Traditional approach to consensus
Web-based approach to consensus
Advantages
Widely used and well known
Democratic
Logistically easy to implement
Inclusive and open
Often supported by learned societies
Consensus could be dynamic and evolve
Politically powerful
Extends beyond “Western” countries
Typically includes some key investigators in the field
Once Web site set up, cheap to maintain, and apply to multiple issues
Typically results in the generation of document
Not linked to political agenda of a given society
Typically results in suggestions or recommendations
No experts are self-appointed, and multiple investigators could offer preparatory comments
Disadvantages
Exclusive and non-democratic
May be unable to issue suggestions or recommendations
Typically only expresses “Western” views
Web responders may not be sufficiently representative
Carries significant costs
Lack of support from learned societies will inhibit distribution of findings and political impact
Often only includes society members and is parochial
May be unable to develop and deliver guidelines
May have unstated political aims as well as scientific ones
Novelty may generate confusion in relation to expectations
Experts may be “self-appointed” and have limited clinical experience
Controversy regarding who controls the Web site and the issues to be addressed
Key investigators with contrary views may be excluded
Possibility of multiple competing consensus Web sites creating conflict and confusion
Suggestions and recommendations may prove biased and misleading
Although these are the first steps and there is uncertainty about the future evolution of this process, this new consensus methodology has the potential to increase our understanding of global practice and to help us better define research priorities. If the Internet has to become a new international tool of clinical consensus decision making, through which clinicians can participate in and influence perioperative processes, it is vital that all health workers irrespective of specialty and geographical location have physical access to it and the skills and confidence to use it. It must be collaborative, cooperative, inclusive, and egalitarian. This is quite different from the current dominant approach, which is often competitive, exclusive, non-egalitarian, and based on academic prestige. Whether this can be achieved remains uncertain.
1.4 Conclusions
The development of consensus and the issuing of consensus guidelines in medicine and in perioperative medicine in particular appear to be potentially useful activities whose impact on patient outcome, however, remains unclear. The current approach based on the creation of semi-arbitrary groups of so-called experts who meet for a period of time, issue statements, guidelines, suggestions, and recommendations has several potential flaws but has not, until recently, been challenged by another approach. The arrival of a Web-based consensus process provides the first challenge to the current model and overcomes some of its limitations while potentially creating others. Which one of the two models will prove empirically superior and will become the dominant paradigm in within a decade or two remains uncertain.
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