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Professional Societies Should Abstain From Authorship of Guidelines and Disease Definition Statements

Originally published Cardiovascular Quality and Outcomes. 2018;11:e004889

    Guidelines and other statements from professional societies have become increasingly influential. These documents shape how disease should be prevented and treated and what should come within the remit of medical care. Changes in definition of illness can easily increase overnight by millions the number of people who deserve specialist care. This has been seen repeatedly in conditions as diverse as hypertension, diabetes mellitus, composite cardiovascular risk, depression, rheumatoid arthritis, or gastroesophageal reflux.1 Similarly, changes in prevention or treatment options may escalate overnight the required cost of care by billions of dollars.2 Should the specialists of the respective field be the developers for such influential articles?

    Many influential professional society documents are written exclusively by insiders. Joining such guideline panels is considered highly prestigious and allocation of writing positions is a unique means to advance an expert’s visibility and career within the specific medical specialty. The number of authors plus collaborators in the masthead of these influential documents sometimes exceeds 100 (eg, 118 for the 2014 European guidelines on myocardial revascularization). Hundreds and thousands of designated guideline coauthors share in the society-wide power game across a large portfolio of guidelines and statements that improve, fine tune, or manipulate disease definition and management. Tens of thousands of society members then cite these articles. This creates a massive, clan-like, group self-citation network.

    Eight of the 15 most-cited articles across all science published in 2016 are medical guidelines, disease definitions, or disease statistics (Scopus search, May 11, 2018). Cardiovascular medicine and its powerful professional societies (European Society of Cardiology, American Heart Association, American College of Cardiology) have the lion’s share. Cardiovascular experts represent almost half of the most-cited scientists in Clinical Medicine according to Clarivate Analytics (Web of Science). Most (not all) citation superstars get bulk citations by coauthoring guidelines, industry trials, and nonsystematic expert reviews. Stardom is the interwoven product of guidelines and industry links (Table). Industry trials nurture opinion leaders who then solidify their clan power authoring guidelines that serve the industry.

    Table. The Overwhelming Representation of Guideline Publications Among the Top-Cited Articles (Citation Counts Are Per Google Scholar) in a Sample of the Most-Cited Authors in Cardiovascular Medicine

    Name of AuthorArticles that have >2000 citations Most-Cited Article CitationsType
    GuidelinesIndustry TrialsOther
    Abraham, William T3305355Guideline
    Achenbach, Stephan7008094Guideline
    Adams, Cynthia D5004115Guideline
    Albert, Nancy M0001551Guideline
    Angiolillo, Dominick J0001167Industry trial
    Anker, Stephan D3008094Guideline
    Antman, Elliott M1531*6604Guideline
    Atar, Dan7106314Guideline
    Avezum, Alvaro021*10 812Other*
    Fagard, Robert H1201*8809Guideline
    Feldman, Ted E1103344Industry trial
    Filippatos, Gerasimos S170019 293Guideline
    Fonarow, Gregg C4006295Guideline
    Fox, Keith AA3006604Guideline
    Fuster, Valentin14029997Guideline
    Halperin, Jonathan8106368Industry trial
    Harrington, Robert A0104953Industry trial
    Hochman, Judith S5014115Guideline
    Hohnloser, Stefan H2205686Industry trial
    Holmes, David R0215134Industry trial
    Huber, Kurt5004987Guideline
    Hunt, Sharon Ann9005101Guideline
    Husted, Steen E1104953Industry trial
    Wallentin, Lars C4308952Industry trial
    Wang, Thomas J0012347Other
    Webb, John G0214509Industry trial
    White, Harvey D2026604Guideline
    Widimsky, Petr12008802Guideline
    Wijns, William9008094Guideline
    Windecker, Stephan15008094Guideline
    Wiviott, Stephen D0405495Industry trial
    Wood, David A1008132Guideline

    Of the authors listed as being the most cited in the world in the past decade in the category Clinical Medicine according to Clarivate Analytics that owns Web of Science (, I randomly selected those with last names starting from A, F, H, or W. Of the 74 most-cited Clinical Medicine authors thus selected, 32 (43%) had a focus on cardiovascular medicine (excluding diabetes mellitus) and these appear in this table. Citation counts are according to Google Scholar (search on June 11, 2018) and they tend to be substantially higher than Web of Science. Guidelines include clinical guidelines, disease definition statements and disease statistics. Industry trials include publications of randomized controlled trials or prospective studies of predictive or diagnostic tools funded exclusively or predominantly by the manufacturer of the tested intervention, predictive, or diagnostic tool. Multiple concurrent publications of the same article in multiple journals count as 1 article, since Google Scholar typically merges their citation records. The sum of the 3 columns for authorship of articles with >2000 citations is 164 authorships of guidelines, 26 authorships of industry trials, and 11 authorships of other articles (3 of them with partial industry funding). There is substantial variability across authors, but highly cited profiles of most (not all) cardiovascular leaders are the product of professional society guidelines and industry trials, little else. Having even a single article with >2000 citations justifiably means superstar status, eg, the 19 Nobel laureates for Medicine in 2010–2017 have a median of 1 such article each (total, 34 such articles across 19 Nobel laureates). Of the 32 cardiovascular scientists listed here, only 8 qualify for this citation superstar status based on nonguideline, nonindustry trial articles and 18 qualify for this status based on nonguideline articles. Using a lower threshold for defining highly cited articles decreases the proportion of guidelines and increases the proportion of industry trials, but these 2 groups of articles combined with nonsystematic expert reviews continue to be the large majority (still with variability across authors). There are 6 scientists in the table who have coauthored ≥8 guidelines with >2000 citations each but have no nonguideline/nonindustry articles with so many citations. These 6 scientists have first-authored 3–12 articles each with over 100 citations. Among their total of 40 first-authored articles with over 100 citations, 10 are guidelines, 7 are industry trials, 7 are nonsystematic expert reviews, 1 is an editorial, only 1 is a systematic review, and 14 are other articles.

    *Study was partially funded by industry, but industry was not the main sponsor

    Professional society journals also benefit. For example, European Society of Cardiology guidelines are published in the European Heart Journal and of the 20 most-cited articles of this journal in the past decade, 19 are guidelines and 1 is an article on definition of myocardial infarction (Web of Science search, May 11, 2018). The impact factor of the European Heart Journal increased from 2.137 in 1997 to 20.212 in 2016 (the highest among cardiology journals). In the US, similarly, most of the top-cited articles in Circulation are disease statistics, disease definitions, and American Heart Association/American College of Cardiology guidelines. Nine of the 10 articles contributing the most to the 2016 impact factor of European Heart Journal and 8 of the 10 articles contributing the most to the 2016 impact factor of Circulation are guidelines, disease definitions, or statistics.

    Thus, these guidelines writing activities are particularly helpful in promoting the careers of specialists, in building recognizable and sustainable hierarchies of clan power, in boosting the impact factors of specialty journals and in elevating the visibility of the sponsoring organizations and their conferences that massively promote society products to attendees. However, do they improve medicine or do they homogenize biased, collective, and organized ignorance?

    Well-conducted unbiased guidelines can be useful.3 However, most published guidelines have one or more red flags that either make them overtly unreliable or should at least raise suspicion among potential users.4 The list of red flags includes sponsoring by a professional society with substantial industry funding, conflicts of interest for chairs and panel members, stacking, insufficient methodologist involvement, inadequate external review, and noninclusion of nonphysicians, patients, and community members.4 Much of the prior discussion has focused on the presence of financial conflicts among panel chairs and members.5,6 After mounting pressure from the 2011 Institute of Medicine report,5 several societies have succeeded in part to ameliorate the composition of their chosen panels to avoid florid financial conflicts and preclude direct industry funding in guideline development. They have also included some methodologists. In recent guidelines, cardiovascular societies have tried to include more primary care physicians, nurses, and patients to their panels. However, it is unclear that such representatives can exert much influence when embedded within a dominant majority of vocal specialty experts. Prioritizing more the role of methodologists with expertise on evidence assessment and biostatistics and excluding content experts with conflicts (both financial and nonfinancial)7 is still uncommon across medical specialties. Moreover, stacking of the panels with specialists who have overt preferences (even without overt conflicts) is more difficult to avoid.4

    Some professional societies are behemoth financial enterprises. Massive producers of medical guidelines and of disease definitions tend to be the largest financial players, again with cardiology being the leading example. For example, the annual American Heart Association budget in the fiscal year 2016–2017 was $912 million, 20% of which came from corporate support.8 Massive industry funding is common. For example, 77% of the 60 million Euro annual income of the European Society of Cardiology comes from the industry.9 Efforts are made to minimize the influence of this funding.7 However, securing objectivity is difficult when industry-manufactured interventions also procure much of the specialty income. Would a society advise its members to change jobs, if evidence proved their medical services a waste?10,11

    Appropriate use criteria and performance measures may help decrease cost and unnecessary procedures. However, these criteria align with what potentially biased guidelines of these professional societies already endorse. An overspecialized worldview is a major disadvantage in making sound recommendations. Specialists cannot compare their merchandise against the merchandise of other healthcare providers. However, diverse specialists and societies compete for the same pie of healthcare resources.

    Proponents of evidence-based medicine have recognized early the need to be critical toward guidelines, for example, the Journal of the American Medical Association User’s Guides series offered guidance on this since 1995. Yet evidence-based medicine and professional societies have had a mutually suspicious relationship. Grading of Recommendations Assessment, Development and Evaluation ( and, an important initiative on evidence appraisal, has tried to improve standards of guidelines and secure their objectivity and methodological strength. However, most cardiology professional societies refrained from joining the Grading of Recommendations Assessment, Development and Evaluation working group, when others, such as the journal Chest guidelines and the Canadian Cardiovascular Society guidelines, did.

    Guideline development also needs to consider the sociopolitical context. Different countries vary on whether guidelines are entrusted to government or professional societies. In the United Kingdom, the National Institute for Health and Clinical Excellence is authorized by the government to consider both efficacy and cost-effectiveness. Conversely, in the United States, the US Preventive Services Task Force is convened by the Agency for Health Research and Quality, but most powerful guidelines are issued by professional societies; these typically place less attention on cost containment. With skyrocketing healthcare expenditures, largely cost-unconscious guidelines make little sense.

    An alternative approach to the current situation would be to avoid having specialists assume any major role in guidelines that pertain to their own fields. The most definitive way to materialize this approach would be to entirely ban professional societies from the development of guidelines. This is, however, impossible to impose. A more realistic solution would be to have professional societies and their members abstain specifically from writing their own guidelines. Instead of having mostly or exclusively specialists write the guidelines and occasional nonspecialists consult or comment on them, guidelines could be written by methodologists and patients, with content experts consulted and invited to comment. This approach has been proposed also for systematic reviews and meta-analyses that synthesize the evidence feeding into guideline development.12

    Another possibility is to recruit also to the writing team medical specialists who are unrelated to the subject matter. Involvement of such outsiders (eg, family physicians involved in cardiology guidelines) could be refreshing. These people may still have strong clinical expertise, but no reason to be biased in favor of the specialized practices under discussion. They may scrutinize comparatively what is proposed, with what supporting evidence, and at what cost. Devoid of personal stake, they can compare notes to determine if this makes sense versus what are typical trade-offs for evidence and decisions in their own, remote specialty. For example, while insider specialists may be willing to endorse an effective but highly expensive drug or device, outsiders may see more easily that this intervention is outrageously expensive. Outsider specialists may improve the calibration of recommendations. Knowledgeable field experts may be uncalibrated, that is, all their recommendations may be stronger or proposed for wider use than what a nonspecialist would propose. What may seem crucially important to a field expert, may appear as minutiae to a less personally involved outsider.

    Outsider specialists who serve as guest guideline writers may also be instructed upfront to mentally envision the following trade-off: any extra budget required for making more aggressive use of services and interventions in that remote specialty that they scrutinize as guests would have to be deducted from the resources dedicated to their own specialty. This mental exercise is realistic because the total resources available for health care are not infinite. Methodologists, patients, and different field specialists add to guideline teams more methodological rigor, patient-centeredness, and impartiality.

    Professional societies should consider disentangling their specialists from guidelines and disease definitions and listen to what more impartial stakeholders think about their practices. Professional societies could still fund these efforts without their own experts authoring them.


    The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.

    John P.A. Ioannidis, MD, DSc, 1265 Welch Rd, Medical School Office Bldg Room X306, Stanford CA 94305. Email