Will You Be Pressured to Perform 'Cookbook' Medicine?

Shelly Reese

Disclosures

July 30, 2013

In This Article

Command to Doctors: Follow These Rules!

A dictionary is a very useful tool...but not if you use it to beat someone over the head. Physicians seem to have the same attitude toward clinical practice guidelines: They are potentially valuable tools that, if mishandled, can become a hefty, skull-crushing medical cookbook.

Clinical practice guidelines are increasingly dictating how physicians approach patient care. Although physicians have historically made care decisions on the basis of their own knowledge and experience, they're under growing pressure to adhere to guidelines as a way to improve and standardize care. A growing number of insurers and healthcare employers are using guideline adherence to measure quality and are factoring it into physician compensation formulas.

Many doctors are chafing under these rules, saying their education and judgment is being ignored, and they resent having to follow a "recipe" about how to treat patients.

Why the Ambivalence?

In theory, guidelines are unimpeachable.

"Guidelines are really taking evidence and trying to translate it into useful information," says Dr. Claire Neely, Medical Director of the Institute for Clinical Systems Improvement, a Minnesota-based nonprofit organization that develops guidelines. "There is so much evidence out there and so much published that there is no way any physician can keep up with it all." Guidelines condense clinical evidence into meaningful decision-making tools for physicians.

The problem -- as is often the case -- lies in the muddled translation of theory to reality. As Dr. Howard Beckman, Chief Medical Officer at Focused Medical Analytics, a Rochester, New York-based medical analytics firm, notes, "There are very few things for which the evidence is incontrovertible."

The National Guideline Clearinghouse (NGC) lists nearly 2600 clinical practice guidelines -- the number fluctuates -- developed by some 230 professional societies, state and federal agencies, and quality improvement organizations. The guidelines often conflict with each other, and charges of conflict of interest and sloppy science have called others into question, causing frustration and doubt in the medical community

Guidelines are written for "average" patients -- and very few patients fit that description, says Dr. Doug Campos-Outcalt, Clinical Sciences Analyst for the American Academy of Family Physicians (AAFP) and chairman of family medicine at the University of Arizona College of Medicine in Phoenix. Randomized clinical trials may be the scientific gold standard, but because trials often underrepresent or exclude certain groups, such as minorities, children, the elderly and people with comorbidities, the AAFP questions whether such evidence should be used as the basis for establishing broad care standards.

"If you have a patient with 5 conditions, you get 5 contradictory guidelines. It's a little unrealistic," Dr. Campos-Outcalt says.

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