Hospital peer review is one of medicine’s most important mechanisms for protecting patients and maintaining professional standards. Physicians possess the clinical expertise necessary to evaluate the work of other physicians, particularly when questions involve complex procedures, specialty-specific judgment, or unusual complications.
But this structure creates an unavoidable tension. The physicians most qualified to evaluate a colleague may also be the physicians who compete with that colleague for patients, referrals, operating-room access, call coverage, procedural volume, leadership positions, or hospital resources.
That does not mean competitors are inherently biased. Nor does the existence of competition establish that a peer-review decision is improper. The more useful policy question is narrower: When professional or economic competition exists, what safeguards should hospitals use to preserve confidence in the fairness of peer review?
Expertise and independence are not always the same thing
Consider two surgeons practicing the same subspecialty at the same hospital. Their overlapping expertise may make one an ideal clinical reviewer of the other’s cases. Yet they may also compete for referrals, block time, service-line leadership, equipment, personnel, or procedural market share.
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Both realities can be true simultaneously. A physician can possess exceptional clinical expertise while also having interests that could reasonably raise questions about impartiality. Recognizing that possibility is not an accusation of misconduct. It is simply good governance.
Medicine already recognizes conflicts of interest in other settings. Researchers disclose financial relationships. Medical journals increasingly maintain policies governing conflicts involving editors and peer reviewers. Corporate directors may recuse themselves from decisions involving personal financial interests, and judges operate under recusal standards designed to protect confidence in impartial decision-making. Professional review deserves comparable institutional rigor.
What the evidence tells us
Conflict management in medicine is not a new concept. A 2025 scoping review in BMJ Evidence-Based Medicine examined empirical research on conflicts of interest among biomedical peer reviewers and concluded that both financial and nonfinancial interests can affect the integrity of peer-review processes.
A separate 2025 study in the Journal of Clinical Epidemiology examined 250 medical journals and found that about 70 percent had conflict-of-interest policies for peer reviewers. Most policies included some form of management strategy, although their comprehensiveness varied considerably. More recent research examining how journals actually implement these policies found that reviewers with identified conflicts were frequently disqualified from reviewing, while substantial variation remained in disclosure, verification, enforcement, and implementation.
These studies involve scientific publishing rather than hospital credentialing, so the two systems should not be treated as identical. But they demonstrate a broader principle: Expertise does not eliminate the need to identify and manage competing interests. Hospital peer review could apply the same principle.
A tiered conflict and recusal framework
Rather than assuming every competitor is biased (or pretending competition is irrelevant), hospitals could adopt a standardized three-tier approach:
- Low-level conflict (document): Two physicians practice in the same specialty and hospital but have no meaningful financial rivalry, active personal dispute, or direct involvement in the matter under review. Participation may be appropriate, with a documented conflict disclosure.
- Moderate conflict (disclose and corroborate): Physicians significantly overlap in referral networks, procedural services, call responsibilities, leadership opportunities, or service-line competition. Participation may still be reasonable, but the competing interest should be disclosed, and important clinical conclusions should be independently corroborated.
- High-level conflict (recuse and obtain independent review): A reviewer directly competes financially with the physician under review, has a substantial personal or business conflict, originated or materially participated in the allegation, or could derive meaningful professional or economic benefit from restricting the physician’s practice. In these circumstances, recusal from final deliberation or voting and independent external specialty review should be strongly considered.
This framework does not presume misconduct. It simply matches the safeguard to the magnitude of the conflict.
Patient safety still comes first
Any reform must preserve the ability of hospitals to respond immediately to genuine patient-safety threats. A surgeon confronting an intraoperative emergency cannot wait for an external reviewer hundreds of miles away. Medical staffs must retain the authority to intervene rapidly when patient welfare may be at risk.
The important distinction is between immediate patient-safety intervention and final professional judgment. A physician with a potential conflict may appropriately provide technical information or participate in an urgent clinical response. That does not necessarily mean the same physician should control the investigation, determine whether a standard was violated, recommend sanctions, and vote on the final professional-review action. Separating these roles may strengthen both safety and confidence in the process.
Federal law already recognizes economic competition
There is an important policy signal within the Health Care Quality Improvement Act of 1986 (HCQIA). HCQIA establishes standards under which qualifying professional-review actions receive protection from damages. Among other requirements, an action must be undertaken in the reasonable belief that it furthers quality health care, after a reasonable effort to obtain the facts, with adequate procedures, and in the reasonable belief that the action is warranted by the known facts. The statute also creates a presumption that qualifying professional-review actions satisfy those standards unless rebutted by a preponderance of the evidence.
Notably, HCQIA’s statutory safe-harbor hearing procedures state that a hearing officer or panel should not be in direct economic competition with the physician involved. That provision does not prohibit every economically competing physician from participating at every stage of peer review. But it demonstrates that Congress recognized direct economic competition as sufficiently important to address explicitly when describing fair hearing procedures.
Courts have also emphasized that HCQIA applies an objective reasonableness standard. In Poliner v. Texas Health Systems, the Fifth Circuit held that subjective bad faith or alleged anticompetitive motive alone does not defeat HCQIA immunity; the key question is whether the professional-review action was objectively reasonable based on the information available at the time.
That makes prospective conflict management even more important. The strongest policy is not one that waits for litigation to determine whether bias occurred. It is one that builds safeguards into the process before consequential decisions are made.
External review as a quality safeguard
External review should not be interpreted as a vote of no confidence in the local medical staff. When substantial conflicts exist, an independent physician from the same specialty can provide a clinical assessment less affected by local referral patterns, economic relationships, leadership disputes, or institutional dynamics.
Hospitals could reduce cost and delay by developing regional peer-review collaborations or maintaining pre-vetted panels of independent specialists available for expedited review. The external reviewer need not replace the medical executive committee. The purpose is to provide an independent evidentiary baseline before consequential credentialing decisions are finalized.
Protecting the credibility of professional self-regulation
Physicians have been entrusted with extraordinary responsibility to regulate their own profession. That authority depends not only on expertise but also on confidence in the integrity of the process.
The question is not whether competitors should ever evaluate one another. In specialized medicine, some degree of professional overlap may be unavoidable. The better question is whether institutions should rely solely on informal assumptions of impartiality when disclosure, corroboration, recusal, and independent specialty review are available.
Peer review is strongest when physicians and patients can reasonably believe that clinical evidence (not economic rivalry, referral competition, institutional politics, or personal conflict) is determining the outcome. Expertise gives peer review its clinical authority. Independence gives it credibility. Medicine needs both.
Babajide Ogunseinde is a Harvard-trained, ABPS board-certified orthopedic spine surgeon, innovator, author, and physician leader with more than fifteen years of experience and over 8,000 spine procedures. He practices as an independent spine consultant. A summa cum laude graduate of Virginia Commonwealth University and valedictorian of Howard University College of Medicine, he completed his orthopedic surgery residency and his spine fellowship at Harvard.
Ogunseinde pioneered the FDA-cleared posteromedial-to-lateral (PML) technique for sacroiliac joint fusion and founded the PML Mastery digital app. He holds a health care leadership certification from Stanford University and is an MBA and Certified Physician Executive candidate. He serves as an ABPS oral board examiner and codirector of its leadership program, and he is a new Distinguished Fellow of the North American Spine Society and an editorial reviewer for the Journal of Spine Surgery.
His scholarship spans sacroiliac joint dysfunction, minimally invasive spine surgery, outcomes in high-BMI patients, and orthopedic trauma, with work appearing in the Journal of Clinical Spine Surgery, the Journal of Spine Surgery, the Journal of Surgical Case Reports, and the Journal of Pediatric Orthopedics. He is the author of four books spanning surgical innovation, sacroiliac joint disease, faith, leadership, weight loss, and preventive health: Faith and Purpose: The PML Story; SI Joint Dysfunction: The Truth Shall Set You Free; Messages From Our Father: Father’s Wisdom; and The Coach Before the Scalpel: A Surgeon and a Coach’s Guide to Preventing Obesity, Chronic Back Pain, and the Surgery You Never Needed. He is a 2026 Global Recognition Award recipient and an international invited speaker.
His books and PML resources are available at ogunseindepml.com, and he shares updates on LinkedIn, Instagram, and YouTube.
