Why Diversity Among Individuals Developing Clinical Practice Guidelines Matters

Clinical practice guidelines — especially those originating in North America, the European Union, or the United Kingdom — are hugely influential publications. In recent years, a lack of diversity among individuals drafting these and other types of guidance documents has drawn increased scrutiny and raised troubling questions.

For Julie K. Silver, MD, a physician at Spaulding Rehabilitation Hospital and associate professor/associate chair in the Department of Physical Medicine and Rehabilitation at Harvard Medical School, the watershed moment was a 2018 paper published in The Lancet. The study found that women physicians, in particular, were significantly underrepresented among authors and contributors developing practice guidelines.

"That inspired me to start looking at this issue," Dr. Silver says. "Clinical practice guidelines have an enormous impact around the world in terms of access to care, the care itself, diagnostic interventions, treatments, allocation of financial resources, and governmental policy. And it's an issue that affects the medical and scientific workforce as well."

Dr. Silver has authored or co-authored several papers examining gender, racial, and ethnic diversity in practice guideline development. The most recent, an opinion piece published in BMJ Opinion in May 2023, provides an overview of the topic and proposes strategies to address the lack of diversity.

Uncovering Underrepresentation by Gender, Race, and Ethnicity

In a 2022 paper appearing in the American Journal of Physical Medicine & Rehabilitation, Dr. Silver and her colleagues reviewed two sets of practice guidelines (17 in total). They found that experts from racial and ethnic minority groups — especially women — were underrepresented on guideline panels in both sets.

Dr. Silver was also co-author of two 2023 papers on this subject. The first, published in Neurology, found that women physicians were underrepresented as authors of American Academy of Neurology-recommended practice guidelines. The second, published in the Archives of Pathology & Laboratory Medicine, concluded that some racial and ethnic minority groups — including both men and women — were underrepresented among authors of pathology practice guidelines.

Receiving invitations to contribute as experts on practice guideline committees has a positive career impact, Dr. Silver says. While acknowledging that the impact on the guideline content itself requires further investigation, she contends this is an undeniably crucial concern.

"It makes sense that panel members from diverse backgrounds may bring unique insights and perspectives, which would impact patient care," she says. "Suppose the diagnostic study of choice is a CT scan, which would be contraindicated in pregnant women due to high radiation levels. A diverse panel might be more likely to discuss alternative diagnostics so that the entire population of pregnant people was not overlooked in the practice guideline."

Furthermore, Dr. Silver notes, participating in practice guideline development can provide a major career boost.

"A single clinical practice guideline is disseminated throughout the U.S. and the world and can garner hundreds or thousands of citations, giving physicians and scientists many career-enhancing opportunities," she says. "When highly qualified women and people from underrepresented race and ethnic groups are not at the table, they don't get to reap these benefits."

What Will It Take to Expand Panel Diversity?

Moving forward, Dr. Silver suggests that four key developments would likely expand gender, racial, and ethnic diversity on practice guideline panels:

• Continuing to publish research on this topic across multiple specialties
• Following up on previous studies, such as the one published in The Lancet, to determine if any progress has been made
• Educating leadership of medical societies and journals on the importance of author/contributor diversity and refusing to publish studies or reports that fall short in this regard
• Ensuring public health officials, politicians, policymakers, medical school leaders, hospital presidents, healthcare system presidents, and other stakeholders understand this issue and its tremendous financial implications

"It is very easy to find physicians and scientists who could be authors and contributors for clinical practice guidelines, and some of these experts happen to be women or people from underrepresented race and minority groups," Dr. Silver says. "A lot of people in our field think this isn't that big of a deal because it doesn't affect them personally. But it is a big deal that affects all of us, and potentially all of our patients."