The Sociology of Medical Guidelines

Allen Frances, M.D, is an American psychiatrist who chaired the DSM-IV taskforce, and later criticized the DSM-5 and American psychiatry for their roles in manufacturing mental illnesses and the epidemic of overdiagnosis. In this blog post he makes a well-founded plea for sociologic contributions to medicine.

Before the Flexner report in 1909, medical education and practice in America were chaotic and of low quality. After the report, both were quickly and dramatically reformed in ways that seemed completely wonderful at the time, but also planted the seeds of our current terrible system.

On the plus side, hundreds of diploma mill medical schools closed; a curriculum combining basic science and supervised clinical teaching was standardized; and research oriented academics replaced part-time local docs as teachers.

But there was a harmful unintended consequence- specialists soon completely dominated medical education, practice, guideline development, and reimbursement. The medical non-system in the US greatly privileges specialists’ interests (leading to massive over-diagnosis and over-treatment) and badly shortchanges the much more cost-effective approaches of primary care. A reductionistic medical model focused on treatment replaced the public health model focused on changing the social context so important in the generation and treatment of disease.

Almost all medical diagnostic and treatment guidelines are created by specialist societies; are geared for specialist use; and offer diagnostic and treatment recommendations that benefit specialists. Most are not optimal for patient care or helpful in everyday primary care practice.

Specialists have an inherent and irresolvable financial conflict of financial interest that biases them toward broadening the definitions of their target illnesses and recommending many more tests and procedures than make sense. 

Specialists also have much less obvious, but often even more important, intellectual and emotional conflicts of interest- they tend to fall in love with their pet diseases and favorite treatments and judge them uncritically. In my work with thousands of experts in psychiatry, not one ever suggested narrowing definitions of any of the mental disorders. They all routinely worry too much about leaving atypical patients out of the definitions; never worry enough about the harms that come from mislabeling and over-treating.

Specialists are also heavily biased by the narrowly specialized nature of their clinical experiences. They see highly selected patients unrepresentative of the typical patients seen in everyday clinical practice. Guideline suggestions that may make sense for them in exotic specialty practice can be an absolute disaster in everyday general practice.

My conclusion is that guideline decisions are too important to be left solely in the hands of specialists. They should be part of the process, but not get to call the final shots. A better alternative is to create guideline committees that are broadly representative of the real world- led by primary care doctors, health economists, public health experts, epidemiologists, and consumers.

And there is a larger question of special interests to sociologists. Only 20% of medical outcomes are determined by medical treatment. Social context is crucial in the generation of disease and in its treatment and outcome. The United States spends more than twice as much on medical care as peer countries, but achieves much worse medical outcomes and has lower life expectancies.

The US boasts the most advanced medical technology in the world- but is shamefully behind the rest of the developed world in providing universal healthcare coverage; a social safety net; economic equality and security; and protection from the predatory practices of drug companies and the medical industrial complex. Life expectancies in the US are now falling for the first time in a century because of deaths of despair caused by drug overdoses, suicides, homicides, and alcoholism. We should be spending less on wasteful (and often harmful) medical excess and more on providing a well run society that encourages the health of our people.

Sociology has a great deal to offer medicine in understanding its past and charting a better future. The best book ever written on the history of US medicine is by Princeton sociologist Paul Starr: ‘The Social Transformation of American Medicine.’ He traces in exquisite detail how the medical establishment has successfully shaped medical care in its own image- usually neglectful of what is best for our patients and our society.

Emil Durkheim’s 1897 classic ‘Suicide: A Study in Sociology’ was the foundational text not just for scientific sociology but  also for modern psychiatric epidemiology. How incredible that the annual suicide rates in different countries is statistically so predictable despite suicide being the most personal of all life decisions. Durkheim’s method discovered a nomothetic lawfulness in human behavior impossible to appreciate when dealing with the ideographic singularities of each individual patient. 

Sociology has made great contributions to medicine in the past & has much to offer in the future.