Medical Guidelines Lack Supporting Evidence
Medical Organizations Make Standards Based on Opinions not Evidence
Dec 12, 2008
Tens of thousands of pages of biomedical research articles are published each day. Doctors can't possibly read and interpret this glut of information. They turn to their professional organizations for help in getting to the bottom line to tell them what to prescribe under what conditions. The organizations frequently do not have the resources to weigh all of the evidence and must rely on the experience of panels of practitioners. The problem is that the advice of the panels differs depending on which authorities are on a particular panel and since the views are not always based on a systematic review of the literature, the advice can be inconsistent with current evidence. In the worst case, the advice may be influenced by factors other than the best patient outcomes.
NY Times Essay Questions Evidence behind Medical Care Guidelines
Dr. Darshak Sankhavi is a pediatric cardiologist at the University of Massachusetts Medical School. In an essay in the New York Times ("Plenty of Guidelines, but Where's the Evidence?" December 9, 2008) he laments the paucity of clinical evidence that informs the US national guidelines for medical care. In the presence of an abundance of experimental evidence, Dr. Sankhavi feels that the opinions of a few become national policy.
Medical Guidelines Questioned Based on Reversals, Lack of Justifications
The care of children provides Dr. Sankhavi's examples, because that is his area of expertise. He points out the sudden shift in recommendations for cardiac testing of children taking medication for attention problems. He was also perplexed by the recommendations for cholesterol testing in millions of school children. The bottom line, is that the guidelines cannot be definitive, because they are not adequately supported by evidence.
Whence Medical Care Guidelines?
Who is responsible for the developing of guidelines for medical care? How does the patient know why his or her doctor recommends a particular drug? The doctor-patient relationship is predicated on multiple levels of trust. The doctor must believe that what he/she prescribes is the best for the patient. The doctor's belief is built on trust that peers empowered to evaluate the state of the art in his/her field have performed that evaluation and developed appropriate guidelines for doctors within a defined, specialized area of medicine. Those guidelines must appear reasonable and to develop organically over time, to both doctors and patients. The inconsistent situation described by Dr.Sankhavi undermines doctor-patient trust.
Insufficient Funding for Development of Medical Guidelines
Who gets the job to review all of the literature, evaluate relevance, and synthesize the consensus as pragmatic guidelines? It falls to the professional organizations that represent medical specialties. These organizations have access to authorities within a specialty, but they frequently lack the resources to thoroughly evaluate the existing relevant research. Too frequently the organizations are forced to rely on opinions. The opinions of a few become the national practice.
Guidance is Flawed, but no Cure Is in Sight
Dr. Sanghavi's article on medical guidelines does not end on a hopeful note. He observes, for example, that only one third of pediatricians follow the national guideline to avoid use of antibiotics for ear infections. Other studies show that this pediatric practice sometimes exacerbates long term care of ear infections and leads to additional office calls. We are left with buyer beware. We must trust our doctors and hope that they pick and choose among the guidelines to keep us safe. In the long run, however, we must become knowledgeable enough to know when to seek a second opinion.
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