Blog | Thursday, February 1, 2018

My descent into guideline fatigue syndrome

It started slowly. My former resident and present colleague, Terry Shaneyfelt, MD, FACP, first authored ”Are Guidelines Following Guidelines? The Methodological Quality of Clinical Practice Guidelines in the Peer-Reviewed Medical Literature“.

This paper alerted us to the problem. But guideline fever continued to rage. Almost every specialty and subspecialty society decided that they needed to join the guideline movement. They needed to tell us the RIGHT way to practice medicine.

While I understood the problems of guidelines (I had found a 40-page guideline on cerumen), it had not yet become visceral. Then the great pharyngitis controversy of the early 21st century made it personal. In 2001, ACP (endorsed by the CDC and AAFP) published ”Principles of Appropriate Antibiotic Use for Acute Pharyngitis in Adults“.

This guideline endorsed the Centor score to exclude testing or treatment for 0 and 1, test 2, and either test or treat with narrow spectrum antibiotics 3 or 4. The IDSA the next year published ”Practice Guidelines for the Diagnosis and Management of Group A Streptococcal Pharyngitis“.

That guideline argued for testing 2-4 (again neither testing nor treating 0 or 1. Some authors of that guideline then published an editorial that took ACP to task for suggesting empiric treatment of some patients. They wrote, “We must conclude, therefore, that the algorithm based strategy proposed in the ACP-ASIM Guideline would result in the administration of antimicrobial treatment to an unacceptably large number of patients with non-streptococcal pharyngitis.”

I strongly disagreed with the IDSA position, but remained puzzled how two reputable organizations could review the same data in an evidence based manner and have such disparate recommendations. And then it gets even worse. The Annals of Family Medicine published this article from Europe, “Differences Among International Pharyngitis Guidelines: Not Just Academic“. It reads, “Although the evidence for the management of acute sore throat is easily available, national guidelines are different with regard to the choice of evidence and the interpretation for clinical practice. Also a transparent and standardized guideline development method is lacking. These findings are important in the context of appropriate antibiotic use, the problem of growing antimicrobial resistance, and costs for the community.”

That 2007 study preceded this 2011 study ”Analysis of Different Recommendations From International Guidelines for the Management of Acute Pharyngitis in Adults and Children“.That study compared 12 guidelines and found great disparities in recommendations.

Now I was certain that the guideline process had a major limitation. For the occasional question the data are clear and all parties agree, but too often different guideline committees have differing values. And values influence how we view data and certainly what we value in developing our guidelines.

You likely know several examples of “dueling guidelines,” breast cancer screening, prostate cancer screening, and goals of diabetes control. Recently we have guidelines for hypertension that give significantly different recommendations.

I realized that I had GFS when I wrote about an excellent IDSA article ”The IDSA takes an admirable position in not endorsing the new Sepsis Guidelines“.

So what causes this syndrome? We want to believe that guidelines come from evidence, but we forget the famous Nietzsche quote: “There are no data, only interpretation”. Depending on our belief system, we value outcomes differently. In the sepsis example, the critical care doctors want sensitivity (few false negatives) and do not see problems with lower specificity (i.e., giving antibiotics to some patients who do not need them). The IDSA worries (appropriately) about antibiotic resistance and antibiotic side effects. So that prefer to maximize specificity and wait for more data in some patients.

Too often guidelines are considered rules. They were always meant to be guides, and clinical judgment should allow us to trump the guides. But each time a major guideline appears, we read about it in the New York Times. Practicing physicians do not know what to believe because of guideline bloat and controversy. We do not need 12 pharyngitis guidelines. We should not even call specialty and subspecialty opinions guidelines. They are making recommendations based upon their view of medicine. We all have biased views of proper medical care.

Guidelines can have serious unintended consequences. When we label our opinions as guidelines we put all physicians in an uncomfortable and even untenable situation.

So I have no idea how to evaluate the seemingly never ending supply of guidelines. I have no idea how to interpret them recognizing the biases involved in creating them.

Please join me and admit that you too have GFS. I fear this syndrome has no cure. It is pervasive and growing. It is not a rare disease.

db is the nickname for Robert M. Centor, MD, MACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and the former Regional Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds regularly at the Birmingham VA and Huntsville Hospital. His current titles are Professor-Emeritus and Chair-Emeritus of the ACP Board of Regents. This post originally appeared at his blog, db's Medical Rants.