Where Those Cardiology Guidelines Come From, Part I

Posted on March 1, 2009
Filed Under Cardiology Topics, Guidelines, Abuse of |

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DrRich would like to congratulate Dr. Robert Centor, affectionately known in these parts as DB, for co-authoring a major editorial last week in the Journal of the American Medical Association. Thanks to his fine efforts, the rest of us in the medical blogosphere can pretend to travel in circles in which we routinely commune with the academically adept.

DB’s editorial was written in response to a study appearing in that same issue of JAMA regarding the many sets of clinical guidelines produced by the American College of Cardiology and their habitual partners in guideline promulgation, the American Heart Association. The authors of this study examined the acres and acres of guidelines executed by the ACC/AHA over the past 20-some years, 53 sets of guidelines in all, which offered up 7196 clinical recommendations, each explicated in solemn detail. In sheer volume alone this massive guideline effort must have put to shame Mr. Obama’s recent Stimulus Bill, whose volume in comparison was a mere pamphlet. What the authors of the JAMA study found, to be brief, was that only a small (and over time, shrinking) minority of the clinical recommendations being continually mass produced by the masters of cardiology are actually supported by a high degree of hard clinical evidence, the great majority instead being supported by the opinions of, well, the opinion leaders.

The editorial produced by DB (and his co-author, Dr. Terrence Shaneyfelt), as anyone who is familiar with DB’s writings would expect, is tightly written and to the point. (DrRich especially admires anyone who can rationally critique the foibles of others without resorting to fancy phrases, verbal eye-rolling, insults or sarcasm, and oftentimes wishes he had that capacity.) DB and his colleague simply and objectively point out the potential drawbacks of a process whereby not-wholly disinterested specialty groups systematically spew forth vast quantities of clinical recommendations, which (intended or not) often seem to institutionalize certain behaviors that require primary care doctors to refer them lots of patients, that require said patients to subject themselves to having sundry instruments and tubes inserted here and there for this and that, and that require third parties to figure out how to pay for it all. Holding out the cardiology community as an object lesson in suboptimal guideline development, DB and co-author then offer several very sensible recommendations for producing clinical guidelines that ought to result in less wasteful and less damaging clinical behaviors. It is all very nicely done.

But reading the article and the editorial, as well done as they both are, DrRich could not help being reminded that he, in fact, is a cardiologist. And that compels him to believe that, as a cardiologist, maybe he has some ’splaining to do. Just where to these poorly supported guidelines come from, anyway?

While he has not practiced cardiology (or any kind of medicine) for nearly a decade, for almost 20 years DrRich used to travel in many of the same circles as the people who write the ACC/AHA guidelines, was on a first name basis with many of them, debated with them over what ought to be done with patients and when, and while he never sat on a formal guideline-writing committee, likes to believe that he had at least some influence in some of the guidelines pertaining to cardiac arrhythmias that were written during that time. Now to be sure, DrRich generally argued on the side of subjecting patients to the the least possible number of potentially dangerous invasive procedures. DrRich’s feeling was that if he ever killed somebody doing an invasive procedure (thankfully he never did), he would want to believe that the procedure had been completely necessary, and totally unavoidable. (In fact, when he wrote his first textbook 20 years ago on electrophysiologic testing - still a “best seller” today, as medical texts go - he wanted to title it, “Electrophysiology Studies, and Why You Almost Never Need To Do One,” but his editors wisely forbade it.)

The counter argument to DrRich’s non-invasive world view was usually that going from a position of being “pretty sure” to one of being certain was often worth risking an invasive test, or that improving outcomes by some relatively small amount was worth an invasive treatment. That is, the argument was always that the patient stood to benefit. DrRich knew a lot of these people, these guideline writers, and even when he thought his colleagues were occasionally misguided, he always believed their hearts were in the right place.

He still does. These are good people who want to do the right thing and who, with a few rare exceptions, deeply believe they are doing the right thing. Today DrRich is old and experienced enough to know that having your heart in the right place and wanting to do the right thing counts for relatively little when peoples’ lives are at stake. If you are in a position of responsibility you owe more to your charges than mere good intentions. (In the same manner, DrRich imputes no ill intent to those people who today are, in his mind, making some disastrous economic decisions for our country.)

But how can sincere people who are trying to do the right thing be so wrong? How does that happen?

DB himself hit on the answer in his editorial. When one has a strong world view on some issue, then interpeting objective evidence that challenges that world view is most often anything but an exercise in objectivity. That is, bias - even, as DB points out, fully disclosed bias - can preclude a true interpretation of the facts.

DrRich does not think cardiologists are unique in this regard, and indeed, he is sure they are not. DrRich has been pretty hard on his cardiology colleagues in this space over the past year or so not because he thinks they are especially bad at being objective, but rather because he understands (or thinks he understands) what the issues are within the universe of cardiology. He suspects that gastroenterologists and endocrinologists (and Democrats and Republicans) are doing exactly the same thing, but he is not knowledgeable enough to detect all the smoke being blown at him by experts in unfamiliar fields of endeavor.

But still, one has to admit that the cardiologists are especially good at this. This is why, DrRich suspects, it was not the neurosurgeons who became the subject of the article in JAMA. The cardiology community fully embraced the guideline wars well before most other medical specialties even realized that a war was taking place. Cardiologists have behaved for decades as if they understood that expertly executed guidelines are not merely a tool for clinical competence, but are a weapon of survival. Accordingly, in those guideline wars, the cardiologists have become adept, through long experience, at wielding  all the most modern weaponry with great skill. They generally win quite handily their guideline duels with other medical specialties, and have become ruthless in advancing predatory guidelines that impinge directly on the turf of others. And yet, every step of the way they remain convinced they are acting with the patients’ best interest at heart.

It stands to reason that guidelines that have been developed - subliminally if not overtly - for the defensive purposes of protecting the turf of a medical specialty, or for the offensive purposes of invading the turf of other medical specialties, may not pass muster when evaluated as if their purpose was something else entirely. In DrRich’s view, judging the cardiology guidelines as if their chief purpose was actually to maximize patient safety and optimize clinical outcomes is like judging the suitability of an M-1 battle tank as a family sedan. It was designed for something else entirely.

In his next post, DrRich attempts to show - using a live, real-world example - how cardiologists have made into a true art form the reinterpretation of objective clinical data in order to support their required world view, and to suggest how such techniques can lead to the kinds of guidelines discovered by the authors of the recent JAMA article.

Comments

3 Responses to “Where Those Cardiology Guidelines Come From, Part I”

  1. Sandra Brown MD on March 2nd, 2009 4:54 pm

    To connect guidelines with P4P…it so happens that our group got some P4P money. I guess you can check out the P4P winners and losers on a federal web site somewhere. We were in the noted minority. Nobody cares about my patients (don’t vote, don’t pay taxes) so I’m not P4P eligible. But when I reviewed the actual P4P criteria I thought, Man! this is pretty dumb basic stuff. You mean someone is treating a glaucoma patient and not checking eye pressure every so often? So either ophthalmology guidelines and P4P standards are sorta reasonable or I’m missing something.

    The difference, I note, is that ophthalmology does not have any invasive diagnostic testing procedures in its bullet belt.

  2. mary efremov on March 2nd, 2009 9:42 pm

    the pay for performance are pretty thin…i am solo, do the coding, send out billing,cannot get a new set of humbers into my head to use those p4p modifiers and i am appalled at the competing “guidelines” in print. by now most doctors knowthat ace or arb are indicated in diabetes, secondly diuretics are not suitable for everyone as the urination is poorly tolerated in the elderly and the active like teachers and clerks where you cannot always run out to urinate…..also in this category are nurses, taxi-drivers and drivers in general.so, if we avoid firt line diuretics in essential hbp for these patients’ lifestyles….we are “bad” or not cost effective…this is cookie cutter, die-stamping for one size fits all. eroding the very nature of medicine.

  3. Trusted.MD Network on March 5th, 2009 7:24 pm

    Two (three) must read articles on clinical guidelines…

    Clinical guidelines,virtually non-existent a few decades ago now have reached hyper-epidemic proportions. Two of the best medical bloggers have recently penned commentaries that are must reading. DM,know in the real world as Dr.Robert Centor published …

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