Blog | Friday, June 19, 2015

Medical talks in India part 3, dangers of guidelines and the pirate's code

Visiting India, I have given several talks. Three times the hospitals asked for my “Dangers of Guidelines” talk. The talk starts with a famous quote from the “Pirates of the Caribbean” that goes, The Code is more what you call guidelines, than actual rules. This talk resonates with all physicians.

In it I talk about the guideline movement, why it started, and what has gone wrong. And much has gone wrong. We have too many guidelines, conflicting guidelines and “guidelines” without adequate evidence.

The worst part of guidelines is their transformation into rules, i.e., performance measures. Some guidelines transform positively into measures, e.g. patients with systolic dysfunction and no contraindications should receive a prescription for an angiotensin-converting enzyme inhibitor, chronic obstructive pulmonary disease patients with a resting oxygen saturation less than 88% should have home oxygen, and we should follow a checklist for central line placement (with a measure of the rate of central line infections).

At each site, the physicians express the same frustrations with “algorithmic medicine.” They smile when I saw that I can prove guidelines are flawed in 2015. The case of conflicting guidelines proves the point clearly. Guideline development succumbs to biases easily. Logic tells us that if guidelines were not subjective that differing organizations would develop the same guidelines. Conflicting guidelines (pharyngitis, screening for prostate cancer, screening for chronic kidney disease as examples) prove that the committees must inject a subjective assessment. Once we have such proof, then we must question the rest of the guideline movement.

We could develop “universal” guidelines, but only on selected problems. We would have far fewer guidelines and thus far fewer performance measures.

The Indian physicians understand this clearly. They see performance measurement coming on their horizon and they are concerned. We in the U.S. must address this incorrect approach to clinical judgment. We should urge everyone to adhere to the Pirate's Code. Allow guidelines to guide us, but not rule us.

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.