November 3rd, 2017

Uncuffing Medicine from Guidelines

John Junyoung Lee, MD

John Junyoung Lee, MD, is the 2017-18 Chief Medical Resident in Internal Medicine at the University of Miami at Holy Cross, Fort Lauderdale, FL

During my first Cardiology fellowship interview, Dr. Schevchuck, one of the cardiologists on the admissions committee, opened the interview with the following question: “Guess how many guidelines there are in the United States?”

If you are reading this and you are planning on applying to a cardiology fellowship too, I have done some homework for you. According to the Agency for Healthcare Research and Quality (AHRQ), about 1732 active guideline summaries have been published in the U.S. since 2000.

The opening question stimulated an interesting conversation, during which Dr. Schevchuck shared an analogy pertaining to the relationship between guidelines and physicians. He said, “imagine a commercial airline pilot and a 1000-page manual about flight rules. If flying and navigating an aircraft were entirely dependent on the pilot’s ability to recall every single word in the manual, then the commercial airline industry would be facing greater troubles than disgruntled customers on overbooked flights.”

Silver Bullets

silver bulletIn 2004, the New York Times reported that some clinicians were not following clinical practice guidelines, and the public’s response spurred what we now refer to as core quality measures. The Centers for Medicare & Medicaid Services (CMS) — a federal agency that administers the Medicare program — decided to attach quality measurements to common afflictions, and they mandated that the measurements be met for medical reimbursement. As a result, organizations and clinicians are now rewarded or penalized based on how carefully clinicians follow the guidelines. This system is founded on the faulty belief that adherence to guidelines is a “silver bullet” to decrease all-cause readmission and mortality.

These solve-all guidelines are sometimes pitted against physicians’ clinical judgments; and slight aberrations from guidelines could now be punished legally. Depending on whether one believes the COMET study or the MERIT study, a physician could be thrown into a legal battle over use of metoprolol tartrate or metoprolol succinate.

Medical guidelines are supposed to help physicians, right?

Guidelines can serve as general checklists that clinicians use to meet “core measures.” However, guidelines must be viewed with discernment, as they are not always apace with the newest research discoveries, and they sometimes make recommendations that are bigger than the evidence. Organizations, clinicians, and the public must remember that guidelines are, after all, guides, which cannot be substitutes for clinicians’ judgment and acumen.

fiat lux -- let there be light

Let there be light

In the past several years, guidelines have been used not as a tool for clinicians to educate themselves and help their patients, but as a tool to micromanage and attack physicians in the legal battles. I believe that, to move forward, we need to simplify and better delineate the standards of practice and designate a knowledgeable governing body to administer the standard. We also need to define acceptable degrees of freedom from the standards. While I understand that guidelines attempt to curb the behaviors of those few who practice “scary medicine” and put patients’ lives in danger, guidelines are also intended to inform clinicians about best practices. In order for physicians to actually benefit and not be harmed by the guidelines, I believe we need freedom to interpret the guidelines in the setting of our own patients, and we need better legal protections when reasonable judgment conflicts with a guideline recommendation.

What are your thoughts?

8 Responses to “Uncuffing Medicine from Guidelines”

  1. Kartik A Valluri says:

    Nice article John,
    Guidelines are akin to guardrails on a multi-lane highway, they’re just there so we don’t go into oncoming traffic. I agree with you supersaturation with rigid metrics and measures based on statistical data are draining the “art” out of Medicine. But that’s why it’s the “practice” of Medicine and no hard cut rule can overcome a rational clinical decision based on an individual patient. That’s why we need more clinicians guiding our policies and approaches to healthcare.

  2. Avinash Singh says:

    Well written. I do agree that guidelines are for guiding the physician and there should be scope for some alteration in management of patient.

  3. Max Voysey says:

    Research suggests that guidelines may not make any or even a negative impact on quality of care . . .there are also guidelines on guidelines. . . . and now thousands of guidelines. . . . .

  4. Xavier Prida says:

    Guidelines with the syntax of “lines” implies that if one is outside the line, a “lane” violation has occurred. We should adopt the concept of “guidance documents”(as the British have done so)- in that 1.) very few are supported by Level of Evidence “A” 2.) fewer patients in practice fit the inclusion or exclusion criteria upon whcih recommendations(Class 1) are based. As I teach, guidelines are a starting point for reconciling the appropriate management of a patient in a diagnostic category, but occasionally to rarely the endpoint of adjudication of testing or treatment. All guidelines contain a proviso to the effect that individual clinical judgement of physicians taken in consideration with patients wants, needs, preferences should prevail.

  5. Charles Carter says:

    I agree overall that the explosive growth of guidelines is absurd to the point of being counter-productive; and that core quality measures are of dubious value.
    This explosion follows trends in meta-analysis publication and science publication overall ( https://www.ncbi.nlm.nih.gov/pubmed/27620683 ), though for different reasons.
    Due to the nature of science in general, in which advances actually are slow and by consensus, coupled with serious replication problems, I would be cautious about attempting to stay apace of the newest research discoveries for application to clinical practice.
    Thanks for bringing this issue to light.

  6. John R. Goheen MD says:

    I completely agree. Consider the ICU strict glucose control that has been debunked. A few years ago (quite a few) a NEJM article suggested hospitalization for pneumonia unnecessary with the advent of Cipro. At the time I was treating a pneumonia with empyema resistant to Cipro.

  7. Emmanuel Hurtado says:

    I absolutely agree with this, Nowadays some patients and their lawyers try to punish everything on medical practice just to profit from our need to “break the rules sometimes” maybe guidelines shoud have a legal disclosure on what to be taken from it as a “rule” and what not to be.

  8. Carl Knopke says:

    I call it the tyranny of the double blind placebo controlled trials. The trials should guide treatment but we need to recognized that each person is an individual and guidelines frequently do not benefit each person the same way.

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