Gooznews takes on conflicts in guidelines
Gooznews posted an interesting commentary on guidelines, conflicts of interest in guideline development and over reliance on expert panels when there are gaps in evidence. Merrill Goozner is a health care ethicist and this is not the first entry on his blog that has caught my attention. You might want to check it out. His post is premised on the recent article by Sniderman in the Journal of the American Medical Association (recent issue), which does a remarkably job outlining the problems with control in evidence based medicine, how "opinions" of the panel members are recharacterized as "science" in the form of evidence based guidelines. Some of the comments to Goozner's post are interesting. One person responds that "Evidence-based medicine has morphed into pharma-based medicine and HMO-based medicine". I thought Goozner's post was a good opportunity to point out some of the problems with the IDSA guidelines. My comment follows:
Gooznews posted an interesting commentary on guidelines, conflicts of interest in guideline development and over reliance on expert panels when there are gaps in evidence. Merrill Goozner is a health care ethicist and this is not the first entry on his blog that has caught my attention. You might want to check it out. His post is premised on the recent article by Sniderman in the Journal of the American Medical Association (recent issue), which does a remarkably job outlining the problems with control in evidence based medicine, how “opinions” of the panel members are recharacterized as “science” in the form of evidence based guidelines. Some of the comments to Goozner’s post are interesting. One person responds that “Evidence-based medicine has morphed into pharma-based medicine and HMO-based medicine”. I thought Goozner’s post was a good opportunity to point out some of the problems with the IDSA guidelines. My comment follows:
Your point about conflicts of interests on guidelines, conflicting guidelines, and gaps in evidence leading to reliance on the judgment of the expert panel is important. Today, with the rise of managed care and treatment guidelines, medicine has evolved to the point that expert panel opinions can “dictate” and limit treatment options for patients and replace clinical judgment and individualized care. When guidelines recognize that an area of medicine is not yet settled or depends upon patient preferences, they typically provide for treatment options and let the physician and patient choose the most appropriate approach. The AAP has a model template for this decision making process (see figure 1, Classifying Recommendations for Clinical Practice Guidelines, http://pediatrics.aappublications.org/cgi/content/full/114/3/874 ), which essentially requires that when a recommendation is based on the “expert opinion” of the panel, the recommendation can only provide for treatment options or no recommendation. When expert guidelines panels take it upon themselves to substitute their “expert opinion” for that of the treating physician, there is centralized medicine without accountability. (Authors of guidelines have not been held liable for malpractice, but physicians are.) This is particularly egregious when a medical society has monopoly power and excludes other points of view and forecloses treatment options.
When the Infectious Diseases Society of America began to update its Lyme disease guidelines in 2006, patient groups, other medical societies, and even IDSA doctors who disagreed with the guidelines sought to have a voice in the process. The IDSA denied these requests for participation out of hand in what appears to be a professional turf war over protecting its role as the “experts” on all matters infectious. For patients, it meant that the fundamental right to choose among treatment options was foreclosed in a set of guidelines that did not acknowledge or permit treatment options, like long term antibiotic care. For physicians, it meant that to practice medicine using their best clinical judgment could cost them their professional medical license. (Malpractice is based on the standard of care determined by a consensus of physicians, but powerful guidelines can displace the standard of care or drive the community practice distorting the standard of care.) The worst part was that because the guidelines did not even acknowledge the controversy or different treatment approaches used, physicians and patients who did not know about the controversy would assume that none existed—that there were in fact no treatment options, no controversy, and no choices to be made or alternate opinions to seek. Innovation, which often springs forth from clinical judgment, is suppressed as well.
Lorraine Johnson, CEO, California Lyme Disease Association
