Tom Sullivan, blogging over at Policy and Medicine, recently noticed another flurry of activity in the long running debate about conflicts of interest. His post is titled Coordinated Ad Hominem Attacks on Physician-Industry Relationships in Guideline Development: The Next Frontier?
He opens, saying, “Recently, we saw concerted attacks on clinical guidelines committees, but interestingly, not on the science coming out of them. Instead, the attacks were focused on whether the writers of those guidelines have a financial interest in the area they are working in.”
That, I believe, is the crux of the whole debate. There has been a lot of criticism of practice guidelines based entirely on the financial interests of the guideline writers. I agree with Sullivan that it really is an ad hominem attack (and therefore fallacious) because virtually all of the criticisms of guidelines that have been written are based not on the science or the primary sources referenced in the guidelines but on the company they keep. I have read many such attacks. Not a single one that I can recall referenced the actual science. The recent examples cited by Sullivan are true to form.
As responsible clinicians we have an obligation to be scholars. That means being familiar with scientific underpinnings derived from primary sources. It’s the only frame of reference we should be using. The arguments of the guideline attackers, devoid of any scientific appeal, always come up empty. More than that, they fail to take into account patient outcomes. Study after study has shown improvement in important patient outcomes, including mortality, associated with adherence to a variety of guidelines. Of scores of guidelines in existence only two have been associated with negative outcomes. (In the case of one of these the flaw is well understood, and known not to be related to industry influence).
I’m not suggesting we follow guidelines uncritically. That would be a violation of the first principles of evidence based medicine, which appeal to the primary evidence and ask the clinician to apply this evidence to individual patient attributes. But there’s no principle of evidence based medicine that tells us to first drop down to the bottom of a scientific paper or guideline document, look at the author’s disclosures then either believe it or reject it based simply on that.
You can’t trust a guideline implicitly but the remedy for that problem is to go to the primary sources and look at the actual science. The Internet is easy to use and PubMed is free. To judge a clinical guideline by the simple litmus test of financial interest is not only an ad hominem fallacy, it is intellectually lazy. We need to do better.
Robert Donnell is a hospitalist who blogs at Notes from Dr. RW.
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