Guidelines

Duncan Etches, MD, MClSc, CCFP, FCFP (biography, no disclosures)

What I did before

Early in my career I wanted to be the best doctor possible (still do I hope!). I admired those physicians who knew the preventive health guidelines for every condition that had one and I admired those who structured their practices to incorporate those guidelines. These physicians created disease registries, recall strategies and flow charts to track progress. However, in attempting to emulate these model physicians, I found a new challenge – the guidelines themselves.

What changed my practice

The McMaster group in Canada introduced me to evidence-based medicine. And Cochrane rigorously collated the evidence. Old standbys that were found useless or toxic could be stopped and only effective treatments would be started.  However, four new problems became apparent:

  • Many guidelines existed for the same condition and these guidelines differed in their recommendations.
  • The guidelines were not always updated as new evidence was generated – they became dated.
  • The guidelines paid lip service to non-drug approaches but tended to emphasize pharmaceutical solutions.
  • The pharmaceutical products recommended in the guidelines tended to emphasize the new and more expensive medications over older and cheaper but equally effective products.
  • Many guidelines seemed to have been co-opted by the marketing arm of the pharmaceutical manufacturers.

Where was I to turn and what treatments to encourage? Reading all the medical literature to form my own opinions on treatments could take all my time and I was already too busy just seeing my patients.

What I do now

I read sources unconnected with the pharmaceutical industry. InfoPOEMS and DynaMed I find on line. The Medical Letter helps and UBC’s Therapeutics Initiative publications give me insights. When I am particularly interested in a topic or a new article, I might delve into it further using the AGREE instrument.

I give higher priority to guidelines such as those from the Canadian Task Force on Preventive Health Care. I give lowest priority to those from disease oriented societies. Using UpToDate can be somewhat problematic, as it is a US based site, not Canadian. This and other online libraries, such as BMJ Best Practice and Dynamed themselves can be out of date.

I apply Poe’s aphorism “Don’t be first with the new or last out with the old” in my practice. I may wait until post-marketing Phase IV studies are published or Health Canada notifies me of new regulations or warnings.  Adverse reactions take time to become apparent; ASA, zopiclone and domperidone are recent examples. Canada’s slow adoption of thalidomide saved children’s limb defects, relative to countries with faster adoption. Slower adoption of Vioxx in British Columbia compared to other provinces prevented numerous cardiac deaths of arthritis patients.

I incorporate patient specific factors such as age, lifestyle, etc. in my decision-making. Just as dosing is different in pediatrics than adults, so geriatrics requires a different therapeutic mindset. For example, guideline recommendations to stop smoking, followed by a 40 year old, saves 9 years of life, a 60 year old, 3 years and an 80 year old no years at all. Because the incidence and mortality of major chronic diseases rise with age, elimination of one condition in an elderly patient still leaves many other causes of morbidity. Partly because of this accumulation of morbidity, colon cancer screened populations live only 2 weeks longer than unscreened populations. More dramatically, if ALL cancers totally disappeared, life expectancy of the population would rise only 18 months. Even eliminating our major cause of mortality, cardiovascular disease, would raise life expectancy by only 8 years or 10% for an 80-year life expectancy. Recognizing these age limits helps to put preventive health guidelines in perspective.

I follow guidelines less slavishly because:

  1. Some adverse drug events, side-effects, and occasionally deaths, may be avoided.
  2. The guidelines may promote recommendations that are more expensive than necessary. We can save our patients some money on the items that they, or their plans, fund.
  3. I can spend more time with my patients on their symptomatic conditions – the respiratory and urinary tract infections, the muscular aches and pains, the psychological distress of anxiety and depression and the serious conditions our patients want me to treat.
  4. Patient values are critical in deciding on treatment and may conflict with the suggestions arising from the guidelines. My patients’ needs and hopes are central to my care, and can take priority over the population based injunctions of guidelines.

In summary, in place of pattern or algorithm driven medicine, clinical experience and ability to determine what is best for our patient lies at the heart of the art of medicine.

References: 

  1. Angell M. The Truth about the Drug Companies: How they Deceive Us and what to do about it. 1st ed. New York: Random House; 2004. (Request with UBC or CPSBC) ISBN: 0375508465, 9780375508462
  2. Angell M. Is academic medicine for sale? N Engl J Med. 2000;342:1516-1518. (Request with CPSBC or view UBC) DOI: 10.1056/NEJM200005183422009
  3. Moynihan R. Who pays for the pizza? Redefining the relationships between doctors and drug companies. 2: Disentanglement. BMJ. 2003;326:1193-1196. (View) DOI: 10.1136/bmj.326.7400.1189
  4. Healy D. Pharmageddon. Berkeley: University of California Press; 2012. (Request with UBC) ISBN: 9780520270985, 0520270983
  5. Genuis S. The proliferation of clinical practice guidelines: Professional development or medicine-by-numbers? J Am Board Fam Med. 2005;18:419-425. (View) DOI: 10.3122/jabfm.18.5.419
  6. Choudhry NK, Stelfox HT, Detsky AS. Relationships between authors of clinical practice guidelines and the pharmaceutical industry. JAMA. 2002;287:612-617. (Request with CPSBC or view UBC) DOI: 10.1001/jama.287.5.612
  7. Stelfox HT, Chua G, O’Rourke K, Detsky AS. Conflict of interest in the debate over calcium-channel antagonists. N Engl J Med. 1998;338:101-106. (View) DOI: 10.1056/NEJM199801083380206
  8. Healy DI. Conflicting interests in Toronto: Anatomy of a controversy at the Interface of academia and industry. Perspect Biol Med. 2002;45:250-263. (Request with CPSBC or view UBC). DOI: 10.1353/pbm.2002.0028
  9. Bronnum-Hansen H, Davidsen M. Social differences in the burden of long-standing illness in Denmark. Soz-Praventivmed. 2006;51:221-231. (Request with CPSBC or view with UBC)
  10. Shaukat A., Mongin S, Geisser M, et al. Long-Term Mortality after Screening for Colorectal Cancer. N Engl J Med. 2013;369:1106-1114. (View)
  11. Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years’ observations on male British doctors. 2004;328:1519-1528. (View)

Resources:

  1. InfoPOEMs http://www.essentialevidenceplus.com/
  2. DynaMed http://www.dynamed.com/home/
  3. The Medical Letter http://secure.medicalletter.org/
  4. UBC’s Therapeutics Initiative http://www.ti.ubc.ca/
  5. Kohn RR. Human aging and disease, J. Chron. Dis.,16:5, 1963
  6. Steven A. Schroeder SA. New Evidence That Cigarette Smoking Remains the Most Important Health Hazard. N Engl J Med 2013; 368:389-390 (View)
  7. The AGREE II instrument Http://www.nccmt.ca/resources/search/100
  8. Canadian Task Force on Preventive Health Care https://canadiantaskforce.ca

Please indicate how this article will change your practice:

Guidelines

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9 responses to “Guidelines”

  1. Therapeutics initiative finally provided me with the evidence that I saw happening in my practice. I learned the hard way adopting drugs too soon caused trouble. In my case it was ponderal caused heart valve problem in a patient.

  2. As a nurse practitioner I have to “appease” managers to pass my annual performance reviews, and often managers consider guidelines “best practice”. As well, I have to survive a provincial regulatory body review of some of my charts every 5 years, and audits are often completed by practitioners who consider guidelines as best practice. This sometimes leaves me feeling like I am walking through a minefield, trying to balance what I may recognize as an outdated or perhaps not most evidence based guideline with the external expectations placed on me.

  3. My practitioning body is trying to keep guidelines more uptodate and to flag guidelines that are out of date and may need review. I try and read the evidence that is new wait for it to be replicated in other trials and than weigh the impact on patient care with risk before deciding when to adopt. I am Obs/Gyne so at least in obstetrics there are very little new drugs which makes it easier and not a tonne of new gyne drugs. I do think it best to try and practice with evidence based guidelines and especially at least consider adopting recommendations in new guidelines but I do very much try and monitor cost and risk to patients.

  4. Great article! Indeed, I think most of us also keep an eye on This Changed My Practice as a source of patient-centred recommendations that are evidence-based or at least honest about the limitations of the evidence applicable to the issue in question.

  5. Many of us will feel like Laura Koop because assessments and audits are often based on such guidelines. Let us hope that as more information comes forth about harms from such unthinking regimented management those approaches will be abandoned.

    I personally have experienced the frustration and annoyance at being followed according to a guideline rather than heard as an individual regarding what issues and approaches I feel are right for me.

  6. Thanks a lot for the post.Really thank you! Much obliged.

  7. Well thought out, practical approach to the application of the veritable snowstorm of guideline- this balances recommendations with individual issues and patient preference.
    Thank you.

  8. Guidelines are just that – a guide. They should not be considered the only way to apply medical care, for the reasons that Dr. Etches makes so plain.
    I view guidelines as a good “prompt” for consideration of care, but not a rigid system that has to be followed slavishly.
    Thank you for reminding me why I try to do things the way you do!

  9. Thank you Dr. Etches for this insightful article and practical approach to incorporating EBM into clinical practice. I would also like to introduce everyone to non-industry funded EBM drug information services across Canada – academic detailing. In BC, PAD Service http://www.bcpad.ca, and more widely known RX Files (Saskatoon).

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