Medical talks in India part 4 – Dangers of guidelines

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Category : Medical Rants

Visiting India, I have given several talks. Three times the hospitals asked for my “Dangers of guidelines” talk. The talk starts with a famous quote from the Pirates of the Carribean – The Code is more what you call guidelines, than actual rules. This talk resonates with all physicians.

In it I talk about the guideline movement, why it started, and what has gone wrong. And much has gone wrong. We have too many guidelines, conflicting guidelines and “guidelines” without adequate evidence.

The worst part of guidelines is their transformation into rules, i.e., performance measures. Some guidelines transform positively into measures, e.g. patients with systolic dysfunction and no contraindications should receive a prescription for an ACE inhibitor, COPD patients with a resting oxygen saturation less than 88% should have home oxygen, and we should follow a checklist for Central Line Placement (with a measure of the rate of Central Line Infections).

At each site, the physician express the same frustrations with “algorithmic medicine”. They smile when I saw that I can prove guidelines are flawed in 2015. The case of conflicting guidelines proves the point clearly. Guideline development succumbs to biases easily. Logic tells us that if guidelines were not subjective that differing organizations would develop the same guidelines. Conflicting guidelines (pharyngitis, screening for prostate cancer, screening for CKD as examples) prove that the committees must inject a subjective assessment. Once we have such proof, then we must question the rest of the guideline movement.

We could develop “universal” guidelines, but only on selected problems. We would have many less guidelines and thus many less performance measures.

The Indian physicians understand this clearly. They see performance measurement coming on their horizon and they are concerned. We in the US must address this incorrect approach to clinical judgment. We should urge everyone to adhere to the Pirate’s Code. Allow guidelines to guide us, but not rule us.

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