The committee members probably reached consensus with the usual tools of negotiation and compromise, but if your position must be compromised to accommodate the views of another, the result is a compromised position. In many circumstances, this creates a good result for all. However, when drafting a clinical policy, too much compromise may result in a dilutional effect not meeting the needs of those most affected by the policy. Compromises may be appropriate when discussing nuances such as dosing. However, when giving guidance on efficacy and/or safety, clear consensus must be diligently sought, and careful consideration of all opinions must occur to ensure a fair and balanced conclusion. An example of fair compromise is the recommendation to administer aspirin for STEMI. No compromise is needed to recommend aspirin. The data are irrefutable, and consensus exists in the house of medicine. However, dosing between 162 mg and 325 mg is less clear. Thus, some compromise in dosing is reasonable.

Some, including the committee, may believe that tPA has attained consensus, and the evidence is irrefutable. Therefore, ACEP’s, and the average emergency physician’s, position was not compromised to draft this policy. Such a thought raises serious concerns. If the committee feels that consensus has been reached and no reasonable emergency physician could interpret the data differently, we have a problem. Again, a specialty society guideline should reflect consensus opinion of members who are well read in the scientific literature. Beyond myself, many others have a persistent healthy skepticism regarding this treatment. Consider just a short list of well-known and highly regarded emergency medicine educators who reach a conclusion different from that of the committee: Drs. Jerry Hoffman, David Newman, Dave Schriger, Ryan Radecki, Stuart Swadron, Billy Mallon, Al Sacchetti , and Greg Henry. On this topic, there is no clear consensus among the thought leaders within our specialty.

Undoubtedly, the most prominent zealot advocating for tPA skepticism is Dr. Hoffman. If consensus is the goal, I am puzzled that he was not included in the panel. Although I cannot speak to the individual perspectives of the panel members, it is clear that several members have an established history of being pro-tPA. It seems reasonable to include in the panel those with a different perspective. Focusing on process, if a panel is balanced with a heterogeneity of opinion, adequate consideration of all perspectives is much more likely to result. Criticisms could be made that opposition of opinion may result in a stalemate. However, if consensus is elusive, then this should indicate the topic may just be too controversial for guideline development, and furthermore, avoiding such controversy or conflict may result in a policy not reflecting diversity of opinion.