Guidelines as goals

I appreciate the erudite comments from my blogging colleagues – DrRich and Dr RW.  I have thought about this issue off and on this weekend.  This morning I found an article that helps explicate my angst.  Ready, aim … fail: Why setting goals can backfire

But a few management scholars are now looking deeper into the effects of goals, and finding that goals have a dangerous side. Individuals, governments, and companies like GM show ample ability to hurt themselves by setting and blindly following goals, even those that seem to make sense at the time. These skeptics draw on a broad array of large-scale failures – the design of the Ford Pinto, the Enron collapse, the rash lending practices of Fannie Mae and Freddie Mac – as evidence of the pernicious effects of goals. Outside the workplace, these thinkers point to the unintended consequences of high-stakes testing in grade schools, and psychological literature showing that goals and other incentives can constrict our thinking. Even the scarcity of cabs on rainy days, some argue, illustrates the ways that goals can blind people to their own best interests.

As Terry Shaneyfelt and I wrote (and I have not seen anyway focus on this issue),

Unfortunately, too many current guidelines have become marketing and opinion-based pieces, delivering directive rather than assistive statements.

Guidelines should not tell us what to do.  They should frame management and diagnostic issues and provide assistance.  However, blind adherence to guidelines can have negative externalities. 

We are now suffering a confluence of good ideas gone bad.  First, the guideline concept started out as a good one.  However, too many subspecialty societies write guidelines, they write guidelines on too many issues, and they then criticize all who do not follow their guidelines.

Second, the research community (and I admit my own personal guilt here) saw performance indicators (adopted from guidelines) as proxies for quality.  As I have written often, quality has many dimensions, but research on performance indicators has confused many administrators into thinking that we can measure quality simply.

Third, therefore we adopt performance indicators as quality measures and thus physicians must divert some of their attention to meeting this performance indicators, even when the patient has other more important issues.

The problem with guidelines stems from the unintended consequences of guidelines.  Guidelines are used to criticize primary care physicians.  They too often conflict because humans (who construct the guidelines) always have biases.

Guidelines carry an undeserved imprimatur.  Sometimes good ideas do not work in practice.  Sometimes good ideas are like goals – all good ideas do not improve clinical care.