Guidelines should rarely become rules


Category : Medical Rants

Five thirty eight has this wonderful provocative article – Patients Can Face Grave Risks When Doctors Stick to the Rules Too Much

The subsequent comments have debates over the value of guidelines. Guidelines are like a box of chocolate, you never know what you are going to get. Many clinical questions yield “competing guidelines”. We all know the controversies over breast cancer screening and prostate cancer screening. Recently BP targets and lipid management have become controversial. Pharyngitis (a personal research interest) has multiple varied guidelines.

In the movie, Pirates of the Caribbean, this classic exchange makes the point:
Elizabeth: Wait! You have to take me to shore. According to the Code of the Order of the Brethren…
Barbossa: First, your return to shore was not part of our negotiations nor our agreement so I must do nothing. And secondly, you must be a pirate for the pirate’s code to apply and you’re not. And thirdly, the code is more what you’d call “guidelines” than actual rules. Welcome aboard the Black Pearl, Miss Turner .

What is the problem? As one of my heroes said many times, everything in medicine requires context. We have differing opinions on the importance of that context.

Given that I have studied the pharyngitis problem for many years, let me use that as my example.

You are a primary care physician seeing an adolescent with pharyngitis. You have two concerns – helping the patient feel better and decreasing the probability of complications, either suppurative or non-suppurative.

Now imagine you are an infectious disease expert. You rarely see pharyngitis patients, but you are worried constantly about antibiotic resistance. Your concern centers on the “overuse” of antibiotics.

You can imagine how these two incarnations of you would view the problem differently. The first you is patient focused; the second you takes a public health viewpoint. Who is correct?

Actually, neither is correct and neither is wrong. The two versions of you have differing context.

Since both views have validity if one agrees with the context, developing a context free rule based on one of these guidelines would constitute a potential error.

The danger of rules (I hope you are reading performance measurement here) comes when they discount context. Some rules have resulted in patient harm.

When insurance companies judge, and even reward, physicians for meeting rule targets, some physicians will overlook context.

This Medscape article about hypoglycemia in the elderly raises important issues about HgbA1c targets. Hypoglycemia a Greater Threat Than Hyperglycemia in Elderly

Performance measures are rampant, primarily because the “suits” believe that we can use them to measure quality. I am proud that the ACP performance measurement committee carefully evaluates many measures. Often these proposed measures get a thumbs down. ACP Performance Measure Recommendations

We need a more widespread accountability on performance measures. The ACP committee careful evaluates the context of proposed measures. Why do other organizations not adopt this enlightened approach?

Comments (7)

Bravo again!

As a patient I have seen the use of guidelines used to drive practice revenue. On multiple occasions doctors have insisted that in following the guidelines I need multiple medications and repeat office visits.

One phrase that sends me over the top is:” Thank goodness, you have arrived just in time.” The follow on is that while everything is ok for now we need to get you medicated and on a 90 day office schedule to assure your continued good health.

Context is important. I am a long time weight lifter and while I would love to loose some bulk I am far from fat. Using a 20 BMI as a set in stone guideline one doctor, after a series of insults, told me not to worry because unlike other doctors he was not afraid to up the dose of fen-phen to get the results he wanted.

With guidelines changing all the time I am frustrated that doctors insist on using them as set in stone practice rules with no consideration of patient preference or past experience. Recent changes in guidelines back to previous levels for such things as BP, BMI, and A1c shows that there is no magic in a number.

Steve Lucas

A t the heyday of his NBA career in 2005, Shaq was classified as obese.

At the time this, and another doctor, told me I was obese my BMI was 24.

Steve Lucas

“The ACP committee careful evaluates the context of proposed measures”

But isn’t the issue really that even when performance measures are valid, they do not evaluate quality of care and shouldn’t be used as a carrot or stick to determine physician compensation? That’s the stand many of us would like to see the medical societies take. (My society, the AAFP, is aggressively pro-P4P, but they’re wrong on just about everything!)

Performance measures evaluate only one aspect of quality. Some performance measures make great sense, for example, central line infections, wrong site surgery.

Since performance measures are being used (and we must continue to show caution about this practice), the ACP committee evaluates measures and provides clinical critiques.

I believe that we will be seeing more overuse measures and safety measures over the next few years. At the same many of the poorly considered measures will cease to be used.

Safety and overuse are two very big issues. One doctor recently posted the number one medical issue he sees at his low income volunteer clinic is bag-o-pills.

Steve Lucas

Post a comment