An illustrative case: physicians failed to adhere to guidelines for management of a common problem. Attempts to improve adherence yielded minimal success. Then, new data suggested that the guidelines were based on bad data. The physicians may have been appropriately skeptical.
Bad Data
Physicians may resist CPGs based on bad data, especially when evidence may have been distorted by vested interests. Distortion may result from manipulations of study design, implementation, and analysis, informed by sophisticated knowledge of clinical epidemiology, to increase likelihood of results that serve study sponsors. When manipulation fails to produce favorable results, studies may be suppressed.
Guideline development may also be distorted. Problems include biased selection of clinical evidence, lack of rigorously critical evidence review, and failure to attend to relevant patient-centered outcomes and patients’ values.
Bad Influences
Deceptive marketing and public relations campaigns may be designed to support their sponsors’ interests. Such campaigns may be based on sophisticated knowledge of principles of propaganda, first espoused by Bernays in US, and of disinformation, as practiced in the former Soviet Union.
Physicians may be influenced by factors that ought to be extraneous to the decision process. These include perverse incentives, such as payments that depend on physicians’ patient management (e.g., additional payments for prescribing specific drugs). They may also be subject to bureaucratic impediments, conflicts of interest, and outright criminal and corrupt activities.
Discussion
We will discuss proposed solutions of some of these problems, as espoused by the Institue of Medicine and watchdog organizations. We will finish with a brain-storming session to develop other solutions and a research agenda.
Objectives
Participants should understand:
- evidence of physicians non-EB decisions
- influences of research manipulation and suppression, distortion of CPGs
- extraneous influences
- proposed solutions to these problems