Articles with guidelines on treating a specific illness are often of value to read, especially if they do a good job of separating what works well from what does not. As you have already pointed out here many times, there are also limits to the application of guidelines, such as in patients with multiple problems. The DCCT was very helpful, but could not be used as a pure cookbook guide to treat every diabetic.

Articles with guidelines are fine as long as left to physicians to consider as one of many sources of information to guide intelligent decision making. They cannot be reliably used by third parties to attempt to dictate care or as sole criteria to judge whether a physician’s treatment is appropriate in any specific case.

Guidelines can even be of use (beyond the hypothetical benefit of protection from liability). I once had a Medicare audit which led to a demand that some payments be returned. This was basically because the medical director of the Medicare intermediary had some ideas which conflicted with published recommendations. I appealed used articles which were essentially practice guidelines to defend my charges and the ruling was in my favor.

If you spend any significant amount of time working with lawyers, you realize that unlike in medicine where doctors tend to draw a specific conclusion from a piece of information, lawyers can and do interpret information in diametrically opposite fashion in many instances. Virtually any “fact” can be viewed with alternative interpretations. It can work for your case or against your case. Lawyers commonly hear a piece of information and ponder it’s meaning for a second figuring how it can help or hurt their advocacy.
Thus it is with medical guidelines – some in the medical community think that establishing them protects you from liability. Sometimes. When you follow them you usually have a good defense and a good defense is usually going to deter a lawsuit. Ah, but it can work the other way- what happens when you follow the guidelines in a case where the patient may not exactly fit whatever criterion the guidelines are for- and the outcome turns bad? Even more importantly, if guidelines have been established, how often are you “liable” if you don’t follow them, even if you pursued an eminently reasonable course? There is a segment of the legal community who may look at the failure to follow guidelines as a decent argument to file suit when things don’t go right, even if you acted appropriately.

Congratulations on a well written and very timely editorial. While I admit to some trepidation in having the government centralize the guideline writing process, at least we all know where the bias will lie there. Currently, with various interest groups engaging in “guideline duels” to further their own special agendas, we have institutionalized chaos where the biases are (as you point out) hidden.

Well done.

Rich

There is also this.
Subscription required.
JAMA. 2009;301(4):429-431 (doi:10.1001/jama.2009.15)
Allan D. Sniderman; Curt D. Furberg
Why Guideline-Making Requires Reform

What percent of what we do can be submitted to double blind studies? So that it can provide us with first rate guidelines? The DCCT was terrific. But is it applicable to the inner city diabetes epidemic?

Do we not have to make very careful observations at the bedside and then make decisions with the best information that we have? Why not first make certain that we know the patient and then work from there. Every patient is different.

If you begin with the premise that the patient comes first and you are not lazy and are competent and well read, are you not capable of making decisions on your own? Are you not capable of being practical, sensible, etc? Are you not capable of looking it up?

I do not know where the idea that cognitive physicians are expendable came from and that doctors, if properly trained and motivated, cannot make decisions on their own.

I do not understand why all these guidelines came forth in the first place.

I remember asthma guidelines that encouraged the use of serevent. Now it is off the market. It should never have been on the market given its similarity to similar long acting fonoterol.

I think that the single biggest impediments to quality economical care are the absent of generalists, the over-indebtedness of medical students which leads to income generating behavior, and outside influences from industry (pharmaceuticals and devices) which influence the language and culture of medicine in this country.

We have over utilization of imaging technology causing unnecessary radiation exposure, yet we have all the guidelines in the world in English accessible online immediately.

If we spend thirty billion dollars on pharmaceutical marketing per year and something less than five billion dollars on medical education, how can we be so serious about guidelines?

Bohdan A. Oryshkevich, MD, MPH
New York City