Understanding the limitations of guidelines within the context of multimorbidity can affect medical education, medical training, primary care practice, and, crucially, how researchers, medical bodies and governments address the multimorbidity challenge.
Guidlines based on population studies, ignore the tremendous variability of the individual patient, by defining a treatment for the mean patient. Only clinical experience and thoughtful relection of the patients wishes and situation, (social, medical, and mental), come to the correct treatment! I fear that our medical education is already corrupted past repair in USA. You will probably get a treatment that is correct for the most probable cause of your complaint/illness for age/sex mean group.
İ think that probleb could be partially solve if medical community would be able to know out how guidelines creators made a decisionhow each person justificate it.
Extremely intersting and actual. But I have to disagree on the proposed solution.
Guidelines pose problems (particularly clear, facing multimorbidity) because they are bad guidelines, not because they are guidelines.
You can have guidelines that say "in these circumstances, it's up to the clinician to decide on the basis of A, B and C".
The idea that a clinician in front of his/her patient isn't following some sort of rule based heuristics (which are just his/her private guidelines) has no basis.
These heuristics can be EB or not. Improving means we have to cut arbitrary decisions in favor of things that work (EB) or in favor of educated guesses by experts (tracked as research).
Does multimorbidity require our guidelines to grow exponentially because of the number of possible different circumstances? So be it. Nothing guarantees that medicine should be "simple".
Allow me to share one anecdote that illustrates just how far off the mark we have strayed.
An 70 year old patient who was dying of end stage liver disease came to see me with her daughter.
The daughter was distraught. "What is wrong?" I asked She responded:"a care coordinator from Mom's insurance company called and scolded me for not taking care of Mom since I didn't take her for her mammogram"....
Thank you for this. What ever happened to patient agency and autonomy?
Guidelines and the incredible encroachment of government and insurance company pressures on the doctor patient relationship leave little to no room for such autonomy.
Patient centered care has become mere lip service
Whether or not someone suffers from multimorbidity should not alter the fact that we must honor human sovereignity n or approaches to care.
Very good stuff as always. This is how I've always thought of receiving health care. The doctor should be informed by guidelines but shouldn't be forced to do certain things if the patient doesn't want it. Ultimately, it's up to the patient how much they want to receive or what might work for them.
Thank you. As patients’ wishes are pushed to the bottom of the priority list, the reality sets in-patients are merely needed to fill in the quota of treatments offered and prescriptions filled. The usefulness of the patient seems to lie in the ability to bill for services. Over the last four years, the truth has emerged-doctors don’t really need to examine a body to determine a course of action; all that’s needed is a list of complaints to check the boxes in the program and relay the recommended advice the computer (or AI) has determined suitable for the person in front of the screen.
Helping the person in front of you is what this author is speaking of, and that is no longer the objective in our world.
Excellent article. The review of the Sackett Venn diagram was useful.
It reminds me of the Thomas Sowell quote: there are no solutions; only trade-offs.
While I have framed it in a different way in the past, I wholeheartedly endorse what I think the author is saying: guidelines are fine and good for the research sphere, but is not (and cannot be) the be-all and end-all of EBM….or of any version of the practice of medicine.
I find current guidelines (and guideline writers) annoying AF precisely because they advocate cookbook formulae (with occasional lip-service to patient values and preferences….and not even as much to patient comorbidities). Such as the oft-target of my disdain….HFrEF guidelines and 4 drugs for everyone, all day everyday. And what really gets my goat is that guidelines like those aren’t even accurate or faithful representations of the research evidence….which is the only Sackett sphere where guidelines IMO are of plausible use. It’s like guideline writers have ONE job, and still fail miserably.
I agree with the author that pt factors and pt preferences are NOT suitable targets for guidelines or even expert opinion….since some old fart sipping scotch and smoking a stogie is ill-equipped to say anything intelligent about those 2 aspects….or at least not nearly as well equipped as a patient’s treating physician.
Fortunately, I practice in Canada….where we don’t have an attitude of indentured servitude to guidelines….yet.
Well stated! If I could just earn a dime from every patient I admit to the hospital suffering issues from guideline- directed recommendations(that is if the patient isn’t bankrupted by their HFrEF meds) I would retire in short order. My service is rife with older folks keeling over with dizziness from some polypharmacy issue. And how bout that ubiquitous transfusion stay for patients with highly dubious blood thinner indications? The eyeball test to the bedside clinician is the best, most trusted way to practice good medicine and EBM serves only to support the decision making at that moment- your humble indentured servant.
Guidelines are the tools that help payers make themselves look good to purchasers but can never be the tool that is used by a clinician to properly care for every patient in the way that they need and deserve.
Excellent article with important additions from many of the commenters below. The practice of medicine is a highly individualistic process in which clinical judgement plays the major role. Anything that fosters an algorhythmic or bureaucratic practice is detrimental.
And to think: during covid, the medical “experts” were trying to push a “one size fits all” solution on every person, regardless of age, weight, co-morbidities, etc.
Some brave docs tried to speak out against this, but were shot down and labeled as promoting disinformation or misinformation. Truly scary times.
The “one size fits all” dynamic has been building for decades. It was very useful to have it already in place when they pulled back the curtain for the reveal
Yes, the scamdemic demonstrated everything that is antithetical to good medical practice. A good first step to restore sanity would be to abolish government "health" departments at all levels.
I've been writing, lecturing and warning about guidelines in medicine since the early 2000's and they have more than fulfilled my worst prophecies. They have been turned into enforceable standards, making medicine a one-size-fits-all trade, virtually removing conscious thought (let alone clinical reasoning and critical thinking) from the process. Guidelines are mostly financed by industry and are written by industry employees and industry-funded doctors. They are little more than marketing tools for their products.
The problems with EBM are much deeper: The entire construct is antiscientific. "Evidence" is not science, and can be produced to support any hypothesis. The hierarchy promoting RCTs and metanalyses over observational data and clinical experience is completely arbitrary and reflects bias. RCTs are often flawed and/or biased. Pharma-sponsored studies should be viewed as marketing rather than science and should not be believed unless source data is provided for independent review. This will never happen, of course. Metanalyses are the epitome of pseudoscience.
Basic science is ignored by EBM, yet should be determinative. This has contributed to an obsession with treating "risk factors" rather than reversing disease. The guideline paradigm for type 2 DM, for example, stresses HbA1c reduction via insulin and other meds, whereas the basic science paradigm seeks to reverse the disease through proper diet.
Multimorbidity is the rule, not the exception. With the enormous prevalence of the metabolic syndrome, most patients today present with obesity, diabetes, hypertension, and various vascular diseases. The guideline approach yields massive polypharmacy, while the basic science approach is disease reversal via diet and lifestyle.
Medicine needs to return to real science and reject the cult of EBM. All guidelines are corrupt and should be discarded.
Very good letter. A MD recommended no intervention, and no more tests for a condition that I had researched and come to the same conclusion, so I thanked him and called him a good old fashioned doctor! I’m not sure he understood how highly I thought of him!!!
Thank you for trying to shed light on the most important issue facing medicine. This matter really captures many of the ills confronting the clinician. At its heart is the compulsion in medicine to think in binary discrete terms(eg EMR) when the practicing physician knows that these decisions reflect non-quantifiable weighing of multiple factors that can not be captured by any model constructions.
With training strongly advocating critical thinking, evolving knowledge with experience through open eyes and ears on a daily basis, health professionals develop a keen “sixth sense” with their individual patients, that is totally missing in today’s corporate healthcare
What is concerning is how this is playing out in the managed Medicare universe. The number of letters I receive regarding what drug the patient should be on or “care gaps” yet I am unable to use effective medications with user friendly dosing for diabetes, COPD and asthma.
The efforts to ensure that every patient who qualifies be on a statin is staggering and feels vastly disproportionate to the whole picture of managing a patients entire care. I understand the power of certain interventions on a population level and can see where statins can be seen as a high return for the $ spent however the resources dedicated to this end as all encompassing and overly narrow.
KUDOS !!
Guidlines based on population studies, ignore the tremendous variability of the individual patient, by defining a treatment for the mean patient. Only clinical experience and thoughtful relection of the patients wishes and situation, (social, medical, and mental), come to the correct treatment! I fear that our medical education is already corrupted past repair in USA. You will probably get a treatment that is correct for the most probable cause of your complaint/illness for age/sex mean group.
Very well written and a nice refreshing take on what EBM is supposed to contribute to patient care
İ think that probleb could be partially solve if medical community would be able to know out how guidelines creators made a decisionhow each person justificate it.
Extremely intersting and actual. But I have to disagree on the proposed solution.
Guidelines pose problems (particularly clear, facing multimorbidity) because they are bad guidelines, not because they are guidelines.
You can have guidelines that say "in these circumstances, it's up to the clinician to decide on the basis of A, B and C".
The idea that a clinician in front of his/her patient isn't following some sort of rule based heuristics (which are just his/her private guidelines) has no basis.
These heuristics can be EB or not. Improving means we have to cut arbitrary decisions in favor of things that work (EB) or in favor of educated guesses by experts (tracked as research).
Does multimorbidity require our guidelines to grow exponentially because of the number of possible different circumstances? So be it. Nothing guarantees that medicine should be "simple".
Allow me to share one anecdote that illustrates just how far off the mark we have strayed.
An 70 year old patient who was dying of end stage liver disease came to see me with her daughter.
The daughter was distraught. "What is wrong?" I asked She responded:"a care coordinator from Mom's insurance company called and scolded me for not taking care of Mom since I didn't take her for her mammogram"....
Thank you for this. What ever happened to patient agency and autonomy?
Guidelines and the incredible encroachment of government and insurance company pressures on the doctor patient relationship leave little to no room for such autonomy.
Patient centered care has become mere lip service
Whether or not someone suffers from multimorbidity should not alter the fact that we must honor human sovereignity n or approaches to care.
Very good stuff as always. This is how I've always thought of receiving health care. The doctor should be informed by guidelines but shouldn't be forced to do certain things if the patient doesn't want it. Ultimately, it's up to the patient how much they want to receive or what might work for them.
Thank you. As patients’ wishes are pushed to the bottom of the priority list, the reality sets in-patients are merely needed to fill in the quota of treatments offered and prescriptions filled. The usefulness of the patient seems to lie in the ability to bill for services. Over the last four years, the truth has emerged-doctors don’t really need to examine a body to determine a course of action; all that’s needed is a list of complaints to check the boxes in the program and relay the recommended advice the computer (or AI) has determined suitable for the person in front of the screen.
Helping the person in front of you is what this author is speaking of, and that is no longer the objective in our world.
Very good article
Excellent article. The review of the Sackett Venn diagram was useful.
It reminds me of the Thomas Sowell quote: there are no solutions; only trade-offs.
While I have framed it in a different way in the past, I wholeheartedly endorse what I think the author is saying: guidelines are fine and good for the research sphere, but is not (and cannot be) the be-all and end-all of EBM….or of any version of the practice of medicine.
I find current guidelines (and guideline writers) annoying AF precisely because they advocate cookbook formulae (with occasional lip-service to patient values and preferences….and not even as much to patient comorbidities). Such as the oft-target of my disdain….HFrEF guidelines and 4 drugs for everyone, all day everyday. And what really gets my goat is that guidelines like those aren’t even accurate or faithful representations of the research evidence….which is the only Sackett sphere where guidelines IMO are of plausible use. It’s like guideline writers have ONE job, and still fail miserably.
I agree with the author that pt factors and pt preferences are NOT suitable targets for guidelines or even expert opinion….since some old fart sipping scotch and smoking a stogie is ill-equipped to say anything intelligent about those 2 aspects….or at least not nearly as well equipped as a patient’s treating physician.
Fortunately, I practice in Canada….where we don’t have an attitude of indentured servitude to guidelines….yet.
Totally agree!
Except for James McCormack’s PEER guidelines, which are indeed well done and useful
Well stated! If I could just earn a dime from every patient I admit to the hospital suffering issues from guideline- directed recommendations(that is if the patient isn’t bankrupted by their HFrEF meds) I would retire in short order. My service is rife with older folks keeling over with dizziness from some polypharmacy issue. And how bout that ubiquitous transfusion stay for patients with highly dubious blood thinner indications? The eyeball test to the bedside clinician is the best, most trusted way to practice good medicine and EBM serves only to support the decision making at that moment- your humble indentured servant.
Guidelines are the tools that help payers make themselves look good to purchasers but can never be the tool that is used by a clinician to properly care for every patient in the way that they need and deserve.
Real-world clinicians know that there is no such thing as an average patient. Even if they have never heard of Simpson's paradox.
Excellent article with important additions from many of the commenters below. The practice of medicine is a highly individualistic process in which clinical judgement plays the major role. Anything that fosters an algorhythmic or bureaucratic practice is detrimental.
And to think: during covid, the medical “experts” were trying to push a “one size fits all” solution on every person, regardless of age, weight, co-morbidities, etc.
Some brave docs tried to speak out against this, but were shot down and labeled as promoting disinformation or misinformation. Truly scary times.
The “one size fits all” dynamic has been building for decades. It was very useful to have it already in place when they pulled back the curtain for the reveal
Yes, the scamdemic demonstrated everything that is antithetical to good medical practice. A good first step to restore sanity would be to abolish government "health" departments at all levels.
I've been writing, lecturing and warning about guidelines in medicine since the early 2000's and they have more than fulfilled my worst prophecies. They have been turned into enforceable standards, making medicine a one-size-fits-all trade, virtually removing conscious thought (let alone clinical reasoning and critical thinking) from the process. Guidelines are mostly financed by industry and are written by industry employees and industry-funded doctors. They are little more than marketing tools for their products.
The problems with EBM are much deeper: The entire construct is antiscientific. "Evidence" is not science, and can be produced to support any hypothesis. The hierarchy promoting RCTs and metanalyses over observational data and clinical experience is completely arbitrary and reflects bias. RCTs are often flawed and/or biased. Pharma-sponsored studies should be viewed as marketing rather than science and should not be believed unless source data is provided for independent review. This will never happen, of course. Metanalyses are the epitome of pseudoscience.
Basic science is ignored by EBM, yet should be determinative. This has contributed to an obsession with treating "risk factors" rather than reversing disease. The guideline paradigm for type 2 DM, for example, stresses HbA1c reduction via insulin and other meds, whereas the basic science paradigm seeks to reverse the disease through proper diet.
Multimorbidity is the rule, not the exception. With the enormous prevalence of the metabolic syndrome, most patients today present with obesity, diabetes, hypertension, and various vascular diseases. The guideline approach yields massive polypharmacy, while the basic science approach is disease reversal via diet and lifestyle.
Medicine needs to return to real science and reject the cult of EBM. All guidelines are corrupt and should be discarded.
Edit: “no more tests or treatment”
Very good letter. A MD recommended no intervention, and no more tests for a condition that I had researched and come to the same conclusion, so I thanked him and called him a good old fashioned doctor! I’m not sure he understood how highly I thought of him!!!
Thank you for trying to shed light on the most important issue facing medicine. This matter really captures many of the ills confronting the clinician. At its heart is the compulsion in medicine to think in binary discrete terms(eg EMR) when the practicing physician knows that these decisions reflect non-quantifiable weighing of multiple factors that can not be captured by any model constructions.
Exactly!
With training strongly advocating critical thinking, evolving knowledge with experience through open eyes and ears on a daily basis, health professionals develop a keen “sixth sense” with their individual patients, that is totally missing in today’s corporate healthcare
What is concerning is how this is playing out in the managed Medicare universe. The number of letters I receive regarding what drug the patient should be on or “care gaps” yet I am unable to use effective medications with user friendly dosing for diabetes, COPD and asthma.
The efforts to ensure that every patient who qualifies be on a statin is staggering and feels vastly disproportionate to the whole picture of managing a patients entire care. I understand the power of certain interventions on a population level and can see where statins can be seen as a high return for the $ spent however the resources dedicated to this end as all encompassing and overly narrow.