Canadian Psychiatric Association Journal Vol. 22
Ottawa, Canada, March 1977
No.2
General Papers PEER REVIEW FOR CANADA Its Dangers and Potentialities*
IAN KENT, M,D.! WILLIAM NICHOLLS, M.A. (Cantab.)"
Introduction Canadian psychiatrists have recently become aware of the development of peer review in the United States. Since the factors which have led to this and the associated developments, such as proposals for periodic re-certification and even relicensure, are also present in Canada, the time has arrived for the profession to become more conscious of the issues involved in peer review. This need has been recognized by the Canadian Psychiatric Association by the setting up of two task forces to study these questions - the first under the chairmanship of Dr. C.A. Roberts; the chairman of the second has yet to be appointed - CPA Bulletin, May, 1976. Fortunately, it seems that the pressures favouring an evolution in Canada similar to that which is taking place in the United States have not yet become so powerful or so urgent as to compel a hasty and perhaps ill-judged adoption of measures which have yet to prove their efficacy in the United States. Perhaps Canadian psychiatrists will have sufficient time for reflection, both upon the
USA experience as it develops, and upon the distinctive situation in Canada. It would be generally agreed that there are significant differences between Canadian and American professional conditions, such as the much greater effectiveness of specialist certification in Canada. However, Canadian psychiatry has also evolved further in the direction of dependence on public funds, and this can only lead to eventual insistence on external or internal measures of economy in expenditure and quality control. In this paper an attempt is made to offer a critical survey of the relevant American literature on peer review and the topics associated with it, as well as to draw attention to highly significant issues which seem to have been neglected or passed over lightly in the American discussions. Some suggestions for Canadians, based on this survey, are offered.
Factors in the Development of Peer Review Peer review in medicine generally, and in psychiatry in particular, is not simply a spontaneous development within the pro'Manuscript received September 1976. The authors are jointly fession; it is also a response to external engaged in a long-term interdisciplinary project on Identity. pressures. No doubt the response to these 'Psychiatrist in private practice and Honorary Research pressures could build on a foundation of Associate in the Department of Religious Studies at the University of British Columbia. professional concern for the maintenance 'Professor and Head, Department of Religious Studies. and upgrading of standards of health care Chairman, Faculty of Arts Committee on Teaching Evaluation and Improvement, University of British Columbia. delivery. But until these external pressures Can. Psycbiatr. Assoc. J. Vol. 22 (1977) began to be strongly felt, the actions 49
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described later in this paper were not taken by the psychiatric profession either in the United States or Canada. Medicine has come under growing pressure in recent years from an increasingly well-informed and critical public. Consumerism has become a force even in psychiatry. The public is no longer prepared to accept in blind faith lengthy and expensive treatment which produces little or no perceptible change, and it is becoming increasingly sceptical of the value of long-cherished methods such as psychosurgery and ECT. The profession has begun to experience the necessity of accounting for its activities to the educated public. However, the pressure which seems actually to have triggered the development of systematic peer review in the USA came from third-party payers for medical care, whose role is rapidly increasing in the United States, and has actually become dominant in Canada, since the entry of the federal government into the field of Medicare. Third-party payers, whether government or the various public and private insurance schemes in the United States, want to see value for their money, and they do not share the inhibitions of most patients against aggressively demanding that they get it. This demand impinges on psychiatry with particular force, because of the specific nature of the care given, and the way in which it is customarily accounted and paid for. To the cost accountant in an insurance office, psychiatric care appears disconcertingly open-ended and therefore liable to be intrinsically costly, as compared with other forms of medical care. It is accounted for in hours of treatment instead of in specific services. There is no clear relationship between diagnosis and the length of treatment necessary. In consequence pressure arises either to exclude psychiatry from coverage under a medical insurance scheme, or to set arbitrary limits (from the point of view of the provider) to coverage where it exists, or to insist on accountability to the payer for the quantity as well as the quality of the care provided.
Vol. 22, No.2
The Profession's Response
The development of peer review has come about as the profession's response to these pressures. It aims at preserving the highest possible level of funding for psychiatric care, at making desirable economies in the expenditure of these funds so that they can be available to those in greatest need, and at retaining the control of professional services in informed professional hands, so that standards of care may rise at the same time as costs are stabilized or begin to fall. In the United States, peer review is already required by law since 1972, under the provisions of Public Law 92-603. An amendment to this enactment, of which the author was Senator Wallace F. Bennett, M.D., from Utah, required the setting up in every state, area and district of Professional Standards Review Organizations (PSROs). The duty of PSROs is to monitor the standard of all publicly funded institutional care, both inpatient and outpatient, including psychiatry. The medical profession in the USA was at first strongly opposed to this development, and a wide body of rank-and-file opinion favoured nonimplementation of the law and working for its repeal. Under the guidance of its leadership, however, the profession eventually changed its stance, coming to believe that only by cooperation could the review of medical services be secured for professionals themselves. It was foreseen that noncooperation would inevitably lead to control passing into lay and bureaucratic hands, with results that would be restrictive both financially and qualitatively. Government control would be likely to lead to priority being assigned to saving dollars over the quality of medical care: peer review, though unwelcome, offered hope that medical priorities would prevail, while desirable economies could still be obtained. The American Psychiatric Association (APA) also took the lead in implementing the measures calling for PSROs, and peer review components have been set up, or are in the process of being set up, in almost every district branch. (10)
March,1977
PEER REVIEW FOR CANADA
Canadian Parallels The potential for a similar demand for accountability and lay or peer review clearly exists in Canada also. The vastly increased role of public funding for psychiatric care, the soaring costs of health care delivery in general, and the inflationary pressure on all public expenditure, make such a development inevitable. Provincial medical plans already limit coverage for psychiatric care. While complete information is not easily available, the arrangement in the Province of British Columbia is presumably fairly typical. Coverage for office treatment is limited to six months; further treatment must be justified by the physician on the ground of specific medical need. Re-referrals are also permitted, on the same terms. Measures for tighter control would probably include reconsideration of the six-month period and its replacement by a fixed number of hours, with requirement for review at the end of this period, instead of simple justification by the physician himself. It would be wise for the profession to prepare itself for such developments. If review is necessary in any case, peer review is obviously preferable to outside review, whether simply lay or bureaucratic. What are the dangers and potentialities of peer review? What does it mean in practice? Could Canadians learn from USA experience to devise a system which, if not necessarily intrinsically superior, might at least be better adapted to Canadian conditions? Problems of Peer Review Simple answers to such questions are not easy to come by. The demand for accountability and quality and cost control comes at a time of peculiar difficulty for psychiatry. The discipline is notoriously going through a period of theoretical fragmentation which may be deplored as a weakness, or regarded as a sign of health. Disagreeme,nt runs to the very roots of both theory and practice and it touches precisely those points which are basic to cost and quality control diagnosis, etiology, treatment, relationship betweeen diagnosis and the kind and length of treatment, and even criteria for success.
51
Notoriously, effectiveness in psychiatry is extremely difficult to specify, measure and evaluate, whatever one's orientation (I I p. 672). Evaluation has not been, and perhaps never will be, put on a fully objective and scientific basis. However, the pressures described tend to short-circuit theoretical debate and the attempt to establish clear concepts and to provide evidence for the superiority of one methodology in treatment over another, and hence to favour a quick (not to say premature) decision for brief therapy and 'brief therapists' (5 - p. 1359). This is not to deny that speed may be one criterion of effective therapy. Peer review has other inherent difficulties, independent of major or minor theoretical disagreements. It is a potential threat to confidentiality, more necessary in psychiatry than in other branches of medicine. It arouses anxiety and resistance in those under review, which may lead to provision of inaccurate information to a board. It locates enormous power over the profession in the hands of a review board. In view of the weight of responsibility faIling on such a board, it is difficult to find in every area staff of sufficient (necessarily superior) competence to serve on it. And since such persons must be compensated for their time, skill and professional experience, it is difficult to determine what the level of such compensation should be. Defenders of peer review have contended that all these difficulties, if acknowledged and faced, can be overcome, and that the outcome has been and will be beneficial both economically and professionally (1, 6, 8).
Unfortunately, peer review is not an issue which can be considered in isolation from other burning problems. Theoretical disagreement has already been touched upon. However, process studies are based on the assumption that there are generally accepted methods of treatment. Peer review is defined as a process study, as opposed to an outcome study, which would evaluate the success of treatment after its conclusion (6). As so far practised in the United States, peer review takes place after a standard
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number of hours of treatment (determined by profiles of practice for each common condition diagnosed). At this point, the therapist presents a treatment plan to the review board, which will authorize further treatment as it sees fit. Peer review could, of course, be further developed to include the whole course of treatment, thus also involving outcome studies. But these, as we shall see, present greater theoretical and practical difficulties. To read some studies advocating peer review it would be easy to suppose that these' generally accepted methods of treatment', on which the feasibility of process studies (to say nothing of outcome studies) depends, actually exist, and that by conscientious application of the PSRO manual, DSM Ill, model criteria sets, and other productions of the APA and its diligent task forces, a streamlined professional approach to the problems of peer review will readily be attained. This is self-deception of a high order, in view of the theoretical and practical disagreements between psychoanalysts and behaviour therapists, psychopharmacologists and existentialists, upholders of the medical model and those who would break with it in favour of some radically different model. Continuing Education and Re-certification Quality control is necessarily linked with education. A perceptive paper (8) argues that peer review can be made a much less threatening and more constructive experience for all concerned if it is regarded as an educational rather than an evaluative or controlling process. This contention seems well-founded; it is one of the few pointers to emerge clearly from the American literature. However, behind education through peer review lurks an even more threatening prospect of compulsory re-education, linked to re-certification and possibly relicensure. The APA has already moved to require 150 hours of continuing education in each three-year period as a condition of maintaining membership in the professional body (Psychiatric News, June 18, 1976). A report by the influential American Group for the Advancement of Psychiatry
Vol. 22, No.2
(GAP) (11) deals with the whole question of re-certification in a comprehensive way. In contrast to the Canadian situation, less than half of the membership of the APA has applied for and received certification by the American Board of Psychiatry and Neurology. Obviously measures would have to be taken to bring the level of certification in psychiatry up to the 90 percent or more, commonly found in other medical specialties, before voluntary re-certification could have a significant impact on the competence of the profession as a whole. However, the same economic pressures are being felt here as in the case of peer review. If the trend among third-party payers to offer income premiums to certified specialists continues, voluntary certification and eventually recertification will probably become the norm - or, to put it differently, cease to be voluntary. However, the GAP report shows clearly how fragile is the basis on which the whole structure of re-certification would rest. The difficulties of evaluating the quality of psychiatric care, especially office psychotherapy, are at present so formidable that the group is forced to resort to phrases like "a variety of methods' ,, "other innovative techniques", "mechanisms as yet to be developed", and "some other as-yet-to-be-discovered technique", to define crucial elements in the evaluative process that will be a prerequisite for the re-certification of already certified psychiatrists (11 - pp. 681, 689). Although the task force has recommended that voluntary re-certification "could and should" begin by 1978" the proposal actually refers to only one element in the complex structure of re-certification multiple-choice examinations to test that the specialist has "kept up to date with the advances in psychiatry." What are these advances? Apparently they are largely confined to neurophysiology, molecular biology, psychopharmacology and genetics, although there is a reference to advances in "our understanding of psychiatric diagnosis (DSM III) and psychophysiologic states" (11 - p. 653). As the same report rightly points out (p. 687),
March,1977
PEER REVIEW FOR CANADA
53
criticism, but unless we believe that debate and criticism are inherently unhealthy, it would seem unwise to pre-empt the development of a major identity crisis by administrative action and in response to external and mainly economic pressures. Certainly the extent of our present knowledge of how to conduct comparative evaluations of different methods in psychiatry does not justify the foreclosure of research and debate on questions of such fundamental importance to a comparatively-new and still rapidlydeveloping discipline. If education will make the profession aware of its own crisis and the astonishing fluidity of its current theoretical basis, it can only do good. But the proposals coming out of the United States sound much more like the administrative imposition of a 'medical-model' approach which is certainly widely accepted, but is also the object of responsible and The Identity Crisis in Psychiatry carefully-researched criticism. We are not Like the pressure for the adoption of ready for uniformity in psychiatry, however standard forms of diagnosis, model criteria good it will make us look with the cost sets and so on, the pressure for re-education accountants. and eventual voluntary (no doubt later to become compulsory) re-certification seems Professional Education The theoretical fragmentation of hard to resist, if one is concerned with the quality of medical care delivery, the psychiatry leads in turn to weaknesses in maintenance or upgrading of the standards professional education, which will inevitaof the profession, and the elimination of bly be reflected in continuing education, substandard care. However, a moment's which is an element in peer review, as well reflection should convince us that things are as in future requirements for renot as simple as that. Robert Spitzer, M.D., certification. University and hospital trainchairman of the APA Task Force on ing of psychiatric residents endeavours to Nomenclature and Statistics, which is be eclectic, and at least to acquaint the responsible for bringing out the new DSM student with the latest developments (4). Ill, recently stated forthrightly that "We But it is notoriously deficient in fostering remain four-square within the medical the personal growth of the resident in model in our approach to the classifica- training, and in dealing with inner problems tions" (Psychiatric News, June 18, 1976). that may later become an obstacle in What is true of DSM III is also true of model interpersonal relationships with his or her criteria sets, PSROs and indeed of the patients. Only the psychoanalysts insist on a assumptions on which the public funding of thorough personal training - therapeutic psychiatric care is now based. Yet in even more than didactic, according to psychiatry's present deep and widespread Lorand (7) - to equip residents to deal with identity crisis, nothing has been more problems they will encounter in relation to frequently or stringently criticized than the actual patients (2, 9). These deficiencies in medical model (12). training bias the profession as a whole in the The medical model mayor may not direction of objectifiable, intellectual eleemerge strengthened from the fires of ments in psychiatry, such as the famous ., .. , in order to develop a certification process which will be viewed favourably by the profession, major improvements in our existing techniques will be required. This calls for substantial planning and research. " We are still in the region of pious hope. Planning and research, the panaceas of a technological society, are to be relied upon to produce essential components of a system whose implementation is recommended almost immediately, although the authors of the report have as yet almost no idea of the direction in which to look for these indispensable advances on our present knowledge. Unfortunately, a casual reading of this report, or one largely confined to its recommendations, could give the impression that re-certification is ready for implementation. One can only hope that the influential third-party payers do not draw this decidedly premature conclusion.
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standard diagnostic categories, psychopharmacology, behaviour modification, hospitalization, and so on, to the neglect of those (in the view of many researchers) all-important aspects in which the personality of the therapist and his interaction with his patients are paramount. These weaknesses will be amplified, and tend to increase almost exponentially, if the key personnel in peer review and continuing education are to be drawn from the same sources as the original educators of psychiatrists. What are the Priorities? If all these well-intentioned qualitycontrol measures are implemented too quickly, without sufficient thought being given to their possible side effects, psychiatrists will in future find themselves spending a considerable proportion of their time and energy in fulfilling essentially managerial requirements. Some may find this temperamentally congenial, but perhaps these are not the temperaments best suited to undertake psychotherapy. It is not as clear to the rest of psychiatrists that the time and energy so expended will lead to a proportionate improvement in patient care. Behind these managerially-oriented demands for accountability in the expenditure of funds, and for quality-control measures, is a massive fact which psychiatrists will ignore at their peril. Professional credibility in the eyes of the public is rapidly being lost. The educated public can and does read the works of the professional critics of psychiatry's present state, as well as more popular books and articles which give the impression that the specialty is in a very serious condition. The growth of a vast profusion of alternative 'therapies' outside professional control would certainly not have been possible had professional credibility been fully maintained. That psychiatry is undergoing an 'identity crisis' is now fully acknowledged by responsible spokesmen, such as Judd Marmor. Perhaps peer review, with all its somewhat frightening potentialities, also has latent within it the possibility of. becoming a form of therapy for this crisis in psychiatry itself.
Vol. 22, No.2
Positive Potentialities of Peer Review Attention has been drawn to some of the dangers to be discerned in the perhaps inevitable development of peer review, re-certification and similar quality-control measures. But to become aware of a danger is notoriously the first step to averting it. The most hopeful aspect of peer review lies in its inseparable connection with education. If review cannot be separated from education, education in turn cannot be separated from growth in self-knowledge and a capacity to interact with other persons both one-to-one and in groups. If the continuing education to which peer review must lead will foster the development of these capacities, as well as more easilyobjectifiable knowledge and skills, psychiatry will be in the best position to regain and enhance its now diminished credibility with the public. If imaginatively and constructively used, for the intrinsic purposes of psychiatry, rather than for withstanding external and managerial pressures, peer review has great positive potentiality. Over a period of time, the experience gained in peer review could gradually lead to the development of more adequate methods of evaluation of psychiatric success, and hence to the possibility of eventual resolution of some at present rather sterile theoretical debates. If carried out, as it should be, in an educational or even 'therapeutic' manner, peer review could be of considerable usefulness to psychiatrists in their professional development. Counter-transference problems could be presented and resolved. New aspects of previously intractable cases could . be drawn to the attention of the therapist. Relations between professional colleagues could be deepened and thus greatly improved. Peer review could in itself become a magnificent form of continuing education through sharing of professional experience. This is the kind of knowledge which is not likely to be found in text-books of psychiatry, and is unfortunately not easy to pass on to psychiatric residents. A Canadian Peer Review Scheme? In Canada, demand for peer review has not yet become urgent or pressing, though
March, 1977
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no doubt it soon will. There is a little time left for reflection before action becomes necessary. Canadian psychiatrists should seize the opportunity to devise an indigenous system of peer review, learning from the American experience so far, but not slavishly copying their methods where they are inappropriate to our own needs. Too hasty adoption of borrowed methods could lead to the collapse of a whole scheme, opening the way to lay control. Even in the USA, the system created as a result of the enactment of Public Law 92-603 is still too new for a judgement to be formed on its effectiveness in meeting its declared aims, or indeed on whether it works at all. Certainly in Canada, any local initiatives to respond to economic and management pressures by instituting peer review boards should be preceded by a national study, which would evaluate the American experience and determine its applicability to Canadian conditions, as well as confronting the larger issues noted above. Pending such a study, the following suggestions are made. • The dangers inherent in the concentration of enormous power in the hands of review boards should be guarded against by relatively frequent rotation of membership. • In a country with as small a population as Canada, peer review should perhaps be a national rather than a local or even provincial undertaking. It is tempting to encourage each provincial psychiatric section to start doing something, but it would be better to learn from the other provinces by exchange of experience. Self-therapy is seldom profitable. • All theoretical orientations should be well-represented in the composition of review boards. A psychiatrist should not be expected to justify his procedures and treatment plans in relation to the criteria of orientations other than his own. • Improvement in the training of psychiatric residents would be the single most important measure for the long-term improvement of the delivery of psychiatric care. On the other hand,
failure to bring about this improvement will lead to the injection into the system of further under-trained practitioners requiring costly peer review and other corrective measures. Peer review should therefore be extended to the educational as well as the clinical side of the profession. Review boards for university and hospital teaching departments should include psychiatrists in private practice as well as fellow academics. • As suggested by the Report of the Professional Standards and Practice Council, a major portion, if not all, of the 1977 CPA Meeting should be devoted to these issues. Not just one, but a number of panels, symposia and workshops should be structured around these themes. A demonstration peer review could be presented so that psychiatrists can see how it is to be done, and offer their own constructive criticism. • On a provincial level, voluntary selfimprovement workshops should immediately be set up and be open to every member. • The whole profession should be involved in debate and planning on these issues, which will intimately affect every member. These suggestions are not intended to replace, but to supplement careful study of what is being done elsewhere. Together, the two approaches can lead to the development of a Canadian peer review system of superior quality. Acknowledgements The authors wish to thank Drs. C.A. Roberts, H. U. Penner and E. Lipinski for reading this article prior to publication, and in particular Dr. Penner for his comments.
References I. Cohen G.P., Conwell, M., Ozarin, L.D.,
Ochsberg, F.M.: PSROs: Problems and potentials for psychiatry. Am. J. Psychiatry, 131: 12, 1974. 2. Goin, M.F., Kline, F.: Countertransference: A neglected subject in clinical supervision. Am. J. Psychiatry, 133: I, 1976.
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Vol. 22, No.2
regard des depenses des fonds prevus par un troisieme parti de contribuables qui a conduit les Etats-Unis a mettre sur pied un plan de revision des depenses encourus par ces professionnels et ceci par leurs pairs. Cette revision faite par les pairs presente certains dangers. La psychiatrie traverse une crise didentite. Le desaccord theorique engage sur des points fondamentaux justifie cette revision par leurs pairs tels: Ie diagnostic, l'etiologie, la modalite, la frequence et la duree du traitement et les methodes pour en evaluer I'efficacite. Cette mise ajour par les pairs cree de la resistance et de I' anxiete chez les psychiatres concernes. Elle est egalement consideree par eux comme une menace a la relation confidentielle patient-rnedecin. Elle accorde aux membres du bureau de revision un pouvoir extraordinaire. Le lien propose entre cette revision et la recertication obligatoire est theoriquernent discutable et de plus devient une entrave additionnelle a la liberte professionnelle. La revue des pairs peut etre plus constructive en faisant valoir la formation au lieu de I' evaluation et du controle; on peut offrir une experience experimentee aux collegues qui ont a traiter des cas difficiles. Nous offrons des suggestion specifiques Resume pour Ie developpement d'un systeme auLes psychiatres canadiens subissent une thetiquement canadien de revision par les pression exercee par une responsabilite en pairs. 3. Gottesman, D.M.: Measuring attitudes about peer review in a university department of psychiatry. Hosp. Community Psychiatry, 25: I, 1974. 4. Gurel, L.: Some characteristics of psychiatric residency training programs. Am. J. Psychiatry, 132: 4, 1975. 5. Langsley, D.G., Lebaron, G.!., Jr.: Peer review guidelines: A survey of local standards of treatment. Am. J. Psychiatry, 131: 12,1359,1974. 6. Liptzin, B.: Quality assurance and psychiatric practice: A review. Am. J. Psychiatry, 131: 12, 1974. 7. Lorand, S.: The founding of the psychoanalytic institute of the State University of New York Downstate Medical Center. An autobiographical history. Psychoanal. Rev., 62: 4, Winter, 1975-1976. 8. Newman, D.E., Luft, L.L.: The peer review process: Education versus control. Am. J. Psychiatry, 131: 12, 1974. 9. Pasnau, R.O., Russell, A.T.: Psychiatric resident suicide: An analysis of five cases. Am. J. Psychiatry, 132: 4, 1975. 10. Sullivan, F.W.: Peer review and PSRO: An update. Am. J. Psychiatry, 133: I, 1976. II. GAP Task Force on Recertification. Recertification: A look at the issues. Group for the Advancement of Psychiatry, 1976. 12. Torrey, E. Fuller: The Death of Psychiatry. Radnor, Pa. Chilton, 1974.
Knowing, as I do, the difficulties attendant on the medical profession, I confess I feel a reluctance in recommending the pursuit of it; and yet I can say, were I to commence life anew, I know ofno profession, arduous as it is, that I should so cordially embrace. Letter to a friend, September 6, 1791 John Coakley Lettsom 1744-1815
Ottawa, Canada, March 1977
No.2
General Papers PEER REVIEW FOR CANADA Its Dangers and Potentialities*
IAN KENT, M,D.! WILLIAM NICHOLLS, M.A. (Cantab.)"
Introduction Canadian psychiatrists have recently become aware of the development of peer review in the United States. Since the factors which have led to this and the associated developments, such as proposals for periodic re-certification and even relicensure, are also present in Canada, the time has arrived for the profession to become more conscious of the issues involved in peer review. This need has been recognized by the Canadian Psychiatric Association by the setting up of two task forces to study these questions - the first under the chairmanship of Dr. C.A. Roberts; the chairman of the second has yet to be appointed - CPA Bulletin, May, 1976. Fortunately, it seems that the pressures favouring an evolution in Canada similar to that which is taking place in the United States have not yet become so powerful or so urgent as to compel a hasty and perhaps ill-judged adoption of measures which have yet to prove their efficacy in the United States. Perhaps Canadian psychiatrists will have sufficient time for reflection, both upon the
USA experience as it develops, and upon the distinctive situation in Canada. It would be generally agreed that there are significant differences between Canadian and American professional conditions, such as the much greater effectiveness of specialist certification in Canada. However, Canadian psychiatry has also evolved further in the direction of dependence on public funds, and this can only lead to eventual insistence on external or internal measures of economy in expenditure and quality control. In this paper an attempt is made to offer a critical survey of the relevant American literature on peer review and the topics associated with it, as well as to draw attention to highly significant issues which seem to have been neglected or passed over lightly in the American discussions. Some suggestions for Canadians, based on this survey, are offered.
Factors in the Development of Peer Review Peer review in medicine generally, and in psychiatry in particular, is not simply a spontaneous development within the pro'Manuscript received September 1976. The authors are jointly fession; it is also a response to external engaged in a long-term interdisciplinary project on Identity. pressures. No doubt the response to these 'Psychiatrist in private practice and Honorary Research pressures could build on a foundation of Associate in the Department of Religious Studies at the University of British Columbia. professional concern for the maintenance 'Professor and Head, Department of Religious Studies. and upgrading of standards of health care Chairman, Faculty of Arts Committee on Teaching Evaluation and Improvement, University of British Columbia. delivery. But until these external pressures Can. Psycbiatr. Assoc. J. Vol. 22 (1977) began to be strongly felt, the actions 49
50
CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL
described later in this paper were not taken by the psychiatric profession either in the United States or Canada. Medicine has come under growing pressure in recent years from an increasingly well-informed and critical public. Consumerism has become a force even in psychiatry. The public is no longer prepared to accept in blind faith lengthy and expensive treatment which produces little or no perceptible change, and it is becoming increasingly sceptical of the value of long-cherished methods such as psychosurgery and ECT. The profession has begun to experience the necessity of accounting for its activities to the educated public. However, the pressure which seems actually to have triggered the development of systematic peer review in the USA came from third-party payers for medical care, whose role is rapidly increasing in the United States, and has actually become dominant in Canada, since the entry of the federal government into the field of Medicare. Third-party payers, whether government or the various public and private insurance schemes in the United States, want to see value for their money, and they do not share the inhibitions of most patients against aggressively demanding that they get it. This demand impinges on psychiatry with particular force, because of the specific nature of the care given, and the way in which it is customarily accounted and paid for. To the cost accountant in an insurance office, psychiatric care appears disconcertingly open-ended and therefore liable to be intrinsically costly, as compared with other forms of medical care. It is accounted for in hours of treatment instead of in specific services. There is no clear relationship between diagnosis and the length of treatment necessary. In consequence pressure arises either to exclude psychiatry from coverage under a medical insurance scheme, or to set arbitrary limits (from the point of view of the provider) to coverage where it exists, or to insist on accountability to the payer for the quantity as well as the quality of the care provided.
Vol. 22, No.2
The Profession's Response
The development of peer review has come about as the profession's response to these pressures. It aims at preserving the highest possible level of funding for psychiatric care, at making desirable economies in the expenditure of these funds so that they can be available to those in greatest need, and at retaining the control of professional services in informed professional hands, so that standards of care may rise at the same time as costs are stabilized or begin to fall. In the United States, peer review is already required by law since 1972, under the provisions of Public Law 92-603. An amendment to this enactment, of which the author was Senator Wallace F. Bennett, M.D., from Utah, required the setting up in every state, area and district of Professional Standards Review Organizations (PSROs). The duty of PSROs is to monitor the standard of all publicly funded institutional care, both inpatient and outpatient, including psychiatry. The medical profession in the USA was at first strongly opposed to this development, and a wide body of rank-and-file opinion favoured nonimplementation of the law and working for its repeal. Under the guidance of its leadership, however, the profession eventually changed its stance, coming to believe that only by cooperation could the review of medical services be secured for professionals themselves. It was foreseen that noncooperation would inevitably lead to control passing into lay and bureaucratic hands, with results that would be restrictive both financially and qualitatively. Government control would be likely to lead to priority being assigned to saving dollars over the quality of medical care: peer review, though unwelcome, offered hope that medical priorities would prevail, while desirable economies could still be obtained. The American Psychiatric Association (APA) also took the lead in implementing the measures calling for PSROs, and peer review components have been set up, or are in the process of being set up, in almost every district branch. (10)
March,1977
PEER REVIEW FOR CANADA
Canadian Parallels The potential for a similar demand for accountability and lay or peer review clearly exists in Canada also. The vastly increased role of public funding for psychiatric care, the soaring costs of health care delivery in general, and the inflationary pressure on all public expenditure, make such a development inevitable. Provincial medical plans already limit coverage for psychiatric care. While complete information is not easily available, the arrangement in the Province of British Columbia is presumably fairly typical. Coverage for office treatment is limited to six months; further treatment must be justified by the physician on the ground of specific medical need. Re-referrals are also permitted, on the same terms. Measures for tighter control would probably include reconsideration of the six-month period and its replacement by a fixed number of hours, with requirement for review at the end of this period, instead of simple justification by the physician himself. It would be wise for the profession to prepare itself for such developments. If review is necessary in any case, peer review is obviously preferable to outside review, whether simply lay or bureaucratic. What are the dangers and potentialities of peer review? What does it mean in practice? Could Canadians learn from USA experience to devise a system which, if not necessarily intrinsically superior, might at least be better adapted to Canadian conditions? Problems of Peer Review Simple answers to such questions are not easy to come by. The demand for accountability and quality and cost control comes at a time of peculiar difficulty for psychiatry. The discipline is notoriously going through a period of theoretical fragmentation which may be deplored as a weakness, or regarded as a sign of health. Disagreeme,nt runs to the very roots of both theory and practice and it touches precisely those points which are basic to cost and quality control diagnosis, etiology, treatment, relationship betweeen diagnosis and the kind and length of treatment, and even criteria for success.
51
Notoriously, effectiveness in psychiatry is extremely difficult to specify, measure and evaluate, whatever one's orientation (I I p. 672). Evaluation has not been, and perhaps never will be, put on a fully objective and scientific basis. However, the pressures described tend to short-circuit theoretical debate and the attempt to establish clear concepts and to provide evidence for the superiority of one methodology in treatment over another, and hence to favour a quick (not to say premature) decision for brief therapy and 'brief therapists' (5 - p. 1359). This is not to deny that speed may be one criterion of effective therapy. Peer review has other inherent difficulties, independent of major or minor theoretical disagreements. It is a potential threat to confidentiality, more necessary in psychiatry than in other branches of medicine. It arouses anxiety and resistance in those under review, which may lead to provision of inaccurate information to a board. It locates enormous power over the profession in the hands of a review board. In view of the weight of responsibility faIling on such a board, it is difficult to find in every area staff of sufficient (necessarily superior) competence to serve on it. And since such persons must be compensated for their time, skill and professional experience, it is difficult to determine what the level of such compensation should be. Defenders of peer review have contended that all these difficulties, if acknowledged and faced, can be overcome, and that the outcome has been and will be beneficial both economically and professionally (1, 6, 8).
Unfortunately, peer review is not an issue which can be considered in isolation from other burning problems. Theoretical disagreement has already been touched upon. However, process studies are based on the assumption that there are generally accepted methods of treatment. Peer review is defined as a process study, as opposed to an outcome study, which would evaluate the success of treatment after its conclusion (6). As so far practised in the United States, peer review takes place after a standard
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number of hours of treatment (determined by profiles of practice for each common condition diagnosed). At this point, the therapist presents a treatment plan to the review board, which will authorize further treatment as it sees fit. Peer review could, of course, be further developed to include the whole course of treatment, thus also involving outcome studies. But these, as we shall see, present greater theoretical and practical difficulties. To read some studies advocating peer review it would be easy to suppose that these' generally accepted methods of treatment', on which the feasibility of process studies (to say nothing of outcome studies) depends, actually exist, and that by conscientious application of the PSRO manual, DSM Ill, model criteria sets, and other productions of the APA and its diligent task forces, a streamlined professional approach to the problems of peer review will readily be attained. This is self-deception of a high order, in view of the theoretical and practical disagreements between psychoanalysts and behaviour therapists, psychopharmacologists and existentialists, upholders of the medical model and those who would break with it in favour of some radically different model. Continuing Education and Re-certification Quality control is necessarily linked with education. A perceptive paper (8) argues that peer review can be made a much less threatening and more constructive experience for all concerned if it is regarded as an educational rather than an evaluative or controlling process. This contention seems well-founded; it is one of the few pointers to emerge clearly from the American literature. However, behind education through peer review lurks an even more threatening prospect of compulsory re-education, linked to re-certification and possibly relicensure. The APA has already moved to require 150 hours of continuing education in each three-year period as a condition of maintaining membership in the professional body (Psychiatric News, June 18, 1976). A report by the influential American Group for the Advancement of Psychiatry
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(GAP) (11) deals with the whole question of re-certification in a comprehensive way. In contrast to the Canadian situation, less than half of the membership of the APA has applied for and received certification by the American Board of Psychiatry and Neurology. Obviously measures would have to be taken to bring the level of certification in psychiatry up to the 90 percent or more, commonly found in other medical specialties, before voluntary re-certification could have a significant impact on the competence of the profession as a whole. However, the same economic pressures are being felt here as in the case of peer review. If the trend among third-party payers to offer income premiums to certified specialists continues, voluntary certification and eventually recertification will probably become the norm - or, to put it differently, cease to be voluntary. However, the GAP report shows clearly how fragile is the basis on which the whole structure of re-certification would rest. The difficulties of evaluating the quality of psychiatric care, especially office psychotherapy, are at present so formidable that the group is forced to resort to phrases like "a variety of methods' ,, "other innovative techniques", "mechanisms as yet to be developed", and "some other as-yet-to-be-discovered technique", to define crucial elements in the evaluative process that will be a prerequisite for the re-certification of already certified psychiatrists (11 - pp. 681, 689). Although the task force has recommended that voluntary re-certification "could and should" begin by 1978" the proposal actually refers to only one element in the complex structure of re-certification multiple-choice examinations to test that the specialist has "kept up to date with the advances in psychiatry." What are these advances? Apparently they are largely confined to neurophysiology, molecular biology, psychopharmacology and genetics, although there is a reference to advances in "our understanding of psychiatric diagnosis (DSM III) and psychophysiologic states" (11 - p. 653). As the same report rightly points out (p. 687),
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criticism, but unless we believe that debate and criticism are inherently unhealthy, it would seem unwise to pre-empt the development of a major identity crisis by administrative action and in response to external and mainly economic pressures. Certainly the extent of our present knowledge of how to conduct comparative evaluations of different methods in psychiatry does not justify the foreclosure of research and debate on questions of such fundamental importance to a comparatively-new and still rapidlydeveloping discipline. If education will make the profession aware of its own crisis and the astonishing fluidity of its current theoretical basis, it can only do good. But the proposals coming out of the United States sound much more like the administrative imposition of a 'medical-model' approach which is certainly widely accepted, but is also the object of responsible and The Identity Crisis in Psychiatry carefully-researched criticism. We are not Like the pressure for the adoption of ready for uniformity in psychiatry, however standard forms of diagnosis, model criteria good it will make us look with the cost sets and so on, the pressure for re-education accountants. and eventual voluntary (no doubt later to become compulsory) re-certification seems Professional Education The theoretical fragmentation of hard to resist, if one is concerned with the quality of medical care delivery, the psychiatry leads in turn to weaknesses in maintenance or upgrading of the standards professional education, which will inevitaof the profession, and the elimination of bly be reflected in continuing education, substandard care. However, a moment's which is an element in peer review, as well reflection should convince us that things are as in future requirements for renot as simple as that. Robert Spitzer, M.D., certification. University and hospital trainchairman of the APA Task Force on ing of psychiatric residents endeavours to Nomenclature and Statistics, which is be eclectic, and at least to acquaint the responsible for bringing out the new DSM student with the latest developments (4). Ill, recently stated forthrightly that "We But it is notoriously deficient in fostering remain four-square within the medical the personal growth of the resident in model in our approach to the classifica- training, and in dealing with inner problems tions" (Psychiatric News, June 18, 1976). that may later become an obstacle in What is true of DSM III is also true of model interpersonal relationships with his or her criteria sets, PSROs and indeed of the patients. Only the psychoanalysts insist on a assumptions on which the public funding of thorough personal training - therapeutic psychiatric care is now based. Yet in even more than didactic, according to psychiatry's present deep and widespread Lorand (7) - to equip residents to deal with identity crisis, nothing has been more problems they will encounter in relation to frequently or stringently criticized than the actual patients (2, 9). These deficiencies in medical model (12). training bias the profession as a whole in the The medical model mayor may not direction of objectifiable, intellectual eleemerge strengthened from the fires of ments in psychiatry, such as the famous ., .. , in order to develop a certification process which will be viewed favourably by the profession, major improvements in our existing techniques will be required. This calls for substantial planning and research. " We are still in the region of pious hope. Planning and research, the panaceas of a technological society, are to be relied upon to produce essential components of a system whose implementation is recommended almost immediately, although the authors of the report have as yet almost no idea of the direction in which to look for these indispensable advances on our present knowledge. Unfortunately, a casual reading of this report, or one largely confined to its recommendations, could give the impression that re-certification is ready for implementation. One can only hope that the influential third-party payers do not draw this decidedly premature conclusion.
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standard diagnostic categories, psychopharmacology, behaviour modification, hospitalization, and so on, to the neglect of those (in the view of many researchers) all-important aspects in which the personality of the therapist and his interaction with his patients are paramount. These weaknesses will be amplified, and tend to increase almost exponentially, if the key personnel in peer review and continuing education are to be drawn from the same sources as the original educators of psychiatrists. What are the Priorities? If all these well-intentioned qualitycontrol measures are implemented too quickly, without sufficient thought being given to their possible side effects, psychiatrists will in future find themselves spending a considerable proportion of their time and energy in fulfilling essentially managerial requirements. Some may find this temperamentally congenial, but perhaps these are not the temperaments best suited to undertake psychotherapy. It is not as clear to the rest of psychiatrists that the time and energy so expended will lead to a proportionate improvement in patient care. Behind these managerially-oriented demands for accountability in the expenditure of funds, and for quality-control measures, is a massive fact which psychiatrists will ignore at their peril. Professional credibility in the eyes of the public is rapidly being lost. The educated public can and does read the works of the professional critics of psychiatry's present state, as well as more popular books and articles which give the impression that the specialty is in a very serious condition. The growth of a vast profusion of alternative 'therapies' outside professional control would certainly not have been possible had professional credibility been fully maintained. That psychiatry is undergoing an 'identity crisis' is now fully acknowledged by responsible spokesmen, such as Judd Marmor. Perhaps peer review, with all its somewhat frightening potentialities, also has latent within it the possibility of. becoming a form of therapy for this crisis in psychiatry itself.
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Positive Potentialities of Peer Review Attention has been drawn to some of the dangers to be discerned in the perhaps inevitable development of peer review, re-certification and similar quality-control measures. But to become aware of a danger is notoriously the first step to averting it. The most hopeful aspect of peer review lies in its inseparable connection with education. If review cannot be separated from education, education in turn cannot be separated from growth in self-knowledge and a capacity to interact with other persons both one-to-one and in groups. If the continuing education to which peer review must lead will foster the development of these capacities, as well as more easilyobjectifiable knowledge and skills, psychiatry will be in the best position to regain and enhance its now diminished credibility with the public. If imaginatively and constructively used, for the intrinsic purposes of psychiatry, rather than for withstanding external and managerial pressures, peer review has great positive potentiality. Over a period of time, the experience gained in peer review could gradually lead to the development of more adequate methods of evaluation of psychiatric success, and hence to the possibility of eventual resolution of some at present rather sterile theoretical debates. If carried out, as it should be, in an educational or even 'therapeutic' manner, peer review could be of considerable usefulness to psychiatrists in their professional development. Counter-transference problems could be presented and resolved. New aspects of previously intractable cases could . be drawn to the attention of the therapist. Relations between professional colleagues could be deepened and thus greatly improved. Peer review could in itself become a magnificent form of continuing education through sharing of professional experience. This is the kind of knowledge which is not likely to be found in text-books of psychiatry, and is unfortunately not easy to pass on to psychiatric residents. A Canadian Peer Review Scheme? In Canada, demand for peer review has not yet become urgent or pressing, though
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no doubt it soon will. There is a little time left for reflection before action becomes necessary. Canadian psychiatrists should seize the opportunity to devise an indigenous system of peer review, learning from the American experience so far, but not slavishly copying their methods where they are inappropriate to our own needs. Too hasty adoption of borrowed methods could lead to the collapse of a whole scheme, opening the way to lay control. Even in the USA, the system created as a result of the enactment of Public Law 92-603 is still too new for a judgement to be formed on its effectiveness in meeting its declared aims, or indeed on whether it works at all. Certainly in Canada, any local initiatives to respond to economic and management pressures by instituting peer review boards should be preceded by a national study, which would evaluate the American experience and determine its applicability to Canadian conditions, as well as confronting the larger issues noted above. Pending such a study, the following suggestions are made. • The dangers inherent in the concentration of enormous power in the hands of review boards should be guarded against by relatively frequent rotation of membership. • In a country with as small a population as Canada, peer review should perhaps be a national rather than a local or even provincial undertaking. It is tempting to encourage each provincial psychiatric section to start doing something, but it would be better to learn from the other provinces by exchange of experience. Self-therapy is seldom profitable. • All theoretical orientations should be well-represented in the composition of review boards. A psychiatrist should not be expected to justify his procedures and treatment plans in relation to the criteria of orientations other than his own. • Improvement in the training of psychiatric residents would be the single most important measure for the long-term improvement of the delivery of psychiatric care. On the other hand,
failure to bring about this improvement will lead to the injection into the system of further under-trained practitioners requiring costly peer review and other corrective measures. Peer review should therefore be extended to the educational as well as the clinical side of the profession. Review boards for university and hospital teaching departments should include psychiatrists in private practice as well as fellow academics. • As suggested by the Report of the Professional Standards and Practice Council, a major portion, if not all, of the 1977 CPA Meeting should be devoted to these issues. Not just one, but a number of panels, symposia and workshops should be structured around these themes. A demonstration peer review could be presented so that psychiatrists can see how it is to be done, and offer their own constructive criticism. • On a provincial level, voluntary selfimprovement workshops should immediately be set up and be open to every member. • The whole profession should be involved in debate and planning on these issues, which will intimately affect every member. These suggestions are not intended to replace, but to supplement careful study of what is being done elsewhere. Together, the two approaches can lead to the development of a Canadian peer review system of superior quality. Acknowledgements The authors wish to thank Drs. C.A. Roberts, H. U. Penner and E. Lipinski for reading this article prior to publication, and in particular Dr. Penner for his comments.
References I. Cohen G.P., Conwell, M., Ozarin, L.D.,
Ochsberg, F.M.: PSROs: Problems and potentials for psychiatry. Am. J. Psychiatry, 131: 12, 1974. 2. Goin, M.F., Kline, F.: Countertransference: A neglected subject in clinical supervision. Am. J. Psychiatry, 133: I, 1976.
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regard des depenses des fonds prevus par un troisieme parti de contribuables qui a conduit les Etats-Unis a mettre sur pied un plan de revision des depenses encourus par ces professionnels et ceci par leurs pairs. Cette revision faite par les pairs presente certains dangers. La psychiatrie traverse une crise didentite. Le desaccord theorique engage sur des points fondamentaux justifie cette revision par leurs pairs tels: Ie diagnostic, l'etiologie, la modalite, la frequence et la duree du traitement et les methodes pour en evaluer I'efficacite. Cette mise ajour par les pairs cree de la resistance et de I' anxiete chez les psychiatres concernes. Elle est egalement consideree par eux comme une menace a la relation confidentielle patient-rnedecin. Elle accorde aux membres du bureau de revision un pouvoir extraordinaire. Le lien propose entre cette revision et la recertication obligatoire est theoriquernent discutable et de plus devient une entrave additionnelle a la liberte professionnelle. La revue des pairs peut etre plus constructive en faisant valoir la formation au lieu de I' evaluation et du controle; on peut offrir une experience experimentee aux collegues qui ont a traiter des cas difficiles. Nous offrons des suggestion specifiques Resume pour Ie developpement d'un systeme auLes psychiatres canadiens subissent une thetiquement canadien de revision par les pression exercee par une responsabilite en pairs. 3. Gottesman, D.M.: Measuring attitudes about peer review in a university department of psychiatry. Hosp. Community Psychiatry, 25: I, 1974. 4. Gurel, L.: Some characteristics of psychiatric residency training programs. Am. J. Psychiatry, 132: 4, 1975. 5. Langsley, D.G., Lebaron, G.!., Jr.: Peer review guidelines: A survey of local standards of treatment. Am. J. Psychiatry, 131: 12,1359,1974. 6. Liptzin, B.: Quality assurance and psychiatric practice: A review. Am. J. Psychiatry, 131: 12, 1974. 7. Lorand, S.: The founding of the psychoanalytic institute of the State University of New York Downstate Medical Center. An autobiographical history. Psychoanal. Rev., 62: 4, Winter, 1975-1976. 8. Newman, D.E., Luft, L.L.: The peer review process: Education versus control. Am. J. Psychiatry, 131: 12, 1974. 9. Pasnau, R.O., Russell, A.T.: Psychiatric resident suicide: An analysis of five cases. Am. J. Psychiatry, 132: 4, 1975. 10. Sullivan, F.W.: Peer review and PSRO: An update. Am. J. Psychiatry, 133: I, 1976. II. GAP Task Force on Recertification. Recertification: A look at the issues. Group for the Advancement of Psychiatry, 1976. 12. Torrey, E. Fuller: The Death of Psychiatry. Radnor, Pa. Chilton, 1974.
Knowing, as I do, the difficulties attendant on the medical profession, I confess I feel a reluctance in recommending the pursuit of it; and yet I can say, were I to commence life anew, I know ofno profession, arduous as it is, that I should so cordially embrace. Letter to a friend, September 6, 1791 John Coakley Lettsom 1744-1815
