November 3rd, 2017
Uncuffing Medicine from Guidelines
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.”
In 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.
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?