Comments on Wall and Brown: “Commercial pressures and professional ethics: troubling revisions to the recent ACOG Practice Bulletins on surgery for pelvic organ prolapse”

Abstract

Dear Editor, As Vice President of Practice Activities at the American College of Obstetricians and Gynecologists, I read with interest Dr. Lewis Wall and Dr. Douglas Brown’s Current Opinion/Update article regarding ACOG Practice Bulletin #85 “Pelvic Organ Prolapse” [1]. The Practice Activities Division oversees development of the evidence-based Practice Bulletins series, which presents clinical management guidelines developed on the basis of the best available evidence, supplemented by consensus and expert opinion. And, while we recognize the right of individuals to express their opinions, I am concerned that Drs. Wall and Brown have misrepresented the intention behind the clarification of Practice Bulletin #79. The initial publication, Practice Bulletin #79 “Pelvic Organ Prolapse” (published in February 2007) used the term “experimental” in describing anterior and posterior vaginal prolapse repair surgeries. The Committee on Practice Bulletins–Gynecology, which oversaw development of this document, subsequently realized that the meaning of the term “experimental” was ambiguous and was being interpreted differently by different individuals. Therefore, in order to clarify the document, the Practice Bulletin was revised to reflect more clearly the original intention of the committee, in a way that would be more informative to clinicians and patients. It is important to note that the development and revision to this Practice Bulletin followed the same consistent process used for the development and revision of all Practice Bulletins. The ACOG document development process begins with a thorough review of the current peerreviewed scientific literature. A standing committee of obstetrician-gynecologists (in this case the Committee on Practice Bulletins–Gynecology), some with subspecialty training, develops an outline and oversees the drafting of the manuscript. Once the manuscript is developed, the committee reviews and revises the document until it meets the committee’s approval. Following approval by the committee, the document is reviewed by a Clinical Document Review Panel, which in this case comprised nine gynecologists including at least one urogynecologist. Lastly, the document is reviewed by certain ACOG senior staff and is submitted to the ACOG Executive Board for review and final approval. Shortly after Practice Bulletin 79 was published, the College received e-mails, letters, and phone calls from ACOG Fellows who objected to the use of the word “experimental” to describe the anterior and posterior vaginal prolapse surgeries. Their concerns centered on the ambiguity of the word “experimental” and their perception that “experimental” did not accurately reflect the wide acceptance of these surgeries. The College followed its routine procedure for handling such correspondence by putting the matter on the agenda for the next meeting of the Committee on Practice Bulletins–Gynecology. The Committee reviewed the correspondence from ACOG members as well as the opinions of four experts in prolapse repair who were not members of the Committee. The Committee concluded that the word “experimental” was ambiguous and revised the document to convey the Related correspondence can be found at doi:10.1007/s00192-0090984-9, doi:10.1007/s00192-009-0985-8, and doi:10.1007/s00192009-1003-x.