For surgeons in particular, this difficulty is heightened because in many cases the only peers nearby are either practice partners or direct competitors. Traditionally, rural surgical peer-review panels have often included nonsurgical local physicians, distant surgeons not familiar with the limitations of the rural setting or expensive third parties.

Now organizations are taking new approaches (some low-tech, some high-tech), working to assemble panels or individual reviewers to get the job done and making these professionals feel a little less isolated.

Sometimes the situations can be even trickier than just dealing with competitors or coworkers, says Dr. Robert Morrow, medical director for quality at the Texas A&M Health Science Center's Rural and Community Health Institute. He explains that it's possible for a small hospital to have three surgeons on staff with two of them married to each other "and the third is one of their dads."

Under contract with more than 60 hospitals and set to expand beyond Texas in 2013, the program uses teleconferencing to assemble a panel to review records over a secure, Health Insurance Portability and Accountability Act-compliant Web portal. The general surgery review panel usually meets once a month to discuss five or six cases.

In surgery reviews conducted for credentialing or reappointments, Morrow says records can be pulled at random for discussion. Some reviews are triggered by outcomes such as an unplanned readmission, unplanned return to surgery, complications during surgery or in post-op, and patient death. Others originate with a patient complaint or by the referral of a medical staff member who may have concerns about the quality or the outcome of a procedure. Names of physicians, patients and hospitals are removed from the files.

Three to seven panelists usually participate in each session, and Morrow says the calls sometimes turn into impromptu consults.

"It's not uncommon for surgeons on the call to ask the other surgeons about a difficult case or procedure," he says "One of the things that I think the urban doctors take for granted is the constant collegiality and the ability to bounce thoughts -- or challenge ideas -- in an informal way."

Kathy Mechler, the institute's co-director and chief operating officer, says the program is successful because of its focus on patient-safety and quality-improvement education. "Peer review is traditionally seen as punitive, and our program removes that and we take more of a learning approach," she says.

Mechler adds that hospitals have amended their bylaws to include the institute's program as part of their own internal peer-review processes. Physician reviewers are not paid for their time, but their participation does satisfy meeting-attendance requirements hospitals may have for physicians.

In Washington state, the Seattle-based Rural Healthcare Quality Network celebrated its 10-year anniversary last year, but it's only been offering "subspecialist peer reviews" for about half that long, says Elizabeth Evans, the network's program director. Subspecialist reviews include general and orthopedic surgery.

The state's 34 critical-access hospitals pay annual dues of $12,300 to $25,000 -- depending on their total annual expenses -- which pay for four annual site visits by an RHQN physician who reviews 50 to 100 charts, develops an improvement plan and meets with hospital leaders to discuss the findings. If the physician finds a chart that merits further examination or is beyond that doctor's expertise, a paper copy of the chart -- with the names of the institution, physician and patient removed -- is sent to a physician of the same specialty as the doctor whose work is under peer review, says Randy Benson, the network's executive director.

Benson adds that general surgeons always go along with his requests to be a peer reviewer. "They've never turned us down," he says, adding that the RHQN pays between $100 and $300 per chart review, and some doctors have refused to turn in an invoice. Benson notes that some third-party reviewers charge up to 10 times that much. He adds that business is booming, and that "external peer review has just taken off" and that this is a sign that physicians value the feedback they receive.

In Kansas, the state medical society coordinates a service to assemble peer-review panels when it becomes difficult to do so because of "local considerations, small staff size or other considerations," according to the Kansas Medical Society website. One physician who has participated in that service is Dr. Tyler Hughes, chairman of the American College of Surgeons' Advisory Council for Rural Surgery.

"Generally, how I look at it is, if I want somebody to help me, I have to help them," says Hughes, a general surgeon practicing at 41-bed McPherson (Kan.) Hospital. "I see that as part of being a surgeon -- as long as it's not all the time."

Hughes says there are more than 60 million people living in the nation's rural areas (which, he notes, "is the size of France"), but this includes only 7% of the country's general-surgeon roster. He adds that, technically, some might view surgeons in communities 10 to 30 miles away as "competitors," but Hughes argues that isn't necessarily true, especially since isolated surgeons often have more work than they can handle.

"Frequently, competitors will work together," Hughes says. "Because there are so few of us, we usually aren't sitting around twiddling our thumbs hoping someone will send us a case."