DrRich hits a grand slam – Where Those Cardiology Guidelines Come From, Part II
This great post raises important questions about biases.
DrRich would like to close with one final observation, one he has already made, to wit: there’s nothing unusual about cardiologists. They are regular people, just like everybody else.
To DrRich this means that, as our new political leaders advance a system under which they will assess clinical evidence to determine what they should and should not pay for, they too – just like the cardiologists – will be applying their own world view to the interpretation of that data. Unlike the cardiologists they will not be interested in encouraging the use of any particular procedure. On the contrary, their own world view – which will be at least as deeply felt and all-encompassing as that of the cardiologists – is one in which too many greedy doctors are ruining the healthcare system by over-utilizing too much expensive technology. (Like all world views there is something to this one, and the recent actions of DrRich’s cardiology colleagues are doubtless adding force to it.) But such bias on the part of the soon-to-be all-powerful governmental payers will quite predictably lead to new tricks of statistical legerdemain, tricks that, one fears, will render the kind of “cardiology logic” we’re seeing today a fond memory from a more innocent time.
Perhaps we should thank our cardiology friends for demonstrating the kind of results a hidden agenda can produce when highly educated individuals are engaging in purported scientific activity. The accurate interpretation of scientific data requires that there be no hidden agendas, otherwise the results will be predictably damaging.
And when it comes to healthcare, covert rationing is the most damaging hidden agenda of all. It is one against which neither scientific methods, nor ethical standards, nor the rules of civil society can prevail.
I do have a response to my esteemed colleague. If you read the original plan for guidelines, the committees were meant to have multiple world views. Cardiology guideline panels should have had cardiologists, cardiovascular surgeons, radiologists, internists, family physicians, methodologists and lay persons. The original AHCPR guideline panels had balanced construction.
I do understand the worry that money will bias "government panels." If done properly, and we do have a history of AHCPR (now AHRQ) creating appropriate panels, then we will get reasonable guidelines.
Almost anything would be an improvement from the current wild west guideline movement we currently have. Having the foxes guard the hen house never works.
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DB,
I agree with your suggestion that we follow the original concept for multi-disciplinary guideline panels, but I would take it a step further. In my view a panel considering cardiology guidelines (for instance) should certainly include all the disciplines you mention, but it should be mandated that the cardiologists (the specialists) themselves either be a decided minority, or non-voting members. I believe generalists should be the key “deciders.”
Of course, this plan only works if the powers that be stop coercing general physicians (by a host of mechanisms you and I have discussed ad nauseum) to withhold/omit important aspects of patient care. If general physicians are assigned the hidden agenda of withholding useful healthcare, then even these “enlightened” guideline panels would remain conflicted, but in a different direction.
Rich