Is Guideline Tyranny Causing Guideline Anarchy? (Part I)

Posted on April 30, 2008
Filed Under Guidelines, Abuse of |

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The Tyranny of Guidelines

Anybody practicing medicine today needs to be serious about medical guidelines.

The original idea behind medical guidelines was to provide (oddly enough) a guide to physicians in caring for patients with a particular medical problem. That is, they suggested a generally preferred approach to medical care in view of current medical evidence, but did not attempt to dictate care in all cases. Medical guidelines were to serve as a roadmap which, while usually suggesting a favored route from point A to point B, always allowed that for individual patients, some alternative route might be preferred or necessary.

As originally conceived, medical guidelines (based as they were in classic evidence-based medicine, as Dr. Poses reminds us) were designed to encourage the “conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” It was simply assumed that in applying such guidelines clinicians would continue “integrating individual clinical expertise with the best available external clinical evidence from systematic research.” That is, guidelines were supposed to serve as a touchstone for doctors attempting to tailor the best available current evidence to the care of their individual patients.

It goes without saying that medical guidelines are actually not being used in this way today.

Under a healthcare system where controlling the behavior of physicians (in a vain attempt to control costs) is Job One, “guidelines” are treated as a set of unalterable rules - as definitive steps that must be followed in all cases, without exception; and that, if taken, will yield that which is defined as high quality medical care, and if not taken, will yield that which is defined as low quality medical care. Once quality is defined as compliance with guidelines, then “physician report cards” based on such compliance can be made available to the public, and can be used to steer patients to the “high quality” doctors and away from the “low quality” ones. Lately, the highly popular gambit of Pay for Performance assures that doctors are explicitly rewarded (like trained seals) for following whichever of the sundry lists of guidelines is preferred by the payer of record, to assure excellent quality (and, incidentally of course, to reduce cost).

And now, the most recent revelation from our friends at Medicare is that the mere existence of a set of guidelines can render certain medical problems, whose incidence in fact can sometimes be reduced but never eliminated, as “never events,” the occasional occurrence of which thus becomes punishable. When Medicare expanded its list of these “never events” a few weeks ago, the agency’s chief justification for doing so appears to have been the availability of guidelines that can allegedly reduce the likelihood of their occurrence.

It is notable that there are no rules for writing guidelines, and no generally agreed upon requirement for transparency (such as, for instance, elaborating on the criteria used for accepting, rejecting or ranking various sources of available medical evidence used in formulating them). A group of “experts” that has been given (or that has taken) the authority to develop a new set of guidelines assumes the role of potentates, and they can devise guidelines every bit as detailed and as extravagant as they choose (so long as they give the nod to, and can plausibly claim their work to be derived from, “evidence-based” considerations).

Once the new guidelines are chiseled onto stone tablets and brought down the mountain to the abject throngs of awaiting doctors (for it is almost always true that the mere practitioners who are charged with living by the guidelines are rarely the same as the exulted experts who get to devise the guidelines), it matters not whether physicians working under strict time limits will find it impossible to comply with each exquisite detail, or indeed, whether strictly following these guidelines might even have harmful unintended consequences for patients. The guidelines, once designated by various insurers or the feds as being “the” guidelines, must be obeyed. (And if it turns out that the guidelines simply cannot be obeyed, say, due to their sheer ungainliness, then large masses of doctors can be threatened with lawsuits for non-compliance, if not for accessory to murder.)

Guidelines treated in this manner clearly violate the original intent of evidence-based medicine in general, and of medical guidelines in particular. But when you’ve got to do whatever it takes to direct the behavior of physicians (the ones who, with the touch of a pharmaceutical-logo’ed pen, can bend the entire medical-industrial complex to their every whim), medical guidelines simply must be perverted into a tool of control.

Medical blogs have done a pretty good job of chronicling the growing tyranny of medical guidelines. A less well-documented result of this tyranny, a phenomenon that is just now coming into focus, is the mad scramble by diverse interest groups to promulgate their own sets of guidelines, and subsequently fight to have them accepted as “the” guidelines, thereby to gain control the medical agenda. Guidelines written by competing interest groups will often direct doctors to do very different things, and will set up some very interesting turf battles.

In Part II we consider this “anarchy of guidelines,” now taking shape as a direct result of the guideline tyranny under which doctors labor, and patients risk their lives.

Comments

5 Responses to “Is Guideline Tyranny Causing Guideline Anarchy? (Part I)”

  1. Bruce Levy on May 1st, 2008 10:52 am

    “is the mad scramble by diverse interest groups to promulgate their own sets of guidelines, and subsequently fight to have them accepted as “the” guidelines, thereby to gain control the medical agenda”

    You raise an interesting point. The argument that these interest groups might advance is that if we do not set such guidelines then they will be imposed upon us by others.

    Perhaps I look at this from the atypical perspective of forensic pathology, where our practice is most commonly within a governmental structure and we frequently are working within our legal system.

    Many medical examiner offices in the country have been financially devastated by governments looking to save money and who do not understand the role that we play. After all, our patients do not vote or lobby anymore. Having some type of accepted guidelines or standards provides us the ammunition to defend our budgets.

    We are also in the only field of medicine where our colleagues in other fields of medicine all believe that they are also experts in forensics, their arguments being “what’s so hard about figuring out why someone died.” These self same experts would be appalled if we attempted to comment on their specialty of medicine. Why else would an orthopedic organization have established “boards” in forensic pathology where surgeons are giving exams to forensic pathologists (fortunately they abandoned this practice in the ’90s although the consequences of their board certification still reverberate today)?

    We also see evidence that attorneys and politicians are attempting to define our practice and how we should practice it. Why should we not fight back against this by attempting to establish our own guidelines before they are imposed on us from the outside?

    I have personally dealt with politicians who have attempted to do this very thing. I was told once that the law could be changed so that we could just put “natural causes” as the cause of death on a death certificate, making autopsies unnecessary and saving the government money. As if merely changing the law makes things OK. I guess we could pass a law that says the sun rises in the west, but that does not make it so!

  2. DrRich on May 3rd, 2008 9:36 am

    Bruce,

    Thanks for your comments.

    I am not trying to disparage all guidelines. Guidelines were invented in the first place because when applied as originally intended they can be extremely helpful to doctors. I am only disparaging their corruption.

    Also, to your point about passing a law making the sun rise in the west - that sort of thing is already happening. The existence of smoking cessation guidelines means that if a doctor’s patient continues to smoke, the doctor is guilty of killing them. Guidelines to reduce the incidence of hospital falls makes hospital falls a “never event.” The only reason the sun still rises in the east is that Medicare hasn’t yet chosen to address this particular fault in God’s plan.

    Rich

  3. James on May 7th, 2008 10:00 pm

    I still don’t understand exactly where your criticism is directed. If there is a potential harm from establishing guidelines for practice based on available evidence, I’m willing to hear it. But, what’s wrong with insurance companies rewarding practitioners who practice based on the best available evidence (i.e. according to guidelines)? Nothing is should be negatively impacting patient care here. If, in your expert opinion, a particular guideline doesn’t apply or for some other reason should not be followed, you are under no obligation to follow it. On the contrary, you are ethically obligated not to follow it.

  4. Gary Levin on August 6th, 2008 6:05 pm

    Usually guidelines are offered by specialty society groups as part of their CME programs.
    They are just that, guidelines…not imperatives, and I seriously doubt if CMS plans to punishc providers for ‘never happen’ events is legal…if hospitals don’t challenge this legally they are foolish.

    Secondly, the administration of policing ‘guideline medicine’ is usually done by clerks or administrative personnel, that have no idea what a guideline is.

    The negative impact of enforcing guideline by insurance companies is that they will mistakenly enforce guidelines by non payment for not following ‘proedure’…There are many instances of not following guidelines due to individual patient’s conditions, ie allergies, conoomitant diseases, treatment failures, and many more to numerable to expand here.

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