Radiation Oncology Peer Review: Measuring Quality

Abstract

I’m with you when you’re right, Governor. But not when you’re wrong. –David M. Kleck, public relations counsel You stupid sonofabitch. I don’t need you when I’m right. –Earl Long, Louisiana governor [1] In a 1992 article, Cosio and Taylor [2] summarized the US Department of Defense experience with a very specific type of military nonbattle trauma: soda pop vending machine injuries. A total of 64 reported events had contributed to 15 deaths and 13 cases of multiple trauma, including 49 fractures. Although one unfortunate man was killed by a machine tipped over by colleagues just as he left his room, the remaining cases were triggered by people trying to retrieve sodas that had not descended (n 33), trying to get free sodas (n 7), trying to clean under the machines (n 3), or trying to retrieve change (n 2). The mean age of the victims was 19.8 years (range, 5-39 years). Because it is unlikely that any of the injured intended to be crushed by a vending machine, we easily may believe the statement of one victim: “It came down faster than I thought . . . it was too heavy” [3]. This is a glaring example of how we can fatally miscalculate our competence in some arenas. In a seminal 1999 article, Kruger and Dunning [4] described the results of experiments in which participants scoring in the bottom quartile on tests of humor, logic, and grammar drastically and reproducibly overestimated their true capabilities. These people considered themselves to be well above average: from the true median of their cohort at the 12th percentile, they thought they had performed at the 62nd. The authors further demonstrated that once these bottomquartile performers were taught in the subject of that incompetence, (1) their performance levels rose, and (2) their self-analysis became more accurate. In other words, we do not well recognize our own lack of competence in areas in which it exists, and the best way to remedy such poor competence calibration is to be taught more in those areas. This phenomenon is extraordinarily apt in the area of quality in radiation oncology as well. Practice accreditation as provided by the ACR [5] or clinical review from Quality Research in Radiation Oncology [6] provides an organization with the benefit of a comparison of institutional metrics and clinical outcomes with national benchmarks. At the individual level, peer review, performed in a collegial and administratively confidential manner, provides essential opportunities for physicians to “sharpen” one another in terms of clinical care and plan review [7]. The American Board of Medical Specialties requires within the Maintenance of Certification construct that Practice Quality Improvement projects provide individual assessments using national norms [8]; such projects serve as critical adjuncts to ongoing local peer review. As a discipline, radiation oncology takes insufficient advantage of these processes. In 2013, it is an uncomfortable fact that many of our peer-review and Practice Quality Improvement projects are merely administrative. Until now, the pre-