Expert consensus—promoting clinical excellence and ultimately benefitting patients
Evidence-based medicine serves as the cornerstone of modern healthcare. Based on current evidence in the field of evidence-based medicine, a team of authoritative experts in the industry engages in comprehensive discussions to develop expert consensus, following standardized procedures. The consensus serves as a foundation for clinical decision-making. However, the abundance of expert consensus varies in quality, and some viewpoints even contradict each other, leading to confusion in clinical decision-making. Medical professionals expect authoritative expert consensus to guide their clinical work but, at times, express frustration, saying that the consensus is “useless”. Various methods are currently available to assess the quality of consensus, such as AGREE II (The Appraisal of Guidelines for Research and Evaluation II) (1) and the credibility assessment tool from the Australian JBI Center for Evidence-Based Healthcare [2016] (2). Additionally, “Guiding Principles for the Formulation/Revision of Clinical Diagnosis and Treatment Guidelines in China (2022 edition)” is published in the Chinese Journal of Medicine (3). The emergence of numerous assessment tools stems from the dire need to evaluate and improve current expert consensus, reflecting the inconsistent quality of those consensus.
I have been a writer and a member of expert consensus groups participating in multiple consensus development projects. And the literature can often supply a decent amount of food for thought. As an author and reader, I would like to share some personal understanding of expert consensus from both perspectives.
Q1: How to write a good consensus?
The distinction between guidelines and consensus is not always clear, but it is generally believed that expert consensus is an industry guidance document with lesser influence and lower quality compared to guidelines. Guidelines refer to higher levels of evidence-based medicine, while expert consensus emphasizes the role of expert experience in the process of guideline formulation, relying more on exploratory research literature.
Topic selection for consensus
Consensus topics should be closely related to clinical practice. For instance, there have been, discussions on conversion therapy for liver cancer for a long time, but the emergence of targeted therapy and immunotherapy in recent years has truly made conversion therapy a hot topic. However, there might not be sufficient related research. By issuing expert consensus, timely standardized guidance can be provided for these new therapies. Another situation is when a clinical problem was discovered for a long time, but the evidence is still insufficient. For example, portal hypertension combined with liver cancer is often considered a surgical contraindication in many countries, while such clinical practices in China are relatively proactive and have gained considerable evidence. Developing consensus on such diseases can help Chinese doctors deepen their understanding.
Composition of expert panels
Expert panels are typically composed of experts from academic organizations or assembled by industry authorities. This approach ensures the expertise of panel members, but it may also lead to potential biases in their opinions. Experts from the same academic organization tend to share similar opinions due to frequent communication; experts convened by industry authorities, on the other hand, might tend to align with the convener’s opinions. To enhance the objectivity of the consensus, it would be beneficial to include peers from other fields within the expert team. For example, when formulating consensus on surgical indications, consulting experts from internal medicine and interventional medicine can lead to more cautious considerations. Similarly, when formulating a consensus on laparoscopic surgery, consulting experts who do not typically perform such procedures can provide a more impartial assessment of its advantages and disadvantages.
Interpretation of literature
The context of consensus is analyzed and cited from clinical literature. This requires including comprehensive literature that presents both supportive and opposing viewpoints. The evidence from the literature should not be duplicated directly into recommendations. Instead, forming a consensus based on the evidence relies on thorough analysis and reasoning. Furthermore, patients’ values and preferences should always be taken into account. For instance, the A+T regimen is currently listed as the first-line regimen for systemic treatment of liver cancer by National Comprehensive Cancer Network (NCCN). However, the economic background of certain patients should be thoroughly considered when recommending this regimen. Many experts contributing to the consensus have made significant impacts on the field, and the consensus will inevitably cite their research work. A relatively objective approach should be taken when this scenario happens. If the expert’s viewpoint is widely recognized, citing it is justifiable; however, if the viewpoint represents a singular opinion, caution should be exercised when including it in the consensus. When the consensus addresses cutting-edge issues, it is important to promptly update the relevant research and consensus to ensure that readers are not exposed to outdated information.
Objectivity during the process
Consensus is generally naturally formed, but its formation process should follow objective standards such as transparency, normative, and independence of recommendations. There are primarily four formal methods for forming a consensus, with the Delphi Method being the most commonly used. The final consensus reflects the viewpoints of the majority, as per the principle of seeking common ground while reserving differences. Achieving a unanimous agreement among all experts is challenging if not impractical. Some recent consensus disclose the poll distribution when the conclusion is controversial. External experts may also be involved in the procedure. This provides a more objective description of how the viewpoints are formulated and allows the readers to perceive the viewpoints in an objective fashion.
Q2: How to read a consensus?
Expert consensus is a condensed overview of clinical problems supported by relevant literature, drawing upon the collective wisdom of experts in the field and offering a valuable learning pathway for clinical practitioners.
Learning from consensus to enhance clinical decision-making
Contemporary medicine follows evidence-based practices. At the apex of the evidence pyramid are meta-analyses of randomized controlled trials. Prospective randomized/non-randomized controlled studies, along with real-world research, establish robust foundations for clinical problem-solving. Conversely, case reports and personal empirical evidence hold the lowest evidentiary value. In practice, many clinicians are occupied with their daily duties, leaving them little time for extensive literature review, often relying predominantly on their past clinical experiences. For local clinic physicians, learning from consensus proves advantageous in refining their clinical decision-making, ultimately enhancing their clinical skills and yielding better outcomes with minimal effort. For physicians in major medical centers, experiences from a single institution may not be universally applicable; hence, gleaning insights from a range of perspectives within expert consensus can be beneficial.
Consensus does not limit clinical decisions
Consensus isn’t a legal mandate but rather a set of recommended suggestions. Strictly adhering to consensus in clinical practice would impede treatment progress and hinder individualized treatment for patients. For instance, current systemic treatment regimens for liver cancer demonstrate efficacy rates of approximately 10% to 30%. Strictly following consensus or guidelines might lead to most patients receiving ineffective treatments. Many studies are now beginning to explore the effective population of various systemic treatment options, but due to insufficient evidence, consensus is rarely adopted. Clinical practitioners must consider reality factors including individual patient conditions and the medical environment to make informed clinical decisions. When confronted with multiple consensus opinions, particularly when opinions are opposed, as seen in the recent expert consensus on “resection” versus “preservation” regarding gallstones, clinicians should thoroughly examine relevant literature, assessing the scientific validity and feasibility of these opinions within the given context. Moreover, considering the cultural, economic, and ethnic variations across different countries or regions, contextual factors should be taken into account when referencing international guidelines or consensus.
Consensus as a valuable source for clinical research
Clinical research enhances clinical practices, and clinicians should actively engage in clinical research. However, topic selection often poses a challenge. While consensus provides some level of standardization in clinical work, many opinions rely on observational studies and lack randomized controlled trials. An in-depth understanding of consensus helps identify meaningful and contentious topics, creating excellent directions for clinical research. In return, the outcomes of high-level clinical research improve consensus quality, enabling clinicians to shift from being evidence learners to evidence contributors.
In summary, medical professionals should learn to interpret and write sound expert consensus, employ clinical and scientific methodologies, and apply it selectively in clinical work to improve decision-making and ultimately benefit patients.
Acknowledgments
Funding: The manuscript is funded by
Footnote
Provenance and Peer Review: This article was commissioned by the editorial office, Hepatobiliary Surgery and Nutrition. The article did not undergo external peer review.
Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-23-435/coif). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
References
- Brouwers MC, Kho ME, Browman GP, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ 2010;182:E839-42. [Crossref] [PubMed]
- Joanna Briggs Institute. The Joanna Briggs Institute Reviewers’ Manual: 2016 edition. Australia: The Joanna Briggs Institute; 2016.
- Chen Y, Yang K, Wang X, et al. Guiding Principles for the Formulation/Revision of Clinical Diagnosis and Treatment Guidelines in China (2022 edition). Chinese Medical Journal 2022;102:697-703.
