When I give presentations on the guideline development
process of the U.S. Preventive Services Task Force, a question I'm often asked
is how many votes of the 16-member panel are needed to approve a recommendation
statement. The answer is a two-thirds majority, with a minimum of 10 votes in
favor in case of absences or conflict-of-interest recusals. In reality, though,
during the four years I attended Task Force meetings, I can't recall a
statement passing without overwhelming (15-1 or 14-2) or, more commonly,
unanimous support. The feeling among members seemed to be that the lack of a
strong consensus on a recommendation suggested that there was something missing
about the way they were approaching the evidence.
The Supreme Court of the United States always provides
justices in the minority the option to write a dissenting opinion for the
record, whose legal reasoning sometimes informs future decisions. In contrast,
minority opinions rarely accompany medical guidelines. In an unusual case,
after the JNC 8 committee published its guideline for management of high blood
pressure in adults, five former panel members who disagreed with the
guideline's target systolic blood pressure of 150 mm Hg in persons aged 60 years
or older formally published their minority view. Even then, this dissenting
report appeared some time later, in a different journal than the original
guideline.
In a 2016 article in Mayo Clinic Proceedings, Dr. Daniel
Musher, a professor of medicine and infectious diseases at Baylor College of
Medicine, made the case for regularly publishing dissenting opinions in medical
guidelines. He cited his experience as a member of the Advisory Committee on
Immunization Practices (ACIP) working group that recommended the use of
13-valent pneumococcal conjugate vaccine (PCV13) in adults 65 years and older,
despite his strong disagreement. As is standard process for the ACIP and most
guideline panels, he did not have the opportunity to voice his dissenting
opinion and rationale in the text of the guideline. His view did not see
publication until more than 18 months later, after the new recommendation had
been largely implemented into clinical practice. Dr. Musher wrote:
The perceived problems with publishing dissenting opinions
are that this practice would (1) cause confusion within the medical community
and (2) diminish the force of the recommendations. Regarding the former, the
current situation, in which dissent is not included but in which subsequent
articles dispute the formal recommendations or different professional societies
publish divergent guidelines, is amply confusing—witness the differing
guidelines for screening for breast, lung, or prostate cancer. It defies reason
to believe that every member of the American Cancer Society's committee thought
that breast cancer screening should begin at age 40 years, whereas all who
participated in the US Preventive Services Task Force agreed that screening
should wait until age 50 years. Inclusion of dissenting opinions in the final
version of published guidelines may well have reduced polarization and
confusion by bringing dissent into the recommendation process.
I can't testify to the presence or absence of internal
discord on the panels that produced the 2015 ACS or 2016 USPSTF guidelines on
breast cancer screening, but my best recollection of the July 2008 meeting
where the USPSTF first voted to recommend routine mammography starting at age
50 is that, contrary to Dr. Musher's suggestion, there was no minority view. When
there is one, I agree with him and the Slow Medicine bloggers that making a
forum available to describe conflicts that occurred within the guideline
narrative (including all of the various options that were considered and later
discarded) could reduce the intensity of second-guessing and better inform
clinicians about the guideline's nuances and potential limitations. Now that I
have had experience as a voting member of guideline panels on atrial
fibrillation and cerumen impaction, though, I wonder if the explication of
dissents belongs in the guideline itself, rather than as a separate stand-alone
perspective.
Would the airing of minority views within medical guidelines
provide useful perspectives for patients, clinicians, or policymakers, or are
conflicting guidelines from different organizations already confusing enough as
it is?
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