Issues With Clinical Guidelines

If we could only get doctors to always follow the clinical guidelines that have multiplied like rabbits, quality would be great and costs would go down, or so the theory goes.  In practice, guidelines appear to cause as many problems as they could solve.  Research at the National Bureau of Economics explores why that may be so.   (NBER Paper)   The National Guideline Clearinghouse has several thousand, that’s right, thousand guidelines.  The premise behind them all is that experts somewhere are better at determining the best care for a patient, without even seeing them and understanding their unique attributes and the unique features of their health and health condition.  Doctors often feel forced to comply with guidelines, even if they aren’t sure it is in the patient’s best interest, because of pay-for-performance programs or malpractice concerns.  It is highly ironic that such centralized clinical decision-making is occurring at a time when we have more and more knowledge of the wide diversity of patient genetics and biochemistry and supposedly such concern for shared decision-making with patients.  These researchers try to examine why there is, or should be, deviation from guidelines because they may not provide optimal outcomes.

Whether or not doctors should trust guidelines and comply with them depends on your assumptions about the state of physicians’ knowledge of their patients and knowledge of the likely outcomes of alternative treatment choices, as applied to a specific patient and that patient’s characteristics.  It is certainly true, as the authors point out, that “experts” have a variety of data and statistical analyses available to them and can sort those by a number of relevant patient and disease factors.  But the experts don’t have the patient in front of them and they don’t always have all the clinical experience that a practicing physician does.  In the abstract, a guideline should produce the best outcomes when applied, most of the time, or at least more often than relying on individual judgment of treating physicians.  Otherwise, why have guidelines at all?  I am queasy that guideline creators actually possess that much better information.  The researchers in this paper point out that many studies underpinning guidelines have serious methodological and other issues, which may limit the value of the results of the research.  And my biggest problem is the potential conflict with the increasingly obvious need to customize treatment by patient and disease factors, and the even bigger conflict with the idea of engaging patients in their health and involving patients in their health decisions.