When I stumbled across hard evidence that many neurosurgeons, out of fear of jeopardizing their careers, admitted to following a clinical guideline they believed was harmful and even deadly – a guideline that was reversed years later due to patient deaths – I knew I had to write, “Why we can’t trust clinical guidelines.” It would take years for me to gather the evidence to show that many clinical guidelines are compromised by financial conflicts of interest, and that doctors too often feel they must follow even those guidelines they suspect are biased and harmful. I examined several other guidelines and gathered statistics. Then I investigated the development of a newly released and highly controversial clinical guideline promoting a drug to treat overed undeclared ties between the former chair of the guideline panel, as well as the professional society, and the manufacturer of the drug under review. But something bothered me. The financial ties of many of the panelists I reported were indirect and weak. I knew the treatment was one of the most contentious issues in emergency medicine; polls showed a majority of emergency doctors didn’t believe the drug was safe or effective. Many cited the dramatic increase in brain hemorrhage among patients given the drug versus those given placebo. I wanted to understand how a professional society and its panelists came to recommend a treatment so widely distrusted by the very doctors who most often treat patients with acute stroke. First, I decided to find out whether the panelists’ beliefs about the treatment were known before they were appointed to the panel. What I found was disturbing; without exception, each panelist had previously published or given talks promoting the drug under review. Not one skeptic was included on the panel. The exclusion of skeptics – who comprised the majority of emergency doctors – undermined the disinterested process and scientific rigor necessary to limit bias and ensure the best possible medical care for the public. This led me to write about a “panel stacking,” and how panelists could be virtually free of financial conflicts, yet be selected in a manner likely to lead to a predetermined (and industry-friendly) outcome. Since surveys show that 90 percent of panel leaders (chairs or co-chairs) have ties to the manufacturers of the drugs they review, and since panel leaders often play a role in nominating or selecting panel members, panel stacking can be a powerful mechanism to promote commercial rather than scientific messages. While reporting the story, most doctors I spoke with (as well as the public) were unaware of the problem. One director of a family medicine residency program told me he thought that the lack of financial disclosures by a recent guideline meant that matters were improving. My story suggests that things may be far more complicated than they appear.
