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NICEXIT: Royal Colleges look to “take back control” of treatment standards

The very fact they call themselves “Royal Colleges” should have been a sign. Simply put, some of these folks have a rather high opinion of themselves.

There seems to be a widespread view within Britain’s “Royal Colleges” that they form a kind of medical aristocracy, a ruling class with feudal entitlements, deriving authority from a pre-ordained divine right of kings. They expect acquiescence, and are shocked when they don’t receive it.

But remember, so-called “Royal Colleges” are basically member-based societies for medical doctors. They are special interest groups partisan to their members’ interests. In any country other than Britain they would be seen as industry lobbyists. Because that is essentially what they are.

Do not think for a moment that the leaders of these Royal Colleges are drawn randomly from the rank and file of the professions concerned. If only such representativeness were the case. As with many such groups, Royal College leaderships typically comprise well-connected members with longer-than-average careers. They are people who have invested years of their reputations, sometimes decades, in defending the status quo.

Some are brilliant scientists, I’m sure. I mean, by the law of averages, there must be some brilliant scientists involved some of the time. But many are just old-fashioned professional-body hacks, deeply experienced at sitting on committees, poring over agendas, and amending minutes.

And so it came to pass that the leaderships of some of the Royal Colleges — chiefly those of the Royal College of Physicians and the Royal College of Paediatrics and Child Health — kicked up a merry old stink over the newly devised NICE guideline for myalgic encephalomyelitis (ME)/chronic fatigue syndrome (CFS). As has now been widely reported, despite having had sight of the draft since November and of the final version over the past few weeks, they waited until just hours before the announced publication date to ambush NICE with some as-yet-undisclosed industrial-relations ultimatum, causing publication to be “paused.”

In short, these Royal College leaders were unhappy with what NICE had proposed by way of evidence-based treatment guidance for ME/CFS.

Over their dead bodies would such independent regulation of standards ever be tolerated.

Perhaps you can see the problem.

* * *

Ordinarily, a willingness to accept second opinions and behavioural boundaries is seen as a mark of human maturity and conscientiousness. A blank refusal to be regulated, on the other hand, is not such a great look.

Entities like NICE exist precisely because frontline clinical judgement is an insufficient and unreliable method to determine what works and what doesn’t. You could say that NICE exists for the same reason that the scientific method itself exists.

Every clinician has great confidence in their own judgement. And therein lies the problem. Objective assessment is always required to combat the conceit of personal wisdom.

Independent regulators are necessary because some processes, and some people, just need to be regulated.

The idea that providers of clinical treatments would personally deign to overrule their regulators is a preposterous one. We do not allow motorists to decide for themselves what the speed limit should be. We send hygiene inspectors into restaurants because we know that otherwise, human nature being what it is, standards of cleanliness will just slide.

But somehow we are expected to feel it’s okay for doctors to stamp their feet and refuse to adjust their treatment practices based on an independent evaluation of empirical research, simply because they say that they know better?

In many countries, the general public go wide-eyed and wobbly-kneed when faced with medical opinion. The title Doctor carries an excessive, but completely undeserved, cachet.

In Britain this deference is compounded by the association with supposedly royal colleges.

If these groups had names like The National Union of Medical Workers, their objections would be received rather differently.

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But not all Royal Colleges have lost their way.

Take, for example, the Royal College of Obstetricians and Gynaecologists:

On Thursday — the very next day after the ME/CFS debacle — NICE published new guidance for antenatal care. This was noteworthy because NICE sought to take account of the role of partners in childbirth, an emphasis found to be warranted by the accumulated research. As with its guideline for ME/CFS, NICE updated previous practice in light of the latest evidence-guided understanding.

But here, the relevant Royal College unhesitatingly welcomed the new NICE guideline. Not only that, it invited one of the “lay” members of the Review Group — a self-styled “campaigner”, no less — to write its blog post praising the new evidence-based standard.

In the ME/CFS world, influential clinicians openly refer to the involvement of “lay” reviewers as a threat, a biasing factor that must be curtailed. They use the label “campaigner” (or “activist”) as if it were a term of abuse.

In truth, those clinicians require more regulation, not less.

* * *

We often refer to such machinations as “political”, and that is fair enough. Any process of group decision-making where power can be exercised disproportionately could be said to be “political”. Much is rooted in perception. Social class and identity are powerful factors.

Many of those involved in the leadership of the dissenting Royal Colleges would no doubt look down their noses at anyone who voted “Leave” in the UK’s 2016 referendum on Brexit. Indeed, at least one such Royal College luminary resigned from their political party to become actively involved in what was then the “Remain [in the EU]” campaign.

But now, watch these folks embark on their own rejectionist uprising: seeking to “take back control” of regulation, as though they have “had enough of experts,” offering up their own “alternative facts” to help push their case. The “will of the people” — or at least that of some doctors — is seen as sacrosanct, while proper procedure is rubbished as a conspiracy by technocrats to meddle in their lives. Britain has long been an outlier when it comes to the science of ME/CFS; these people feel that British exceptionalism, not error, is the reason.

All they need now is to paint their slogan on the side of a bus.

The agitators within these Royal Colleges — few in number, but influentially well-connected — have succeeded, at least briefly, in wagging the dog. The Royal Colleges themselves, however, should consider the implications of such putsches. They need to reflect on the responsibility that is infused within their role.

Uneasy lies the head that wears a crown.