Citizen Journalism: Why I Blog on Healthcare Informatics

I am teaching my current students about alternate media, a.k.a. citizen journalism, also known as "blogging", in a course on organizational and social aspects of healthcare informatics.

I am using a (de-identified) personal experience as an example of why alternate media is valuable in getting "inconvenient" memes into circulation.

In addition to recent articles such as "The Problems with Peer Review" (in the British Medical Journal by Mark Henderson, Science Editor, the Times, London. BMJ 2010;340:c1409), "Ghostwriting at Elite Academic Medical Centers in the United States" (LaCasse & Leo, PLoS Medicine, February 2010, Volume 7, Issue 2) and others about ghostwriting and other ills affecting the conventional biomedical literature, I provided my students the personal example below.

I thought the example might be interesting to blog readers as well.

Here is the example I used with my students:

Regarding a paper I wrote a few years ago and that I ultimately simply posted on Scribd, "Remediating an Unintended Consequence of Healthcare IT: A Dearth of Data on Unintended Consequences of Healthcare IT" (link), an anonymous peer reviewer had this to say when I submitted it to "journal XYZ":

Comments to the Author

This paper addresses a potentially important issue but adds little that is new or that goes beyond what a reader might find in a major city newspaper. Proposing a classification of sources of UC and analysis of reasons for undereporting of each type in the resulting classification could be a useful addition to the field.

This was certainly an ironic if not bizarre comment. A paper on a scarcity of data on unintended consequences of health IT due to a "closed culture" in the HIT industry does not add anything new "beyond what one might find in a major city newspaper?"

Unfortunately, the anonymous peer review process does not allow me to ask what newspaper this reviewer reads, but it was clear to me this reviewer was 1) attempting to prevent the paper's publication and 2) "moving the goalposts" to delay it or have the focus on scarcity removed by seeking for me to "propose a classification of sources of UC" (tangential or even irrelevant to the paper's topic).

I felt it likely the review of a revised paper by this reviewer would have led to negative comments on any proposed classification schema.

Worse, was this, in a dialog via several emails I've condensed for readability. It is very likely it came from the same reviewer above:

EDITOR OF JOURNAL XYZ: I suggest Scot that you modify this into an editorial. One reviewer recognized the writing and asked me if this may have been pre-published on a blog. Any possibility for that?

In other words, I was being accused by the anonymous reviewer of possibly violating the ethics of journal publication and the contract I signed to not pre-publish (the journal has exclusive rights).

My response:

SS: No, this work was entirely original, written from a clean slate, and was not pre-published on a blog. I would think the reviewers would know me better than that in terms of integrity.

The editor shot back:

EDITOR: My response as well. Good - looking forward to the edits. Happy snow day

I reminded the editor:

SS: Not to mention the extensive footnotes showing where I sourced my material. In an age of search engines, I have to ask the following:

- was the person who raised this concern so technologically limited they were unable to search themselves to answer their own question?
- did this person have such a lack of trust they felt compelled to make such a statement?
- did this person raise this due to bias against the fundamental thesis of the paper?

I think it's fair to say there is very, very strong pushback against articles such as this being published. I have to consider whether it's worth my while to continue, or to withdraw the paper.

At which point I received the following revealing comment from the editor:

EDITOR: I think, Scot, that you have a talent for sniffing out problems, dangers, risk, failures and by addressing them in your head on ways, you are likely to make enemies. You are doing a valuable job, but you have to realize that people are threatened by you. That's why the respond in this manner. Not that it is excusable, but it is understandable.

I decided it was not worth revising the paper due to that reviewer's comments and the editor's observations, and therefore disseminated the paper via the Healthcare Renewal blog and Scribd.

(I note that "making enemies" by directly confronting possible risks of a new technology in healthcare suggests skewed priorities among those so affected.)

While I believe the current Wikileaks web exposures have gone insanely too far, as those incidents involved exposure of sensitive material held illegally that could people to be harmed, damage international relations, and cause other unforeseen ill effects, the web has proven valuable for dissemination of one's ideas that have not been able to escape the gravity of the sometimes "peer review Black Hole."

-- SS

Sham Peer Review: Could This Bad Faith Practice Contribute to the Silence About Healthcare IT Problems?

Health IT problems and failures seem to be rarely heard about in the public media, yet almost every physician and student I know, including those actively involved in HIT projects, privately tell me of many mishaps, traps and difficulties they encounter frequently. Some of these problems impact patient care, up to and including some only-by-the-grace-of-god "near misses" - and worse. They also state they do not want to be quoted publicly for fear of reprisals.

While I'd thought that part of this issue was fear of retaliation from vendors and hospital executives for contractual "defects gag clause" violations, another practice that may be uncomfortably common might also be a significant contributor to the general lack of information about bad HIT: bad faith ("sham") peer review.

Sham peer review or malicious peer review is a name given to the alleged abuse of a medical peer review process to punish a physician for personal or other non-medical reasons (Wikipedia).

This practice is really a show trial for physicians deemed by hospital management to be whistleblowers (e.g., on quality issues) or troublemakers. Sometimes it is used as a tool by competing physicians as well.

The article "Tactics Characteristic of Sham Peer Review" (PDF) by Lawrence R. Huntoon, MD PhD of the American Association of Physicians & Surgeons spells out some of the characteristics of this process:

The tactics used by hospitals and others in conducting a sham peer review are remarkably similar throughout the country. The common feature of these tactics is that they violate due process and/or fundamental fairness, and they often represent an attempt to make the incident or event "fit the crime."

Although our legal system is not perfect, it does incorporate sound principles and procedures designed to protect an accused individual's right to due process and fundamental fairness (e.g. an accused person is considered innocent until proven guilty). In evaluating the fairness of peer review, one can often find corresponding principles of due process and fundamental fairness in our legal system.

This article is worth reading in its entirety. It details tactics such as:

• Ambush Tactic and Secret Investigations - unprepared physician is surprised by what amounts to a well-organized interrogation panel

• Depriving Targeted Physician of Records Needed to Defend Himself - bureaucracy and red tape prevent a physician from mounting a timely defense.

• Considering a physician "Guilty Until Proven Innocent" - burden of proving innocence shifted to the accused physician.

• Numerator-Without-Denominator Tactic - cherry picking of cases to unfairly highlight (unavoidable) adverse outcomes.

• Misrepresenting the Standard of Care - hospital administration hires an outside expert who opines that because the targeted physician did not use the same surgical technique or medical treatment that the expert prefers, the targeted physician must be practicing beneath the standard of care.

• Trumped-Up and/or False Charges - "spin" and outright fabrications are deployed.

• The "Disruptive Physician" Label - this deserves full explanation here:

The definition of "disruptive physician" is highly subjective and subject to manipulation and abuse. Recently, the general and vague definition of "disruptive physician" has been fortified with the more specifically vague and subjective descriptions in the "Code of Conduct" as promulgated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Nonverbal conduct, such as facial expression and body language, can be used to label a physician "disruptive," and no evidence is required beyond how the accuser feels. [Unbelievable - Ed.]

Increasingly, the term "disruptive physician" has become synonymous with "mentally impaired" physician. A physician who is wrongfully labeled "disruptive" because he does not agree with the hospital administration's views, or complains about substandard care in the hospital, can be subjected to inpatient treatment at a facility that specializes in treating "disruptive physicians." "Treatment" at one of these facilities may include treatment with medications, which if the "dissident physician" refuses to take "voluntarily," may result in automatic termination of privileges for failure to comply with the recommended "treatment." Physicians typically emerge from one of these "treatment" facilities with psychiatric diagnoses of narcissistic personality disorder, obsessive-compulsive disorder, or both.

• Dredging Up Old Cases from the distant past to Justify Summary Suspension

• Ex-Parte Communications - although such communications taint the entire hearing process and clearly violate fundamental fairness and due process, hearing officers, hired by the hospital, often allow ex-parte communications.

• Hospital Attorney or Conflicted Attorney Used to Influence the Peer Review Process - Hospitals that employ sham peer review often will use an attorney who represents the hospital or who represents both the hospital and medical staff simultaneously (i.e. a conflicted attorney) to influence the peer review process.

• Bias - e.g., stacking the investigative committee or hearing panel with physicians who have personal animus or bias against the accused physician; allowing the prosecution much more time to review records or present the case than the targeted physician; etc.

Also see the article "Twelve Signs of Sham Peer Review" here by a healthcare law firm.

Also of interest is "Readers' Responses to the Letter by Chalifoux and the Editorial by Bond in Regard to Sham Peer Review" at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1681969
in response to an article by Roland Chalifoux, Jr, D.O. entitled "So what is a sham peer review?", MedGenMed. 2005;7:47 available at Medscape here.

If the threat of sham peer review is being leveraged against physicians who are deemed "complainers" or "troublemakers", to the point of prosecution for facial expressions deemed "disruptive" by others, than it is understandable how physicians might be reluctant to complain about multimillion dollar HIT projects (the outcomes of which hospital executives' reputations and career advancement may depend upon) that have gone awry.

Finally, I should probably ask: does sham peer review contribute to silence about healthcare C-suite mismanagement and malfeasance in general?

-- SS