Abstract
Guidelines articles, Consensus Statements, and publications such as the “Bethesda System” have appeared with increasing frequency in the medical literature, born of efforts by medical societies and institutions to organize and codify the management of complex disorders. They attract widespread interest, not only from providers, but also from those who manage providers. A testament to this is the National Guideline Clearinghouse (NGC). As noted on its website (5), the NGC was originally created by the government's Agency for Healthcare Research and Quality in partnership with the American Medical Association and a trade group now known as “America's Health Insurance Plans.” Missing from this triangle of government, medical establishment, and insurance empire are patients who, incidentally, are also keenly interested in new guidelines, particularly those applying to them.
The NGC website lists four criteria to be met by Guidelines articles. They must contain systematically developed statements to help providers make appropriate health care decisions, they must be produced under the auspices of a medical organization not an individual, they must include a methodical review of the scientific evidence published in peer-reviewed journals, and they must be available in print or electronic format in the English language (5).
Any primer should include all but the penultimate word in the last sentence as the key requirements for a Medical Guidelines article. It should also reflect on the terminology that has evolved since the NGC was formed. Unfortunately it is doubtful that it would weigh the difficult questions that Guidelines and Consensus Statements pose for peer-reviewed journals. Are they “Reviews”, “Scholarly Dialog”, or are they simply “Commentaries”? Do they belong in the extensible mark-up language (XML) category “Article” or should they be considered “Notices”, presented by a Society or organization to inform and educate? Are most “Original Studies”, the raison d'être of medical journals?
Given the mandate that Guidelines must be available in the print or electronic format, it is surprising that the place of Guidelines and Consensus Statements within a medical journal has received so little attention. Perhaps this is not surprising. It might be thought self-evident that content should determine where a Guidelines or Consensus article appears within a journal. By this criteria the two Guidelines articles on thyroid cancer in June and November 2009, and the “The Bethesda System for Reporting Thyroid Cytopathology” should be assigned to the Thyroid Cancer and Nodules subsection. Further, were Guidelines on the management of hyperthyroidism to be published, they should appear in the subsection Thyroid Function and Dysfunction. Both of these subsections are in the ORIGINAL STUDIES, REVIEWS, AND SCHOLARLY DIALOG section. If this were to be split into its components the assignment would become more difficult since Guidelines are a combination of the three. They require not only a detailed review of the literature, but also a systematic and method-driven approach to information processing, evaluation, conclusion generation, and elucidation.
But content should not be the most important feature in deciding where to place Guidelines and related articles. Nor should it be the degree to which authors are accountable for their work, or whether the article was peer reviewed. Regardless of where in the journal the article is published, the authors are equally responsible for the final product. Likewise, peer review is not the issue because, with the exception of some Editorials and Commentary, all articles in Thyroid including Guidelines and Consensus statements are peer reviewed and usually revised before they are accepted.
In the present issue “Revised American Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer” was placed in the ORIGINAL STUDIES, REVIEWS, AND SCHOLARLY DIALOG section while “The Bethesda System for Reporting Thyroid Cytopathology” was placed in the ARTICLE section. The reason for the different assignment of these two articles can be summed by two words: intellectual ownership. “Revised American Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer” was produced by authors who were chosen for their expertise by the American Thyroid Association (ATA). The ATA also provided the financial support required to produce this document. The ideas advanced in this Guidelines article were, however, those of the authors, not those of the ATA. Thus the authors can claim intellectual ownership of the contents of “Revised American Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer”. When the intellectual ownership of an article extends beyond the authors, who act at least in part to report the work of a large group, the article will likely be assigned to the ARTICLE section. This is a matter of editorial judgment and is not perfect; there is little doubt that the authors of the articles that appear in the ARTICLE section of this issue of Thyroid made important intellectual contributions to their articles and can claim, at the very least, partial intellectual ownership.
An ironic aspect of Guidelines articles is that they must be produced under the auspices of a medical organization, but are most credible when they appear in the original research sections of journals. To do so, at least in Thyroid, they must have individuals, not societies as authors. Moreover, these authors must be able to claim intellectual ownership of the article. It is only in this way that there will be persons, not intangible societies, who can be held accountable for all aspects of these articles with their increasingly important role in medical care.