Ever wonder how doctors stay up to date on the best way to treat a given condition–diabetes, hypertension, stroke or heart disease, to name just a few common health problems? The answer is “guidelines.”
It seems like such a good idea. Health care providers are incredibly busy just seeing patients. There is so much research published in medical journals every day that it is virtually impossible to stay on top of the latest and greatest treatments. Most practitioners have a hard time determining which medications are working best and which are falling by the wayside.
Doctors who don’t have hours to spend combing the medical literature often rely on guidelines developed by their professional organizations. Sometimes these recommendations carry the weight of law. A doctor who follows the guidelines is perceived to be practicing good, cutting-edge medicine. A physician who ignores or rejects the guidelines may be considered a black sheep by his colleagues. State medical societies may frown on medical practice that strays too far from the guidelines.
So how are these guidelines developed and how good are they? Most patients and health professionals are clueless about the process. Ideally, one would hope that the most knowledgeable and objective health professionals gather together periodically to review the best available evidence and determine the most appropriate therapies for any given disease or condition. That’s the way it should be done.
But a powerful new article published in the BMJ on June 14 suggests that the reality falls far short of the ideal. Medical investigative journalist Jeanne Lenzer has just written a powerful feature in the Evidence Based Medicine section of BMJ titled “Why we can’t trust clinical guidelines.” In it, Lenzer documents scandalous conflicts of interest among guideline writers from professional organizations.
She begins her article with an arresting example of the treatment of spinal cord injury. In 1990 guidelines were issued urging the use of high-dose steroids for such serious trauma. Many neurosurgeons worried about a high rate of drug-induced complications, but a great many followed the recommendation for fear they might be punished if they did not. More than two decades later the guidelines were changed because of a lack of evidence of benefit and substantial evidence of harm.
Conflicts of interest among the panelists that establish guidelines are a major concern, according to Lenzer. She cites numerous examples of direct or indirect ties to the pharmaceutical industry. Associations that are often believed to be patient oriented may derive millions of dollars in support from drug manufacturers.
We would never approve of the umpires in a baseball game receiving funds from one of the teams. Why we permit guidelines to be drawn up by individuals with connections to the products they review remains a mystery to us. We need objective experts with no ties to industry examining the best available evidence and making honest recommendations. Lenzer’s full article is accessible for one week at the BMJ website. Take a few moments to read this compelling investigative report. Let us know what you think in the comment section below.