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"For every complex problem, there is a solution that is simple, neat, and wrong." - HL Mencken
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"There are no facts, only interpretations." - Nietzsche
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"An education isn't how much you have committed to memory, or even how much you know. It's being able to differentiate between what you do know and what you don't." - Anatole France
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"In character, in manner, in style, in all things, the supreme excellence is simplicity." - Henry Wadsworth Longfellow ====
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Dr. RW and the JAMA editorial
13 Mar2009
Apparently we did not make our point clear enough. What’s really wrong with the cardiology guidelines? Dr. Shaneyfelt and I participated in the cardiology conference on Tuesday at UAB. During that conference we had strong supporters and those who thought they disagreed with us. After the discussion, we found that we really had few differences.
Here is the main point. When you do not have sufficient evidence, do not call it a guideline. Call it an expert consensus statement. Call it expert opinion. But do not call it a guideline.
The guideline movement needs baratric surgery. Most guidelines address too many questions. The term guideline carries too much weight to write guidelines with inadequate evidence.
I am interested in expert opinion – but please do not call it a guideline.
Related posts:
- Another performance measure challenged – BP goal
- Shaneyfelt and Centor on guidelines
- Can expert panels improve health care?
- Getting around the cardiology (insert favorite specialty) guideline problem
- How to insure quality
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- In: Medical Rants
4 Responses to Dr. RW and the JAMA editorial
Robert W. Donnell
March 13th, 2009 at 9:26 am
DB,
Your point is well taken, but I wonder if the words in the hierarchy of recommendations you suggest might confuse people. In the minds of most of us guidelines are documents created to help us make decisions, not to dictate care. Terms like “expert” and “consensus” have an air of authority and imply standard of care. “Guideline” has a softer ring to me.
Maybe what’s needed is a set of more clearly defined terms for a hierarchy of recommendations we can all agree on.
Transparency is the key. Cardiology guidelines as they are now written achieve transparency by rating the strength of evidence and assigning classes to the recommendations. If I understand you, you are suggesting removing the weaker classes of recommendations from the guideline document and placing them in another document. That would be another way to achieve transparency. To me it’s six of one and half a dozen of the other, the important thing being that the reader understand the relative strengths and weaknesses of recommendations.
I think at least we would both agree that the terms need better definition. What do you think?
DrRich
March 14th, 2009 at 9:33 am
Gentlemen,
They are called “guidelines” because the overseers have deemed that doctors are to act according to “guidelines.” It will not suit one of the major purposes (arguably the chief purpose) of specialty organizations, in promulgating these documents, to call their efforts by some name other than that which officially compels the desired behavior.
I realize how cynical this sounds, and I am suitably ashamed for it.
Rich
Robert W. Donnell
March 14th, 2009 at 3:14 pm
Doctors are compelled by guidelines?? The last time I looked adherence was pretty low. 30% or so for VTE prophylaxis. Surviving Sepsis guideline adherence was 10% in a recent study, only reaching 30% after a vigorous campaign. Whoever is compelling doctors isn’t doing it very effectively. Now if new crimes embedded in Obama’s health care reform provide penalties for non-adherence, well…
DrRich
March 16th, 2009 at 12:55 am
The distinction here is between actually compelled (your construction) and officially compelled (mine). I agree that doctors often do not follow guidelines, which is one reason PCPs are being coerced to leave the field, presumably in favor of some more compliant variety of medical professional.