On Guidelines, Should Dissenters Be Heard?

After talking with three doctors, they all said dissenters should not be heard and said that this causes problems for patients who read the guidelines and the dissenting opinions. My one comment to all three doctors was, then you believe there is no room for individualism and for all patients it is a one-size-fits-all way of treatment. They felt this was the case until someone proved that something did not work for a large group of people and then the guidelines should be reflective of this.

Since I respect two of the three doctors highly, I did not pursue this further. Now I wish I had after talking to two more doctors recently. They both said that doctors that are afraid of dissent should not be on guideline committees to begin with and there are always exceptions that some forget about or try to ignore. One of the two asked me about the article from MedPage Today and if I had read it. I laughed and told him that was the reason for my questions and while the article was about the two different types of pneumonia vaccines, I said it was easy to have dissenters on this topic, but how did this apply to primary care and other medical professions and their guidelines.

Both agreed that my point was valid, but both agreed that there were times when dissent would be proper and to prevent it could create situations that made doctors follow guidelines when they should look to circumstances not covered by the guidelines or other reasons. The other doctor said he felt dissenting was good and guidelines were just that – guides that could not cover every medical situation.

Then the one doctor said that doctors that do not want dissent often feel that they are the only doctors that know the topic and others should learn from them. Not only that, but doctors that are uncomfortable with dissent often are not comfortable with their decisions and not want other doctors speaking out against the majority opinion.

The other doctor emphasized the above point and said “experts” are not always knowledgeable about everything and want to have readers of guidelines think they are experts. He continued that the article was about medical decisions that can often be complex. Rather than undermine the majority decision, He believes that dissenting opinions could strengthen guidelines by highlighting some of the nuances clinicians should consider when implementing the guidelines.

He concluded that the ability to learn about dissenting viewpoints within the framework of medical guidelines could help clinicians better perform shared-decision making, helping them guide their patients to the decision right for them.