Why We Can’t Trust Clinical Guidelines
On 13 April 1990, in an unprecedented action, the U.S. National Institutes of Health faxed a letter to every physician in the U.S. on how to correctly prescribe a breakthrough treatment for acute spinal cord injury. Many neurosurgeons were skeptical of the evidence that lay behind the new recommendation to give high dose steroids, yet when two respected organizations released a review and a guideline recommending the treatment, they felt obliged to give it. Now, over two decades later, new guidelines warn against the serious harms of high dose steroids. This case and others like it point to the ethical difficulties that doctors face when biased guidelines are promoted and raise the question: why do processes intended to prevent or reduce bias fail?
Doctors who are skeptical about the scientific basis of clinical guidelines have two choices: they can follow guidelines even though they suspect doing so will cause harm, or they can ignore them and do what they believe is right for their patients, thereby risking professional censure and possibly jeopardizing their careers. This is no mere theoretical dilemma; there is evidence that even when doctors believe a guideline is likely to be harmful and compromised by bias, a substantial number follow it.
Full article in the BMJ worth reading.
This seems to also be the case for scientists who are skeptical of global warming.
Certainly. Unfortunately, going against the consensus is dangerous.
I agree. I just cannot support sweeping claims, when significant alternatives have plausible solutions.
Legislators do this all the time. They consistently legislate with incomplete information.
That is nearly all we get from legislators. Good legislation allows for the flexibility of differences of opinion and choice. Because we live in a dynamic world where we have changing and incomplete information, rigidity will always result in failure.
Exactly. Scientific consensus will be often be questionable because we are always learning new things that could change what we “know”. More flexibility and less closed-mindedness is essential.
I agree with the scientific principle of ever-evolving knowledge, but there is something to be said about following certain standards from what we currently know.
“There is evidence that even when doctors believe a guideline is likely to be harmful and compromised by bias, a substantial number follow it.”
That’s not cool. But the implications for the rise of guideline medicine are even less cool.
“A recent survey found that 71% of chairs of clinical policy committees and 90.5% of co-chairs had financial conflicts”
The appearance of corruption can be almost as damaging as the reality of corruption.
Guidelines are great in theory, but suffer from perverse incentives when put into practice. One problem with guidelines is that the very people who are qualified to create the guidelines (i.e. doctors specializing in a disease condition), are almost always involved in mutually beneficial relationships with other stakeholders. These stakeholders — drug makers, hospitals, medical device makers, etc. — all have a vested interest in promoting a particular guideline that makes them money. It’s not necessarily always malevolent, they undoubtedly believe in the value of their therapies. For example, surgeons want to promote surgery, diagnostic imaging manufacturers and radiologists want to promote MRIs, drug makers want to promote drug therapies. These can bias a guideline.
Doctors are very handicapped with limited options and lack of the doctor-patient relationship.
And patients are handicapped as well. What a system.
There has to be a standard of care. And there can be multiple standards of care for related and multiple medical problems.
As a physician, if I use the standard of care wisely, it is in my own best interests as well as the patient.
When the standard of care has failed when appropriately and sufficiently applied or the standard does not apply based of the facts of a particular case, a physician simply documents that.
It has always been that way. Nothing has changed by the use of titles such as “evidence-based medicine” or “clinical guidelines.” Physicians and patients always want clinical guidelines. It is a good starting place for all physicians.
The reason we as physicians spend 7 or more years in medical training after university is to develop the skill set and clinical acumen to:
(1) know the standard of care and all its known ramifications and
(2) then develop the skills and courage to go the distance from that starting place where good medicine leads us
Real physicians are not afraid to go beyond clinical guidelines. It is no different than a firefighter or a cop who has the authority to risk his/her life by going above and beyond to safe the life of another. It is our job. It is inherent to being a physician that you choose to make the tough decisions.
A standard of care / evidence based medicine / clinical guidelines are a starting place – like choosing a specific common language to speak in as a starting place.
Some lawyers, insurance companies etc. can and do abuse standard of care / evidence based medicine / clinical guidelines. So what? Medicine is a tough sport. We’re trained to deal with all these realities.
As long as the physician and patient make the appropriate decisions, the REAL threat is that the US federal government will arbitrarily and capriciously decide what is “medically necessary” and what is not. Federal bureaucrats enjoy this power now in Medicare & Medicaid. Physicians and patients are denied due process and equal protection. This is the real malignancy.
Dorothy Calabrese MD
allergy-immunology.com