Who should write medical guidelines?

There are few other medical specialties that boast more guidelines than Cardiology. We don’t say a specific treatment plan was good or bad; we say it was “I, IIa, IIb, or III”

Today, a well publicized health story (WSJ, and NY Times) from the Archives of Internal Medicine reported that more than 50 percent of guideline-writing heart doctors have financial conflicts of interest with industry.

On the surface, these “arrangements” seem preposterous. Dr Steve Nissen, from the Cleveland Clinic said that it “defies logic.” The NY Times quoted the president of the Institute of Medicine, Dr David Rothman, as saying:

“The guy who’s calling balls and strikes should not be a shareholder in one of the teams,” It’s so self-evident that if you’re going to be doing guidelines, it should be clean.”

My sophomoric analogy goes like this: One of my first blog posts lambasted the unhealthiness of Gatorade. Not a day later came an email from a senior bike team member reminding me “to go easy on Gatorade because they sponsor your bike team.”

You get the point. That side of the argument is obvious, and not inconsequential.

The Solution:

Dr Nissen and Rothman advocate that those who write guidelines should cut all ties with industry.

Ah, if it was only that easy.

The real-world problem with the simple solution:

The present paradigm is that most medical guidelines are penned by clinical scientists. In Cardiology, clinical research means conducting trials with medical devices or medicines. Innovation requires collaborating with industry. And it’s only fair that those doctors who dedicate themselves to science get paid a fair wage. Right now, a substantial portion of that wage comes from industry.

Dr Nissen’s solution puts clinical scientists into a jam. They can either turn down the money from industry, and work for less pay. (Which of course would make them like all of us regular docs.) Or, they can simply not write guidelines.

But if academic doctors don’t write guidelines, who will?

Would it be regular doctors like myself?

If you haven’t heard, most regular (employed) heart doctors are valued only by the RVUs (Relative Value Unit) they generate. Creating anything without a CPT code no longer reaps any monetary value. Even if there was a “stipend” for time spent writing guidelines, when would regular doctors have the time? (And heart rhythm doctors have it easier than do the “squishers,” who rescue people from heart attacks at every hour of the day, within 90 minutes.) What’s more, if we took a day per week to write, who would see the patients that day?

Alright then, if scientists can’t write guidelines because of their ties with industry, and clinicians can’t write guidelines because they are busy being doctors, who’s left?

Some might task the government with writing the rules guidelines. And in the case of ICDs, there would be a precedent.

The last update to the government’s ICD guidelines was in 2005. Nope, nothing new in the management of heart arrhythmias has come out in the past six years. And of course, Medicare’s budget woes play no role in their medical coverage decisions. Unlike clinical scientists, government is immune from conflict.

The obviousness of the middle ground:

Clinical science needs to collaborate with industry. You want gifted people in science working with engineers in Minnesota to design better tools to treat your heart.

People have different skill sets, and in general, most academic doctors are well equipped to write guidelines. It’s what they do. And it’s a natural extension of their research.

Regular doctors that are free of financial ties with industry should have a reasonable incentive to participate in the guideline-writing process. We would like it better, and we would be better doctors, if our worth was measured by more than just RVUs.

Less government involvement with clinical medicine is always better.

And the most obvious…

Quality care doesn’t always require more guidelines.

JMM