On Medical Consensus and Guidelines
"The religions we call false were once true."
Previously, I raised the question why upper GI endoscopy (EGD) had virtually replaced the more useful, safer, and cheaper, upper gastrointestinal series. There are many possible answers to this query, including, but not limited to, the explosion in the consensus and medical guideline movements. A climatic change has occurred in the practice of medicine, resulting from the changing economics of healthcare delivery and a new participant mentality. This has been driven by professional organizations and especially the Government. This conceptual shift was accelerated by the Medical Guidelines Movement in the United States in the mid-1980's when The National Institutes of Health came under intense pressure from policy makers to provide a formal system of assessing new medical developments. Thus was born the Agency for Health Care Policy Research (AHCPR). Thanks to the emergence of "evidence-based medicine", a major area of policy focuses on "Outcomes and Effectiveness and Technology Assessment." A previous press release: "The Agency for Health Care Policy and Research (AHCPR) is inviting health care organizations as well as other public- and private-sector entities to submit their clinical practice guidelines for inclusion in the National Guideline ClearinghouseTM (NGC), a comprehensive electronic database." (My emphasis)
In addition to these and other Government-sponsored sites, physicians, health plans, patients, and hospitals are constantly besieged by an archipelago of professional societies and organizations, (over 2.6 million Google hits on search terms "medical professional societies" alone) many devoted to their own area of interest, issuing periodic guidelines and consensus opinions.
Should We Worry?
It's no wonder so many physicians are confused and overwhelmed, pondering the moral, medical, and legal implications of medical consensus and practice guidelines. For instant relief go to this page. Here, in succinct language is an important disclaimer, reading in part, "...These guidelines are not fixed protocols that must be followed... While they identify and describe generally recommended courses of intervention, they are not presented as a substitute for the advice of a physician or other knowledgeable health care professional or provider. Individual patients may require different treatments from those specified in a given guideline. Guidelines are not entirely inclusive or exclusive of all methods of reasonable care that can obtain/produce the same results..." If you require more reassurance, see the Federal Register, the final word on Governmental regulations having legal effect. Federal Register (CFR Vol. 63 no. 70) officially defines Clinical Practice Guidelines, but publishes not a single guideline.
How Consistent Are Medical Guidelines?
Most consensus policies are still achieved by selection of expert panels or organizations whose opinions conform to each other. Far too many professionals, HMO's, and other healthcare organizations, even sophisticated patients, are eager to follow the latest schematic orthodoxy, whether it be the "standard" for treating advanced cancer, or the decision to perform invasive studies. These standards, described as "Medical Guidelines" are often far from uniform or consistent.
Several years ago in the Lancet, an editorial pointed out that The American Medical Association listed 2200 guidelines, and that within 6 weeks in the same year two governmentally sponsored groups issued opposing guidelines on screening mammography. There continue to be multiple guidelines for mammography as well as prostate and other cancer screening. For example, guidelines for colon cancer screening differ between the National Cancer Institute and the American Cancer Society, as well as the American Society for Gastroenterological Endoscopy. Up to 50% of cardiologists in a previous national study disagreed on indications for invasive studies. When ill-conceived guidelines like the preference for early upper endoscopy over the barium X-ray, edge into "Community Standards of Care" they cause untold medical mischief, if not economic havoc. Far too often they express specialty bias and by implication economic self-interest.
Most disturbing was a study reported in the Journal of The American Medical Association, (JAMA. 2002; 287:612-617): 72-90% of physicians writing clinical practice guideline articles show conflict of interest.
Whose Consensus Anyway?
Consensus, according to the dictionary, is "agreement in the judgment or opinion reached by a group as a whole". Despite the unavoidable difficulties outlined above, clearly the practice of medicine cannot exist without a considerable degree of consensus. The democratization of medical opinion has been on balance a powerful and useful, if not a breathtaking development. Darryl F. Zanuck, the film producer once remarked, "If two men on the same job agree all the time, then one is useless. If they disagree all the time, then both are useless." Unlike pornography and pestilential politics, you don't necessarily know consensus when you see it as advertised, since it depends so much on who is doing the talking, and perhaps why.
Martin F. Sturman, MD, FACP
Copyright 2006, Mathemedics, Inc.
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