Most of us are familiar with the concept of medical guidelines. These are sets of criteria that are supposed to “guide” physicians facing certain medical circumstances.
As physicians know, and often lament, guidelines over time morph to become mandates. Even though by definition, a guideline is voluntary, many hospital oversight committees and insurance companies require physicians who deviate from guidelines to explain their actions.
The U.S Preventive Services Task Force guideline states that folks 75 and older should not receive screening colonoscopies. The reason is that medical studies have demonstrated that the benefits of colon cancer screening in this age group is not justified by the risk and expense of the effort. Of course, there is an age when colonoscopy does not make sense, but I'm just not sure what this
magic number is.
Consider these 2 hypothetical patients.
(1) A 78 year old man in excellent health has never had a screening colonoscopy. Should he be denied this as it will violate the guideline even though this guy has a decent chance of living another decade?
(2) A 60 year old comes to my office from his dialysis session dragging his oxygen tank behind him. He's never had a colonoscopy. Does a screening study really make sense here?
Guidelines and all their ilk are a 1-size-fits-all approach to a profession that needs to individualize its advice to living, breathing human beings. There's more absurdity to come. Insurance companies and the government are increasingly tracking physicians to assure that they are following all appropriate guidelines. Those who deviate face the prospects of decreased reimbursements and being highlighted publicly on websites and elsewhere as being deficient.
How easy do you think it would be to argue your case to an insurance company that a particular guideline didn't apply to a particular patient? Having had the thrill and pleasure of dealing with medical insurance companies and the government, I can answer this in a quiz format, 1 of my preferred educational tools. Please arrange the following 4 actions in increasing order of difficulty.
(1) Stumbling into a bee hive while walking in the woods
(2) Swallowing glass shards
(3) Watching C-SPAN for 24 hours without interruption
(4) Reversing a claim of Medical Guideline Violation
This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.