Imagine you’ve worked in a clinical environment for an extended period. You might be a resident or fellow getting ready to graduate, an attending who has been operating for years, or a full-fledged partner in private practice. As your morning alarm sounds, you check your email and see: “Informal Meeting–Mandatory.” The content of the email is vague, but it seems you’re being asked to meet with several colleagues in your department to discuss your recent performance. The sender claims this is standard protocol, but you’ve never attended such a gathering for other colleagues. While brushing your teeth, your post-call brain starts processing this mysterious meeting. What could they want to talk about? You scan through your memory to that weird patient interaction, that time you forgot to sign a chart, every time you were distracted, and fear sets in: What have I done? It could be anything.
The days leading up to the meeting are tense. You want to ask colleagues what the meeting is about, but you figure it’s better to be nonchalant. Play it cool. How bad could it be? You reassure yourself: “You’ve made it through 100 percent of your worst days.”
On the day of the meeting, you see higher-ups and some of your friends around a large conference table. Your heart races as you attempt to steady your breath. Finally, someone speaks. “It’s come to our attention that you’ve not been performing your work duties up to expectation. We’ve put you under a performance improvement plan for the next three months, including monitoring your charts, time spent with patients, and a thorough review of your procedures for the past six months. Your cooperation with this standard process, which is meant to provide the highest quality care, is appreciated.”
Confused, you ask for specifics, such as an example of what prompted this investigation. You assure yourself that your best strategy is to be compliant. This will all blow over quickly. But epinephrine and cortisol have flooded your bloodstream, and you’re struggling to control your outrage and befuddlement, wondering how you’re going to focus on any of your responsibilities.
You tell a coworker, your chosen confidant, what’s going on. They reassure you to stay calm, that they’ve got your back. However, an estrangement develops after you learn that your confidant is part of your peer review. Your efficiency precipitously declines, cementing your purported incompetence.
You confide in your best friend from college who is not in medicine. They encourage you to get a lawyer. You remind them the committee specifically said no lawyers could be present, prompting further questions: What do the bylaws say? You don’t know. You just know it’s important to cooperate for self-preservation. You’ve been convinced lawyers are out to get you, so you’re afraid to hire one.
The dreaded day arrives when the committee reconvenes. They’ve found you’re not only performing below standard, but there’s hearsay you’re a “disruptive physician.” They hand you anonymous evaluations describing how you left the OR to go to the bathroom, that you were five and fifteen minutes late to work on two occasions, and that a family member complained you weren’t nice to the patient. You were so close to advancing to your next career milestone, and now a part of you fears that will never happen. You find it strange that you’re still taking full responsibility for call and weekend coverage alone, even amid speculation that you may be incompetent.
“Sham” means something that is not what it’s purported to be: bogus, false, to falsely present something as the truth. The story I’ve placed you in above is an abstraction of a strategy that is taking hold nationwide. In preeminent academic institutions, training programs, and private practices, sham peer review proceedings are being used to expunge colleagues for a variety of petty reasons, none of which are readily disputable. No standardized system of checks or balances exists. Put differently, there’s no way to prove that the person making an accusation is any more reputable or competent than the accused, only that they feel “safer” or more empowered to make a claim. All it takes to prompt a sham peer review is for a person who has more perceived power than you to casually comment, “That person doesn’t seem competent to me,” or “They just don’t fit in here,” and the domino effect kicks in. Add that to the list of things that make working in medicine psychologically unsafe.
What’s ironic is that we’ve invested so much trust in the institution of medicine that we inherently believe it will care for us, too. We believe we’ll be compensated and safe forever. I remember my own parents telling me to go into medicine: “You’ll always be needed. You’ll always be able to get a job.” But this is no longer the case. Sham peer reviews are keeping trainees from graduating, leaving mid-career physicians scrambling to find work and academic superstars bargaining for pardons—all in the midst of massive doctor shortages.
Tracey O’Connell is a radiologist and physician coach.
