In the Lymelight: Law and Clinical Practice Guidelines

Susan J.D. Ronn

Disclosures

South Med J. 2009;102(6):626-630. 

In This Article

Why Does It Matter?

In the United States, clinical practice guidelines quickly become the standard of care and also influence insurance company reimbursements to patients. Insurance companies adopt their own guidelines for reimbursement based, in large part, on prevailing treatment guidelines.[13] Patients treated with antibiotics outside IDSA guideline recommendations thus bear the burden of payment for their treatment, despite being insured. Also, when medical opinion is divided and one side of the divide is perceived as the mainstream, physicians, fearing medical board investigation and censure, become wary of treating outside that model.[14] IDSA Lyme guidelines are widely used as justification that chronic Lyme disease does not exist.[15]

So who decides? If the science truly remains uncertain, should patients have the right to knowledge about the disagreement? And, perhaps more importantly, should physicians be made aware of the disagreement, and the differing opinions regarding diagnosis and treatment modalities?

Another issue invoked by the disagreement lies in the process used by medical societies to develop practice guidelines. IDSA has guidelines for its guidelines-rules to follow to ensure good science and fair and ethical practice. These rules state: Practice guidelines … are never a substitute for clinical judgment. Clinical discretion is of the utmost importance in the application of a guideline to individual patients, because no guideline can ever be specific enough to be applied in all situations.[16] Further, one of IDSA's stated purposes for guidelines is clarification of controversy, and in choosing panel participants guideline developers are strongly encouraged to include members of relevant professional societies and to work toward consensus in their recommendations.

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