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Draft Policies for NHMRC Committees and Working Groups Developing Guidelines Submission

ID: 
12
Personal Details
First Name: 
Brett
Last Name: 
Forge
C. Additional Information
Please add further information: 
General physician and cardiologist
E. Submission
Submission options: 
Section 1 – Policies Document
Section 1 – Policies Document
1. Are there any gaps in the issues addressed in this document?: 

In the area of medicine the conflict relating to the craft activities of the expert is rarely even declared as a conflict let alone does it exclude them from serving.

As a result medical guidelines have been corrupted for years. My area of expertise is cardiology, and my article in the MJA (The “Acute coronary syndromes: consensus recommendations for translating knowledge into action” position statement is based on a false premise [Acute Coronary Syndromes — for Debate] Brett H Forge Med J Aust 2010; 192 (12): 696-699). Referred to some of these issues.

In the case of the National Heart Foundation guidelines they were written by a panel of experts many of whom had no conflict of interest. However the intellectual heavyweights of the committee were interventional cardiologists. Now in many cases these experts derived a large percentage of their income from interventional procedures, or if not then much of their influence status and fame relates to their skills as interventionalists. As a result of the coronary interventional industry, cardiology has become the most influential medical division in hospitals and in health planning throughout the western and developing world.

For a member of such a committee to recommend widespread use and adoption of interventional cardiology (use of stents) in virtually all heart attacks adds greatly to the demand for the procedure and clearly has a massive potential benefit for the practitioners of the procedure and for the heads of departments whose status relates to the numbers of patients their departments treat.

How often have we seen a declaration of conflict of interest: “I perform coronary stent procedures and I make most of my income from this procedure, and as a result I earn more than twice as much as doctors that do not perform this procedure”? Never!

In some cases the investment in the technology is more intellectual than financial and results from a lifetime of doing the procedure and advocating it.

I know of no example where the conflict is greater nor more obvious and yet in countless committees this is never declared as a conflict.

As I pointed out in my article the recommendations of the NHF guidelines on Acute Coronary Syndromes are not evidence based, and they don’t even provide references for their claims.

The ability of medical experts to selectively interpret the literature to agree with their convictions is astonishing and usually quite transparent even to a relatively uninformed critic.

Unfortunately as knowledge becomes more specialized it gets harder to find experts without a major conflict.

The solution has been proposed in the United States and implied in Prof Ian Scotts review of the issue in the MJA (partly written as a follow up to my article). These committees should be headed by methodologists with no investment (emotional financial or intellectual) in the technologies being discussed.

Craft specialists must have an input into the process as they often have the greatest knowledge. However they should not outnumber the methodologists and shouldn’t be involved in final recommendations and submissions.

These principles apply to many medical specialties from oncology to surgery radiology and gastroenterology.

 In conclusion there has been a total failure to acknowledge the most blatant of conflicts in the area of interventional medicine. The question must be asked: do you derive any income or status from any of the procedures or tests that are being discussed?

If the answer is yes then they must not head the committee which should be lead by a methodologist with sufficient  experience knowledge and gravitas.

In conflicts of interest statements these issues should be stated: that Dr X performs these procedures and derives income rom them. 

I would be more than happy to supply the original articles and the subsequent discussion if that were helpful, or to give a more detailed submission.

 

2. Does the document strike the right balance between ensuring adequate expertise is available to be deployed on the committee and creating a framework to ensure conflicts are managed appropriately? : 

Not without dealing with the issues raised above.

Page reviewed: 5 November, 2012