Blog | Thursday, July 24, 2014

Guidelines should rarely become rules

The blog FiveThirtyEight 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 2 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 HbA1c 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?

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.