Debate regarding Peer Review continues actively on the American medical scene. Our own organization has had a long and highly disciplined tradition of peer review, both of the quality of training in member institutes, and of the quality of psychoanalytic knowledge and its practice in applicants for membership to our organization. Our quality control procedures have rightly been the subject of continuous scrutiny and debate over the years. However, since a structure of Peer Review organizations is rapidly becoming an inescapable reality on national, state and local levels, questions regarding the meaning and consequences of participation in such systems by psychoanalysts are assuming steadily increasing importance.
Arguments for and against the participation of psychoanalysts in a peer review system may be divided roughly as follows:
Dr. Robert B. Hunter, Chairman of the American Medical Association's advisory Committee on PSRO's has said, “If physicians decide to ‘uninvolve’ themselves in PSRO, then the federal bureaucracy will just go ahead and obtain its assurances of effectiveness, efficiency, and economy from somebody else. … We must view these developments in the context of a possible national health insurance plan covering all citizens.”
For psychoanalysis also, third party payment has figured increasingly, and cultural-economic-political signs portend a continuation of this trend.
Physicians themselves are being asked to govern the quality of care, rather than submitting to lay controls.
As analysts we no doubt would feel that a most equitable form of control would be one in which psychoanalysts
would review these matters when psychoanalytic treatment is under consideration. Recent discussions concerning extending training and membership to a larger population of non-medical analysts who would have a special relationship to medical peer review bodies must be considered in this context although the complexity of this matter goes well beyond the scope of a report on peer review.
Peer review will improve some of the worst practitioners.
This argument is irrelevant to our organization.
Confidentiality (according to Dr. Henry Simmons, national PSRO chief) is protected by the law. This is in contrast to current review procedures, in insurance companies, for example, where non-medical people may review reports. The new legislation has built-in penalties for breaking confidentiality. Confidentiality should not be a shield for poor practice.
Analysts need far greater assurance of confidentiality than other disciplines since the material presented in case summaries is of a different order of personal disclosure from physical-medical situations.
Data gathering is likely to be chaotic and its validity may be doubtful.
This area has been a scientific problem for our field and remains largely unresolved.
The following problems obtain in establishing norms for care, diagnosis, and treatment:
What standards shall be applied?—optimal or minimal?
Is outcome an appropriate yardstick for measurement?
Consumer groups see peer review as not protecting consumer interests, a case of “the fox guarding the chicken coop.” They demand public disclosure and feel peer review does not allow for consumer input and participation.
Psychoanalysts have at times been criticized as an interest group protecting their own discipline by being secretive and non-reporting about their effectiveness. However, consumer input is especially complicated in our field because of the transferential phenomena which psychoanalysis encourages to far greater degree than any other doctor-patient transaction. Most important, these phenomena involve unconscious processes which can only be understood by those who have already experienced them in the analytic situation.
Conservatives fear governmental meddling. Their strongest concern is in the omnipresent threat to confidentiality between doctor and patient.
Confidentiality in psychoanalysis is a keystone to the integrity of the therapeutic alliance. This has been an important issue in reporting to insurance companies, and in the training setting as well, where the effects on treatment of reporting or non-reporting training analysts have been the subject of wide study and debate. (See the notice of the November conference on Confidentiality on page one of this Newsletter)
The added costs of a peer review program must be balanced by savings in medical costs, which may result in a drastic reduction in the application of medical care.
Because of its length and frequency of treatment sessions, psychoanalysis has been viewed as a particularly costly treatment modality, although hospital stays for major surgery or severe medical illness certainly rival or exceed such costs. Psychoanalysis has been viewed with alarm and reservation by third party payees.
Physicians may refuse care because of accountability in complex cases.
Analysts may indeed be wary of taking cases which might present questionable analysability or outcome, especially where the diagnosis is of narcissistic or borderline disorders. Prognosis would be difficult to assess in the early phase of the analysis when peer review judgments would be made. The fact that psychoanalysis is a research as well as a treatment modality presents subtleties when assessments are made that non-analysts may not comprehend or approve.
In his report to the Executive Council at the Denver meeting in May of 1974, Dr. Donald L. Burnham, chairman of the Committee on Peer Review urged local psychoanalytic societies to make Peer Review a matter of concern in their deliberations. He urged strengthening their links to local Psychiatric and Medical Societies and to Medical Care Foundations (future PSRO bodies). Affiliate Societies are urged to get on the mailing list for PSRO newsletters and to order copies of the PSRO program manual published by the Dept. of HEW. Each society should have a Peer Review Chairman, and his name should be forwarded to Dr. Burnham. The committee has established liaison with other national groups such as the American Psychiatric Association, GAP, Academy of Child Psychiatry, and the American Association of Child Analysis. In addition, within our own organization,
a day-long meeting was held in March by the chairmen of our Committees on Health Insurance, Continuing Education, and Certification. The Committee is gathering information to establish criteria for assessing the need and suitability for analysis.
Dr. Burnham stresses the importance for each analyst to become knowledgeable about peer review and to establish his personal and professional presence in organizations which are concerned with peer review. The eventual active participation of analysts in functioning PSRO's are likely to be essential for the healthy growth of psychoanalysis in this country.
Frederick M. Lane, M.D.
Liberal groups see a danger in physicians governing themselves. Professional and personal vendettas may be acted out.
Psychoanalysis may be particularly vulnerable to damage as a profession and science because of intra-disciplinary or interprofessional antipathies. We are all aware of the tendency for factional tendencies to arise within psychoanalysis as well as with non-analytic and extra-psychiatric professional colleagues.
Peer review may provide other opportunities for abuse. There are no channels for disclosure and this may help to cloak situations described above in Item 7. Peer review bodies may be empowered to force a change of doctor for a particular patient.
Such manipulations and bureaucratic intervention could be catastrophic to an ongoing analytic engagement and consequently to the patient.
Peer review fosters cookbook conformity in medical care.
Our science grows in fits and starts and always has as its fountain-head, clinical experience. It is conceivable that under the weight of peer review, not only would capricious misapplication and bizarre variations in psychoanalytic procedure be discouraged, but in addition, more sober clinical exploration and trial and error approaches which are essential in our growth and evolution might be deterred.
Peer review carries the danger that medical care may become a cost-oriented rather than a quality-oriented procedure.
The pressure to allow or encourage abbreviations of psychoanalyses with infringement upon the evolution and analysis of the transference neurosis, in fact every essential element of what constitutes a psychoanalysis, could become formidable, and such influences may be either conscious or unconscious.