Surgeons with Purpose

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Dr. Stephen Cohen is a board-certified general and colorectal surgeon, Section Chief of Surgery at the VA, and an experienced medical expert witness with nearly 30 years in the medicolegal field. We explore what it really means to build a sustainable career in surgery: one that allows surgery to enhance your life rather than consume it.
Dr. Cohen shares why he left more than 20 years in private practice for academic medicine, how financial conflict influenced that decision, and why he believes every physician should consider developing multiple streams of income. We discuss the many career opportunities available outside of direct patient care, including medical expert witness work, utilization review, consulting for medical device and pharmaceutical companies, research, and other non-clinical physician roles. He also offers practical advice on how physicians can get started, how to value their expertise, and why it's important to understand both plaintiff and defense work as a medical expert.
We also talk about medical malpractice lawsuits and the emotional toll they take on physicians. Dr. Cohen openly shares his experience of being sued five times, what it was like to be served, how those cases were resolved, and why being named in the National Practitioner Data Bank (NPDB) does not define your career. He explains why malpractice litigation is fundamentally adversarial, why the legal system doesn't always reward the truth in the way physicians expect, and what every doctor should know before ever stepping into a deposition or courtroom.
Along the way, we discuss one of the biggest lessons he learned as an expert witness: knowing the medical record better than anyone else. He explains why carefully reviewing the chart, understanding every detail, and studying depositions can make all the difference in litigation. We also explore why a poor outcome does not necessarily mean poor medical care and the single question from a plaintiff attorney that changed the outcome of a malpractice trial despite excellent surgical care.
Our conversation turns to risk management and the everyday habits that protect both patients and physicians. Dr. Cohen shares why thoughtful documentation is so important, why physicians should never argue with colleagues in the medical record, when to involve risk management after complications, and why communication remains one of the most powerful ways to reduce malpractice risk. He also discusses the surprising benefits of giving patients your cell phone number, approaching every patient with a beginner's mind, and asking yourself how you would care for the patient if they were your own parent.
Finally, we reflect on what changes after residency and fellowship, when technical excellence alone is no longer enough and physicians begin redefining success on their own terms. Dr. Cohen shares what he still loves about colorectal surgery, how the specialty has evolved throughout his career, his thoughts on the rising incidence of colorectal cancer, and why every surgeon should build a career that creates freedom, purpose, and longevity, not just more time in the operating room.
Whether you're interested in medical malpractice, becoming a medical expert witness, physician consulting, utilization review, physician burnout, career diversification, or building multiple streams of income as a doctor, this conversation is filled with practical advice and hard-earned wisdom from someone who has successfully navigated every stage of a surgical career.
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Dr. Racheal Peterson joins me to share her journey into neurosurgery, a path she set her sights on before medical school and ultimately made a reality. We talk about her first experiences in the operating room as a medical student and the sense of wonder that comes with being able to truly change a patient's life with surgery.
Our conversation explores what made her residency genuinely formative rather than simply something to survive, the unique "bro nerd" culture of neurosurgery, and the common trap of believing the next milestone will finally make you feel like you've arrived. We also discuss how she discovered an unexpected creative outlet through social media, her experience becoming a mother during training and as a young attending, and how her aspirations, priorities, and communication style have evolved throughout her career.
This is a thoughtful conversation about identity, ambition, growth, and what it means to build a life in surgery that continues to evolve alongside you.
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Dr. Cameron Roth is a fellowship-trained orthopedic doctor specializing in hand, wrist, and upper extremity surgery and co-host of the podcast, Behind the Sports Medicine Podcast.
In this episode we talk about what it actually feels like to finish training and go out into the world as an attending for the first time when the buck stops with you.
We talk about imposter syndrome and the real divide between how men and women experience the culture of surgery, particularly orthopedic surgeons.
We touch on the fallacy of certainty. You train under one attending who tells you there is one right way to do things. Then you rotate to another attending who tells you the same thing about a completely different technique. Both are certain. Both are wrong about their certainty.
We also get into the first complication after training, and how it hits differently than anything you experienced as a resident.
We consider whether being a woman in surgery might be a superpower, or, perhaps, that surgery selects for badass women. The extra scrutiny, the bias, the being underestimated, done consciously, can produce antifragility. Not just toughness. The capacity to grow stronger under pressure. I think every surgeon, regardless of gender, needs to hear this reframe.
We also cover what genuine availability to patients looks like versus the kind that breeds resentment, and what it means to show up for patients from service energy rather than fear.
This one is for every surgeon who has ever stood at the scrub sink before a hard case and wondered why their career doesn't feel like they thought it should.

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Sham peer review can be one of the most devastating threats facing surgeons today. But it doesn’t have to.
Physician, educator, and coach, Dr. Tracey O'Connell, pulls back the curtain on a reality most surgeons don't see coming until they're already inside it. This conversation is sobering. It is necessary. And it ends with a message of genuine hope: that the surgeon who protects herself, serves her patients, and diversifies her professional identity is also the surgeon who is hardest to destroy.
What Is Peer Review, and What Is Sham Peer Review?
Legitimate peer review is a quality assurance process initiated when a patient, fellow physician, or staff member reports that a physician failed to meet the standard of care or acted improperly. A hospital committee reviews the case, the physician may testify and present evidence, and a determination is made.
Sham peer review is something else entirely. It is the weaponization of that same process for personal, competitive, or political reasons, not to protect patients, but to target a physician. It is used to intimidate, silence, retaliate, and in some cases, end careers.
Sham peer review is defined as “the abuse of a medical peer review process to attack a doctor for personal or other non-medical reasons." Physicians most at risk are those employed by large hospital systems.
How Often Does This Happen?
The honest answer is that precise data is hard to come by, and that itself is part of the problem. Many cases are buried under non-disclosure agreements or never reported because physicians are too isolated, too afraid, or too ashamed to speak.
What we do know
- 56% of U.S. physicians surveyed by Medscape report higher concern that peer review could be misused to punish them for reasons unrelated to the case being reviewed.
- At least 10% of peer review investigations are estimated to be sham peer reviews used to weaponize the process rather than ensure quality care.
- 15% of physicians surveyed in a 2007 AMA investigation indicated awareness of peer review misuse or abuse.
- Hospital disciplinary actions, including suspected sham peer reviews, average 2.5 per year per hospital, according to National Practitioner Data Bank (NPDB) records.
- In Texas alone, 68% of adversely peer-reviewed physicians in 2004 were later adjudicated by the Texas Licensing Board, meaning the reviews were found to be without merit, yet their NPDB reports remain.
The pattern is hard to see because it happens in the confidential, protected setting of hospital committees. But the incidence and severity are increasing.
What You Must Know about the NPDB:
The NPDB was originally created to prevent physicians who had committed dangerous acts from crossing state lines and practicing without consequence. A legitimate and necessary tool, in theory.
In practice, it has become one of the most powerful weapons in a sham peer review.
Key facts Dr. O'Connell wants every surgeon to understand:
- Do not resign while a review is underway. Resignation during an active peer review or Performance Improvement Plan (PIP) can trigger an adverse report to the NPDB and, critically, waives your right to challenge the review. This is one of the most common and devastating mistakes physicians make.
- The only person who can remove an NPDB report is the person or institution that created it. Once reported, removal requires cooperation from the very party that filed it.
- An NPDB report does not have to end your career. This is important. While it can be weaponized as an indicator of incompetence, it is not an automatic career death sentence. Many physicians navigate NPDB reports and continue to practice successfully.
- Get legal representation early. Do not wait. Find an attorney with specific experience in sham peer review and NPDB reporting requirements before the process accelerates.
The Psychological Weight of This Reality:
Dr. O'Connell is direct. This is depressing to know about. It is genuinely sad that the systems designed to protect patients are being turned against the physicians who serve them.
The isolation is real. Physicians under review are often told not to discuss the matter with colleagues. This is a deliberate strategy, and it works. Physicians blame themselves. They question their competence. They feel shame. They feel alone.
Dr. O'Connell's core message: a sham peer review is not a reflection of your worth as a physician or as a person. It is, in many cases, a reflection of institutional politics, competition, and the absence of adequate legal protections for doctors.
We must be able to survive this psychologically and emotionally.
Resources:
Physician Just Equity (PJE)
Founded by Dr. Pringl Miller, MD, FACS, PJE is a 501(c)3 organization of 50 physicians, all of whom have experienced workplace injustice and are dedicated to preserving justice in medicine. PJE offers free, confidential peer support teams for physicians navigating conflicts. They are also collecting data on the nature of workplace conflicts and the career trajectories of physicians after workplace injustice.
Association of American Physicians and Surgeons (AAPS)
1-800-635-1196
Sham Peer Review Hotline: 719-627-7759
AAPS is the only national medical association actively helping physicians fight sham peer review. Their general counsel, Andy Schlafly, has stated plainly: "The biggest misconception about sham peer reviews is a denial of how pervasive they are." AAPS offers free legal consultation for physicians facing a sham peer review.
Dr. Lawrence Huntoon, MD, PhD — AAPS
Dr. Huntoon has run the AAPS sham peer review hotline for over 20 years and is one of the foremost experts on recognizing and combating sham peer review. His resources include:
- Sham Peer Review: Resources for Physicians
- Sham Peer Review: Recognizing Possible Early Warning Signs
Center for Peer Review Justice
A resource for physicians who want to get back to work and avoid expensive legal battles.
Dr. Tracey O'Connell's Writing
- The Sham Peer Review: A Hidden Contributor to the Doctor Shortage — KevinMD, July 2024
- Sham Peer Review: Strategies for Saving Your Career and Soul — KevinMD, October 2024
The surgeon who is most vulnerable to sham peer review is the surgeon whose entire identity, livelihood, and sense of self is housed in one institution, role, and set of privileges. When that is taken away or threatened, everything collapses.
The surgeon who is hardest to destroy is the one who has built differently.
This brings us back to the three essentials of a resilient surgical career:
1. Protect Yourself as the Asset
You are the most valuable instrument in the operating room and in your career. That means investing in your psychological health, your self-concept, and your ability to weather attacks that are not about your competence. Sham peer review is designed to make you question your worth. The surgeon who has done identity work, who knows who she is separate from her title, her privileges, and her outcomes, is the surgeon who survives.
2. Serve the Patients
Staying anchored in your purpose is both a psychological and a strategic act. The surgeon who takes actions genuinely in service to patients, not to institutional approval, compensation, politics, or accolades, is the surgeon who makes clean decisions, communicates clearly, and builds a reputation that outlasts any investigation.
3. Diversify Your Professional Identity
This is the structural protection. A surgeon whose identity and income are entirely dependent on one skillset has no leverage and no safety net. Diversifying through speaking, writing, coaching, consulting, or building an independent practice creates not only financial resilience but psychological resilience. You cannot be completely silenced if you have a platform that doesn't belong to the institution.
The medicolegal, interpersonal, and politically-motivated landmines of a surgical career are real. Sham peer review is one of the most dangerous. The best protection is not legal; it is architectural. Build yourself in a way that no single institution can dismantle.
Dr. O'Connell is a resource for you! Learn more about how she can help you here.

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Every surgeon enters the profession knowing the clinical risks. Complications happen. Patients are unhappy. Outcomes fall short. That is part of the contract.
But what about the other risks? The systemic and structural ones that have nothing to do with how compassionate of a human you are, how good of a diagnostician you are, or how slick of a technician you are? You got into this to take care of people. But the system was designed to protect patients from bad actors, and those protections can be weaponized against good doctors for nefarious reasons.
In this 100th episode, neurosurgeon Dr. Christian Bowers joins me for an unfiltered convo about the systems governing physician careers and the gap between what those systems were designed to do and how they actually function. Dr. Bowers draws on years of watching colleagues' careers upended to illuminate what no one teaches in training.
"The thing that could totally derail someone's career overnight, with no fault of their own, is never discussed," — Dr. Christian Bowers
THE KANGAROO COURTS
Academic medical centers operate as large corporations with financial incentives that diverge from physician protection.
The house always holds the cards, and that matters for surgeons who find themselves in its crosshairs.
A predetermined outcome can be built through paper trails before a physician ever knows they are being targeted.

SHAM PEER REVIEW
The "disruptive physician" label is legally vague, subjectively applied, and the starting point for building a paper trail.
Things that were never a problem before all of a sudden become problems when an institution has decided to move on from you.
HCQIA (1986): designed to protect peer reviewers from retaliation, with the unintended consequence of making bad-faith reviews difficult to challenge.
A small group of aligned physicians often leads the charge, which makes this harder to see coming.

DARVO
Deny, Attack, Reverse Victim and Offender: the pattern coined by psychologist Jennifer Freyd that Dr. Bowers has seen play out repeatedly in institutional settings.
Physicians who have never heard of this concept are the most vulnerable to it.
DARVO typically shows up alongside sham peer review.

THE ROLE OF PIPS, THE MEDICAL BOARD, AND THE NPDB
Performance improvement plans and professionalism reviews are tools institutions use alongside sham peer review when they have decided to move on from a physician.
Medical board complaints and NPDB reporting are downstream consequences that can encumber a physician's ability to find their next position.
The damage is typically done upfront.
The goal of legal counsel is protecting you for the next job, not saving the current one.

THE ACGME & STRUCTURAL ACCOUNTABILITY
The ACGME is a private organization, not a government agency. It is accountable to its interests, not to trainees.
The Glass-Steagall parallel: the same perverse incentive structure between regulators and the institutions they regulate contributed to the 2008 financial crisis Medicine now has a version of exactly that.
Resident unionization may be one of the few structural checks on this dynamic.

PRACTICAL ADVICE FROM DR. BOWERS
Going into academic medicine as a highly sub-specialized surgeon may be the highest-risk career setup.
The two-hospital model: having multiple institutions competing for your cases fundamentally changes your negotiating position and safety.
When to consult an attorney, why you do NOT need to tell the hospital you have one, and what an attorney can and cannot do for you.
The controlled retreat strategy: protect yourself for the next job even when the current one is already lost.
Non-competes, NPDB, contracts, and what to investigate before signing anything.

Closing Reflection: The 100th Episode
Every system discussed in this episode was built with a legitimate purpose. The Board of Registration in Medicine protects the public. HCQIA was designed to encourage good-faith quality review. The ACGME exists to ensure training standards. Each one began with a just cause.
Over time, changes in how medicine is organized and how physicians are employed have created dynamics the original frameworks were not written for. The physician who simply showed up and did excellent work inside a broken system did not cause that drift. But they are the ones absorbing its cost.
The majority of physicians are not the bad actors these systems were designed to catch. They are doing their best inside systems that apply the same rules to the rare bad actor and to the exhausted surgeon who had a difficult patient or staff interaction after a long night of call.
Knowing that is clarity of environment, and clarity is the first form of protection.
Key Terms Referenced
Sham Peer Review: The use of the peer review process to target a physician for non-clinical reasons, typically when an institution has decided to remove someone and needs a documented justification.
HCQIA: Healthcare Quality Improvement Act (1986). Grants qualified immunity to hospitals and peer reviewers. Designed to encourage good-faith review; the unintended consequence is that bad-faith reviews are difficult to challenge.
NPDB: National Practitioner Data Bank. A federal repository of adverse actions against clinicians. An adverse report follows a physician across state lines and employers permanently.
PIP: Performance Improvement Plan. Can be a legitimate corrective process or a documented pathway toward termination, depending on the institutional context.
DARVO: Deny, Attack, Reverse Victim and Offender. Coined by psychologist Jennifer Freyd. A pattern that can arise when individuals or institutions face accountability, with or without conscious intent.
ACGME: Accreditation Council for Graduate Medical Education. A private, non-government organization that accredits residency and fellowship programs.