Having a peer observe your practice and provide you with feedback can be an intimidating process. However, the potential benefits may justify putting yourself through that anxiety.

That said, if done poorly, peer review can be unhelpful, and even cause harm.

In this article, I’ll review some of the important steps to consider.

What is peer review of practice?

Doctors are inherently good reflectors when provided with quality data to reflect on - good data should be relevant to their practice, objective, concrete, and obtained from a trusted source.

Feedback provided from peer review is one source of data, and ticks many of these boxes. Feedback from a peer is usually regarded as credible, as the peer has a detailed understanding of what is regarded as standard practice.

Peer review of practice involves a colleague who has a similar scope of practice observe you in the clinical space doing your normal duties, and then providing you with feedback. Peer review of practice may sometimes include review of medical notes or other data sources, but this will not be considered in this article.

While not well studied, peer review is thought to have benefits to practice in traits such as professionalism, teamwork and communication skills (1).

Additionally, peer review of practice has potential benefits for the peer too, as it inevitably results in the peer considering their own practice during the review. As such, the process of acting as a peer reviewer is often able to be claimed for your CPD.

Process of peer review practice

When done well, peer review of practice should contain the following steps

Agree to scope - you should meet with your peer and agree to the scope and setting. Agree on the purpose, the need for confidentiality, and the qualities of practice that will be reviewed
Observation - the peer should observe practice without influencing it in any way, with the exception of critical emergencies. All efforts to ensure the workspace is as normal as possible should be made
Consideration - the peer should have time to organise thoughts and consider their feedback carefully
Feedback - detailed, structured and objective feedback should be provided. A minimum duration of 30 minutes is recommended
Reflection and planning - during and after the feedback session, you should carefully consider the feedback and make discrete achievable plans to improve your practice where necessary. Where possible, these should be agreed with your peer, and be documented in your portfolio.

What makes a good peer review process?

Peer review is most likely to be beneficial if:

you and your peer have similar levels of experience and scope of practice
quantitative measures are used (1).
peer review is frequently performed (2), by different reviewers (one session cannot meaningfully reflect all practice)
both the observation and feedback are structured (2)
your peer is trained to provide feedback – there is the potential for the process to be harmful if not done well (2)
assessment is based on evidence-based guidelines (2)

How do I do it well?

We can consider this question in 4 parts - the preparation, observation, the feedback and the actions.

Preparation

The success of a peer review of practice session is heavily dependent on trust. The first step to establishing trust is to agree on the scope and terms of the process. Both parties should recognise that the purpose of the process is to provide honest feedback designed to help you improve your practice. You should discuss what parts of your practice are included - for example, you may wish to include communications skills, but exclude physical examination.

Templates for peer review of practice are available elsewhere, but you can always construct your own. One approach is to consider the domains in the CANMEDs framework (3), and add items you’re interested in receiving feedback on under each heading. An example is provided here :

Medical expert
- Diagnosis
- Procedural skills
Communicator
- Communication
- Consent
- End of life discussions
Collaborator
- Teamwork
Leader
- Leadership skills
Health Advocate
- Preventative health
Professional
- Treating patients with respect
- Cultural safety
- Professional boundaries
Scholar
- Use of information technology

Importantly, care should be taken not to turn the exercise into an assessment, and thus rating scales should be avoided.

It may also be important to document the consent, terms and scope, with the signatures of both parties. Additionally, consider the need to inform patients of the purpose of the process, and ask their permission.

Confidentiality is an important step in creating a psychologically safe space for you (and your peer).

Observation

Peers should seek to sink into the background, having no influence on your practice.

Feedback

In many respects, the quality of the feedback provided can make or break the peer review of practice process.

Where possible, peers should be trained in providing feedback. Where this is not possible, peers should consider providing feedback using the Advocacy Inquiry model :

State what was seen
State what was expected to be seen / the possible consequences
Ask what the reason for the action was

For example, “I noticed you didn’t mention death as a potential complication of surgery, and this may mean the patient was not properly consented, but I’m interested in your reasons for this.”

It is critical that sufficient time be allowed for the feedback and discussion session, with a minimum of 30 minutes recommended, though the session should occur on the day the review occurred. The peer reviewer should also have adequate time to prepare their feedback, with each item acting as a stimulus for conversation and reflection.

Action

Peer review sessions will not translate into performance improvement without direct action. Each session should have a documented set of (preferably agreed) outcome actions, ideally in a SMART goal format. This is covered elsewhere.

Limitations

The major limitations of peer review relate to the concept of “failure to fail”. Many observers feel uncomfortable when providing critical feedback, which potentially reduces the positive benefits that could otherwise be obtained. This is amplified in an environment where the peer believes “their turn is coming”.

The other key limitation is the time and opportunity cost imposed on the peer - few clinicians are able to create sessions lasting multiple hours in their already overstacked calendar. It is here that the support of workplace managers is critical to the success of a peer review program.

Finally, concerns are occasionally raised regarding the legal implications for both parties. It is best to discuss these concerns with your employer or medical indemnity agency prior to undertaking the exercise.

Conclusion

Done well, peer review of practice provides a rich source of data for reflection which can lead to performance enhancement. Trust between the two parties is critical to its success, which can be facilitated through clear agreement to the scope, and the use of a structured approach to both observation and feedback. Finally, the process is futile unless definitive action is taken.