Many readers know that I often test out ideas for talks on this blog. Readers’ comments often help me sharpen an idea or reject a poorly considered point. So once again I am asking for your help.
I am currently working on 5 talks at once (3 are written and just require editing). One talk concerns didactic teaching. In preparing for that talk I am currently reading Presentation Zen. Garr Reynolds makes the point that all talks should develop from an understand of the central premise.
So I have spent “free time” thinking about the central premise and now understand that I want to make the point that our problems stem from insurance companies (including Medicare) perverting guidelines into rules. Guidelines have their name precisely because medical decision making is often very complex. We have to consider context that guideline developers could never prospectively include in the guidelines. Human beings are complex and have opinions. We make decisions based on multiple factors, and guidelines can help us.
The problem comes when guidelines transform into rules. Guidelines (and EBM) account for judgment. Rule development, which I dislike in general, could work if we considered rules like new medications. Rules, or performance indicators, need testing. New medications have benefits and risks. So do rules. Unless we prospectively evaluate performance indicators, we will continue to have a spate of articles describing the unintended consequences of poorly considered rules.
{ 3 comments… read them below or add one }
Great idea for a talk. (Maybe you will post it on Slideshare or Scrbd later?)
Some thoughts you may want to include is what is a principle versus a guideline versus a law vs. a rule vs. common wisdom vs. standard of care, etc. Maybe a four corners x/y axis graph showing forced compliance versus freedom on one axis and formal versus informal on the other axis, and then outline where different types of clinical decision making lies.
Also may touch on factors of emotional versus analytical intelligence as well as emotions play a large part in decision making whether we like it or not.
Even if a rule can be shown in a carefully controlled study to improve outcomes vs. “no rules”, it still doesn’t follow that for an individual patient the rule is appropriate.
Each patient, as you’ve said many times before, has unique preferences, circumstances, disease burden, etc. and deciding an appropriate course of action should take these factors into consideration. A simple “rule based” recommendation will often ignore what is ultimately best for the patient, which is usually more complex than what a rule advises.
Very interesting topic. You’re probably aware of Coyne DW, “Influence of Industry on Renal Guideline Development” Clin J Am Soc Nephrol 2: 3-7, 2007 and Aron D and Pogach L, “Transparency Standards for Diabetes Performance Measures” JAMA 301: 210-212; Jan 14, 2009. Painful to realize how much the pharmaceutical industry influences guideline development. Since you asked for feedback, Sei Lee posted on this at GeriPal (and I’ll link back to your post on GeriPal).