Guidelines II


Category : Medical Rants

Yesterday I started my ranting about guidelines. Today I want to talk about audience, thickness and priorities.

In 2007, most guideline committees write for their subspecialty. I have no problem with this goal, however, we have a major problem when the committee writes a guideline for subspecialists, and then a researcher does a study which finds that generalists do not follow the guideline. The problem here is that the audience for a guideline should influence how the guideline is developed and how it is written.

Most guidelines are so thick, covering so many issues, that they become overwhelming. Guidelines often address very specific issues in addition to common general issues. Given the number of guidelines published each year, even a dedicated generalist (I use the term generalist to include primary care outpatient physicians, hospitalists and subspecialists who care for problems outside their subspecialty) cannot possibly stay current.

I would like to see guidelines written for a generalist audience. Moreover, I would like the committees to prioritize their recommendations. For example, the most important issue in CHF might be the use of an ACE-I or an ARB. Others might consider the most important the use of beta blocker. Regardless, we generalists need to have panels prioritize guidelines so that we can pay attention to the most important issues and modify our practices accordingly.

More soon …

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Comments (4)

Don’t you think that this is done on purpose in order to make it clear to everyone that generalist care is always inferior to subspecialist care?

There is an inherent problem with guidelines developed by specialists, which has to do with the priorities of doctors, and which I believe are, in order of importance:

1) maintaining one’s viability as a practitioner
2) maintaining ones’ turf (protecting one’s professional group, i.e., subspecialty)
3) doing what’s best for the patient.

Most doctors would like to fulfill priority 3, but you can only do that if you first attend to priorities 1 and 2.

Which brings us to guidelines. Guideline development by specialists almost invariably becomes, to at least some extent, an exercise in turf protection. The turf protection often requires different subsets of specialists to do battle with each other, jousting over whose favorite flavor of diagnostics and/or therapy ought to receive priority under the guidelines. All are interested in emphasizing the things that would require other doctors to refer patients to them. The younger, less-well-known members of the committee are also interested in currying favor with the older, more famous members. Committee members are often influenced by the industries (or, indeed, by the government agencies) that have sponsored (and continue to sponsor) the research that got them invited on the panel in the first place.

With such competing interests, what you often wind up with is a compromise document. Setting out clear priorities in such a document is usually impossible, since obfuscation is a vital part of the compromise. And while the document may end up favoring one faction of specialists over another, it will almost never favor the generalist. (Generalists who become too adept at treating a complex illness are always a threat to turf.)

A partial solution might be to insist that generalists participate in these guideline committees (if for no other reason than so they can understand what the real “issues” are), or better yet, that the recommendation of the committees must be passed on to a panel of generalists – which is to send them back until they meet the needs of non-specialists.

– DrRich,

“Don’t you think that this is done on purpose in order to make it clear to everyone that generalist care is always inferior to subspecialist care? ”

Good question.

also, if one deviates from guidelines and a bad outocme occurs..whether related or unrelated to the use of guidelines, is the generalist at increased legal risk ?

Good points. What we see as patients is a bottom lined dictate that often does not make sense or fill a pressing need. Age related demands for statin use. A dentist desire to cut sugar and increase fluoride intake results in a demand that an overly thin, 11 year old girl, only drink tap water and diet drinks. The message about weight and self-image is lost on the dentist.

May of us have been refereed to specialist with pressing problems, only to be told there is no need to worry.

All of these situations undermines the generalist credibility as well as creating unnecessary concern on the part of the patient. Generalist then become married to the diagnosis in an effort to prove they are right resulting in even further credibility issues.

Generalist do need to be a part of this process so as to better understand the issues in determining the guideline.

Steve Lucas

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