http://bmj.com/cgi/content/full/324/7334/0/i

BMJ 2002;324 ( 16 February )

Editor's choice

A modest proposal

In the 1990sthe heyday of guideline developmentdoctors were receiving far more guidelines than they could possibly read. Judging by the papers we published on guideline compliance, doctors would do almost anything other than read guidelines. The more industrious doctors either weighed them or measured the height of the pile, sending us the details in the hope of publication.

And now it seems that the best fate for these guidelines might be the furnace, or better still, the recycling bin. Researchers in Toronto wrote to 192 authors of 44 clinical guidelines on 10 common conditions; all had been endorsed by professional societies in North America and Europe (p383). Despite two mailings, barely half the authors responded to questions about competing financial interests. Though 87% of respondents admitted financial links with one or more pharmaceutical companies, only one of the 44 guidelines declared these. The researchers were unable to check whether these influenced treatment recommendationsthere were too few independent guidelines in the sample for a meaningful comparison. But evidence cited by the researchers suggests that it would have.

If guidelines are worth devisinga big if, given doctors' reluctance to follow themthen authors and guidelines will have to be explicit about competing interests, conclude the authors. Intended recipients of guidelines should demand nothing less.

Systematic review is supposed to be the antidote to selective use of the literature in arguments over interventions. Nevertheless, the authors of a recent Cochrane review questioning the value of mammography are finding that the big guns have lined up against them. Ten medical organisations, including the American Medical Association and the American Cancer Society, vigorously upheld the status quo in a full page advertisement in the New York Times, eschewing any supporting evidence for their stance (p432). Is the fact that mammography is worth $3-4bn a year relevant here?

And what can explain the vituperation levelled at two members of the Western Journal of Medicine's editorial team after they wrote in the San Franciso Chronicle that the routine blood test for prostate specific antigen was unreliable, often picking up innocuous tumours resulting in avoidable anxiety and treatments with nasty side effects. Compared to Mengele and accused of having the future deaths of hundreds of thousands of men on their hands, they were subjected to calls to their employers to sack them (p431).

From this month the BMJ Publishing Group is providing free access to the electronic versions of its 23 specialist journals to anybody in the world's 100 or so poorest countries (p380). This coincides with a WHO initiative providing institutions in the developing world with free or very low cost access to the publications of many of the big commercial publishers. Now the rest of the world can watch how Western medicine beats the swords of research findings into the ploughshares of special interest.

Footnotes

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© BMJ 2002

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