Medical Guidelines and Medical Consensus-II

Most consensus policies are still achieved by selection of expert panels or organizations whose opinions conform to each other. Far too many professionals, insurance companies and other healthcare organizations 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 so-called “Medical Guidelines” are often far from uniform or consistent.

A few 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. A study reported in the Journal of The American Medical Association, reported that 72-90% of physicians writing clinical practice guideline articles show conflict of interest.

Consensus, according to Webster, is “agreement in the judgment or opinion reached by a group as a whole.” Despite the problems of bias and self-interest, 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 medical consensus when you see it, since it depends so much on who is doing the talking, and perhaps why.

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