Use Your Judgment

Adapted from an April 6, 2014 post on In My Humble Opinion, a blog by Jordan Grumet, an internist in Highland Park, Ill.  

A recent article in The Atlantic laments that physicians act on tradition and emotion over adopting new science. It cites the example of how cardiologists use angioplasty and coronary artery bypass to treat coronary disease.

What it fails to mention is that guidelines have changed over the years based not on new evidence, but more on the whims of the so-called experts chosen to give their opinions. These are the same experts who told us to shoot for an LDL of 70, treat low HDL with niacin, and use non-statin lipid-lowering drugs. All of which have fallen out of favor. These are also the same experts who often make an income consulting for pharmaceutical companies who stand to benefit from such guidelines.

We are not expected, or required, to blindly follow guidelines. I didn’t when I was told to get everyone’s LDL down to 70 or when I was pushed to use gemfibrozil and niacin. And I won’t now, not until the scientific data that went into such decisions make sense.

Constructive Conflict

Adapted from a March 19, 2014 post on Common Sense MD, a blog by Kenny Lin, a family physician in the Washington, D.C. area.  

There has been much hand-wringing about the potential negative impact of conflicting guidelines. Whose guideline should doctors follow?

Sure, it’s easier when guidelines agree on what to recommend for a particular patient in a particular situation. But when “reaching alignment” is simply a euphemism for one guideline group exerting political pressure on others, that isn’t good for medicine or for patients. After all, it wasn’t long ago when medical groups marched in virtual lock-step to recommend menopausal hormone therapy to reduce the risk of heart attacks and strokes, and to lower blood glucose levels as close to “normal” as possible in patients with type 2 diabetes. Both guidelines now appear to have done much more harm than good.

Consider the Context

Adapted from a June 22, 2014 post on db’s Medical Rants, a blog by Robert M. Centor, an academic general internist at the University of Alabama School of Medicine. 

Many clinical questions yield “competing guidelines.” As one of my heroes often said, everything in medicine requires context.

You are a primary care physician seeing an adolescent with pharyngitis. You have two concerns—helping the patient feel better and decreasing the chance of complications. Now imagine you are an infectious disease expert. You rarely see pharyngitis patients, but worry constantly about antibiotic resistance.

You can imagine how the two incarnations of you would view the case differently. The first you is patient focused; the second takes a public health viewpoint. Neither is correct and neither is wrong. Because both views are valid 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 (read “performance measurement” here) comes when they discount context. Some have resulted in patient harm.

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