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.

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  1. K.E.M.
    Reply

    I am a LPN, worked in Nursing-Homes and Doctors’ Offices and observed the tactics of Pharma Corporations’ Representatives. They DO regularly offer physicians certain perks (from free concert tickets to Golf vacations and more) if they give samples or prescribe the meds they hawk.
    Physicians who voice reservations towards a new med, are very skillfully brow-beaten and admonished by pharm. representatives. Pharmaceutical Corporations rather risk law-suits than take a questionable new med off the market. It takes months if not years before enough complaints about negative outcomes concerning a new med reaches a control agency like NIH, and by then the P.C.s have already made so much money that the resulting settlement payments to patients are of little consequence to their profit margin.
    My advice: If prescribed or handed a medication which is new on the market do research on the NIH.gov or other med websites. Read JAMA or other pertinent Physician’s Journals/Magazines.
    Don’t get me wrong, the Pharmaceutical Corporations have done and do a lot of research and we can thank them for the eradication of some formerly incurable/untreatable diseases. Just be careful and take those advertisements with a large grain of salt. Take care!

  2. VFC
    Reply

    If only the general public realized how insidious practice guidelines are, not only for doctors but hospitals as well. Their malpractice carriers know these guidelines better than they do and expect them to be followed because otherwise, a healthcare provider has nothing else to back them up if they go to court. It takes a lot of daring to venture too far from these guidelines. Personal injury lawyers know and use these guidelines, too. We patients bear some responsibility for this situation with our willingness to sue so readily- medicine is still an art. Man has not been given the ability to cure or fix everything. Each of us must take care of ourselves when possible by changing our lifestyles to a healthier way and by being active participants in our own medical care. Not only am I a patient, but I am an RN, too.

  3. CRL
    Reply

    We all have a personal responsibility to read and research medicines and diagnosis before we take them. It is for darn sure that doctors know less than many of us from my experience. I find that when I get a diagnosis and the sure-to-follow prescription, that my first stop is at the pharmacist. I don’t fill the prescription right away but instead ask the pharmacist to give me an insert for that drug so that I might read about it first.
    I then take that to the library and read about it in the Physicians Desk Reference (a book all doctors should have either in hard copy or on their computer but most of them ignore after their first couple of years in practice); I look up the drug and research books both in hard copy and on the computer about the “condition” that led to the prescription.
    I also look for alternatives (herbs and nutrition) to treat the condition. Once I have done this (takes a couple of hours at the library and sometimes I have to check out some of the research books on the condition), I make a decision if the side effects are worth taking the drug or if I can ease or control my symptoms with better nutrition and alternative supplements.
    Most herbal supplements don’t have side effects because the body recognizes them as food (with a few notable exceptions that have been widely publicized by those against taking natural remedies!). They also don’t work as quick as chemicalized drugs but the condition didn’t happen overnight either!
    Your piece of mind is certainly worth the extra effort before you begin the drugs. So even if you decide the drug is safe and the side effects can be lived with, you can do it with more confidence than just believing in the doctor’s god complex.

  4. SalW
    Reply

    Your analogy of conflicts of interest such as umpires in a baseball game receiving funds from one of the teams is a perfect one! Thank you so much for keeping us informed on the other side of medical guidelines.
    I don’t want to sound like a broken record because I have before commented elsewhere on your site on the 2004 cholesterol guidelines being lowered, not based on any clinical studies, and made by “experts” on the panel when all but one of the nine had connections with the pharmaceutical companies manufacturing cholesterol lowering drugs. As Jeanne Lenzer states in her BMJ article, “Biased guidelines can have powerful and wide ranging effects . . . most guideline panellists have conflicts making the guidelines they issue less than reliable.”
    I was shocked by Jeanne’s further comment about a lecturer at a meeting on geriatric care in the Virgin Islands earlier this year who said, “We like to stick within the standards of care, because when the shit hits the fan we all want to be able to say we were just doing what everyone else is doing–even if what everyone else is doing isn’t very good.” I now know why my elderly geriatrist never reads any new studies I give him with his comment, “It depends who you listen to.”
    New cholesterol guidelines will be forthcoming later in the year by a board of 15 cardiologists. What are their relationships with the pharmaceutical industry? As cardiologists do they have conflicts of interest and can they be trusted with our lives at stake? Who finally will remember, “first, do no harm?”
    On a recent visit with my husband to his cardiologist’s office, I can’t forget the enormous and delicious looking cart of shrimp piled high on ice, beautiful salads, etc. being wheeled in at lunchtime. I then saw a sign on the inside door stating that there was a change in policy for visiting pharmaceutical reps the first of the year now telling them that the only time they could see the doctors was at lunchtime and they were responsible for providing it. I wonder what high-powered company provided the mouth-watering spread we witnessed?
    At my husband’s appointment, I then asked his young cardiologist what questions he asked such reps at their meetings. He commented that he asks them how much better their product is than other companies’ meds. I wonder if adverse side effects ever enter the conversation? He also told me I didn’t know what I was talking about when I referred to your article on the dangers of taking “beta blockers (metoprolol) with calcium channel blockers (amlodipine) is generally not advised since the combined effects may lead to serious heart problems.” He is on both (in addition to a clonidine patch and benicar) and, at age 75, we have been to the ER twice since his back surgery on February 14, and his diastolic pressure is getting very low.

  5. SalW
    Reply

    Your analogy of conflicts of interest such as umpires in a baseball game receiving funds from one of the teams is a perfect one! Thank you so much for keeping us informed on the other side of medical guidelines.
    I don’t want to sound like a broken record because I have before commented elsewhere on your site on the 2004 cholesterol guidelines being lowered, not based on any clinical studies, and made by “experts” on the panel when all but one of the nine had connections with the pharmaceutical companies manufacturing cholesterol lowering drugs. As Jeanne Lenzer states in her BMJ article, “Biased guidelines can have powerful and wide ranging effects . . . most guideline panellists have conflicts making the guidelines they issue less than reliable.”
    I was shocked by Jeanne’s further comment about a lecturer at a meeting on geriatric care in the Virgin Islands earlier this year who said, “We like to stick within the standards of care, because when the shit hits the fan we all want to be able to say we were just doing what everyone else is doing–even if what everyone else is doing isn’t very good.” I now know why my elderly geriatrist never reads any new studies I give him with his comment, “It depends who you listen to.”
    New cholesterol guidelines will be forthcoming later in the year by a board of 15 cardiologists. What are their relationships with the pharmaceutical industry? As cardiologists do they have conflicts of interest and can they be trusted with our lives at stake? Who finally will remember, “first, do no harm?”
    On a recent visit with my husband to his cardiologist’s office, I can’t forget the enormous and delicious looking cart of shrimp piled high on ice, beautiful salads, etc. being wheeled in at lunchtime. I then saw a sign on the inside door stating that there was a change in policy for visiting pharmaceutical reps the first of the year now telling them that the only time they could see the doctors was at lunchtime and they were responsible for providing it. I wonder what high-powered company provided the mouth-watering spread we witnessed?
    At my husband’s appointment, I then asked his young cardiologist what questions he asked such reps at their meetings. He commented that he asks them how much better their product is than other companies’ meds. I wonder if adverse side effects ever enter the conversation? He also told me I didn’t know what I was talking about when I referred to your article on the dangers of taking “beta blockers (metoprolol) with calcium channel blockers (amlodipine) is generally not advised since the combined effects may lead to serious heart problems.” He is on both (in addition to a clonidine patch and benicar) and, at age 75, we have been to the ER twice since his back surgery on February 14, and his diastolic pressure is getting very low.

  6. BH
    Reply

    I agree that the guidlines for Lyme Disease is totally out of date. There is a Chronic Lyme Disease State that occurs in lots of patients…especially those with co-infections. This chronic condition needs to be treated much longer and more agressively than the Lyme Guidelines dictate. Is there hope that these “totally outdated” guidelines will ever be changed. Watch the documentary “Under the Skin” and see what Lyme Disease can do to a patient!

  7. s
    Reply

    I hope Ms. Lenzer will look at rheumatology next.

  8. curt y.
    Reply

    nowhere is the inanity of published guidelines more evident than in the treatment of lyme disease. my doctor, an expert in infectious disease control, and really good at getting his colleagues to wash their hands, roll up sleeves, not wear ties, etc, seems only to refer to the Infectious Disease Society of America (IDSA) viewpoint, whereas more pointed recommendations from the International Lyme and Associated Diseases Society (ILADS) seem never to be referenced. as a result, many in CNY suffer unnecessarily from effects of a disease about which most patients are clueless.

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