor is entitled to his opinion as a peer reviewer, his “blanket statements” are not in the best interest of the public’s health. Peer reviewers get tremendous latitude at the expense of patients and often at the expense of the doctors in trying to create standards where they have no right. Chiropractors have additional issues regarding “risk factors” that are not shared with their medical counterparts. In some of the medical literature, it clearly states that immediate MRIs are not warranted for various reasons. However, most of those authors have no training or knowledge of chiropractic care. Chiropractors usually deliver high velocity thrusts into the spine, a very safe form of care unless a risk factor is present. Although in certain tumors or central canal stenosis immediate MRIs are warranted with overt symptomatology, it would not be considered the standard of care to use MRIs as a screening process to look for possible tumors without those overt signs and symptoms, as the cost factor far outweighs the benefits. However, with the clinical presence of significant radicular or myelopathic findings, it is a current standard of care for the chiropractor to determine the etiology as the risks significantly increase with co-morbidities by delivering high velocity thrusts without first having an accurate diagnosis.
In considering the cost vs. benefit when ordering MRIs, chiropractic offers a savings of $5.74 billion over medicine and physical therapy4 for low back conditions alone, thereby validating the benefit of immediate MRIs with chiropractic care when clinically indicated. Should a chiropractor deliver a high velocity thrust into a patient with co-morbidities, including, but not limited to, the cause of radiculopathy or myelopathy and hurts the patient or delays necessary surgery or medical care in the case of tumors, that chiropractor would be subject to licensure misconduct by his/her state board for not following the standard of care.
Peer reviewers realize that doctors and lawyers often do not have the ability to understand how to use research and more often lack the ability to look up citations. This peer review doctor’s actions of partially quoting a published “opinion article” is problematic and common among unethical peer reviewers. According to a chiropractic board member in the State of New York, this peer review doctor’s lack of full disclosure is a potential licensure misconduct issue and should be reported in a complaint to the state’s disciplinary board. Unless treating doctors take the time to read all of the research quoted in the peer review reports and IME reports, this abuse will continue unnecessarily. By refuting inaccurate peer review reports with additional facts from the same research paper(s) originally used, identifying misquoted information and using research to support your care, the truth will prevail in court because of the presentation of the complete set of facts. If you add the licensure complaints to root out the “unethical doctors,” the goal of rendering and being compensated for necessary care can be achieved. In the end, the real winners are the patients being afforded necessary care to get well.
REFERENCE:
- New Jersey Law Revision Commission (2004). Medical peer review. Retrieved from http://www.lawrev.state.nj.us/medicalpeerreview/mprM083004.pdf
- Grover, F., (2003). Is MRI useful for evaluation of acute low back pain? Journal of Family Practice, 52(3), 231-232.
- Fish, D., Kobayashi, H., & Pham, Q. (2009). MRI prediction of therapeutic response to epidural steroid injection in patients with cervical radiculopathy. American Journal of Physical Medicine & Rehabilitation 88(3), 239-246.
- Studin, M. (2011). The chiropractic solution for work related injuries, Recurring LBP and chronic care. Dynamic Chiropractic, 29(18), 13, 29, 34.