I may be confused here, so feel free to correct me if I am: It seems to me that the Achilles Heel of leaning too strongly on guidelines for making clinical care decisions is that the Ecological Fallacy always lurks in the background -- bluntly stated, that well-known fallacy in epidemiology involves a presumption that "what is true for s…
I may be confused here, so feel free to correct me if I am: It seems to me that the Achilles Heel of leaning too strongly on guidelines for making clinical care decisions is that the Ecological Fallacy always lurks in the background -- bluntly stated, that well-known fallacy in epidemiology involves a presumption that "what is true for some defined group of patients will be also true for each of the individual patients belonging to that group". The linguistic wrinkle that sets up this fallacy should be obvious in every medical or surgical specialty --- what is observed for any group of size N receiving treatment X (viz. what gets published in books and journals) is the AVERAGED resulting outcome over all N patients. It follows that, for any given treatment X (whether X is prophylactic or therapeutic) that results in "nearly the same" excellent outcome in every patient, choosing X for the patient sitting before you right now will very likely be a "winning" decision. The same logic will apply to observed complications of using a given X. Thus, the actual problem when following guidelines too religiously in cook-book or knee-jerk, algorithm-driven fashion to craft clinical care decisions is that the great majority of our pills, potions, powders, poultices, ointments, and operations do NOT act with perfection. Some teachers in my career have opined that "lay folks do not often understand the concept of probability so that clinicians should shy away from mentioning that concept". I think that is a bullshit notion. In my experience as an academic surgeon (now retired) very few adult patients will not understand a sentence that sounds like the following example: "Mr./Mrs. Jones, the problem we must face together is that the operation (or drug) needed for you is not perfect in every patient, but it is known from multiple investigations to act perfectly *on average* in about 85-90 percent of patients like you". In sum, what needs to happen when counseling patients is absolutely not like attempting to decode mysterious material on the level of explaining details of quantum mechanics, nuclear fission, or plate tectonics.
I may be confused here, so feel free to correct me if I am: It seems to me that the Achilles Heel of leaning too strongly on guidelines for making clinical care decisions is that the Ecological Fallacy always lurks in the background -- bluntly stated, that well-known fallacy in epidemiology involves a presumption that "what is true for some defined group of patients will be also true for each of the individual patients belonging to that group". The linguistic wrinkle that sets up this fallacy should be obvious in every medical or surgical specialty --- what is observed for any group of size N receiving treatment X (viz. what gets published in books and journals) is the AVERAGED resulting outcome over all N patients. It follows that, for any given treatment X (whether X is prophylactic or therapeutic) that results in "nearly the same" excellent outcome in every patient, choosing X for the patient sitting before you right now will very likely be a "winning" decision. The same logic will apply to observed complications of using a given X. Thus, the actual problem when following guidelines too religiously in cook-book or knee-jerk, algorithm-driven fashion to craft clinical care decisions is that the great majority of our pills, potions, powders, poultices, ointments, and operations do NOT act with perfection. Some teachers in my career have opined that "lay folks do not often understand the concept of probability so that clinicians should shy away from mentioning that concept". I think that is a bullshit notion. In my experience as an academic surgeon (now retired) very few adult patients will not understand a sentence that sounds like the following example: "Mr./Mrs. Jones, the problem we must face together is that the operation (or drug) needed for you is not perfect in every patient, but it is known from multiple investigations to act perfectly *on average* in about 85-90 percent of patients like you". In sum, what needs to happen when counseling patients is absolutely not like attempting to decode mysterious material on the level of explaining details of quantum mechanics, nuclear fission, or plate tectonics.