Specialists vs Primary Care: Whose Guidelines Matter?

Alicia Ault


June 14, 2018

In This Article

A 'Free-for-All'

Increasingly, guidelines issued by professional societies are being viewed with a jaundiced eye—even by someone such as Stafford. And the profusion of guidelines is leading to confusion among clinicians and patients.

Because theoretically less-conflicted nonprofit or governmental organizations, such as the JNC, have dropped out of the guideline business, "we're back in a situation where we have competing organizations promulgating their own guidelines in such a way that providers and consumers are more confused than ever about what they should do about certain conditions," said Stafford.

"It seems like too much of a free-for-all right now," he said.

The majority of medical organizations that produce clinical guidelines do not disclose the organizations' ties with biomedical companies.

Lin said, "I don't think it's necessarily bad there are different guidelines," but added that if there are so many, it suggests that "maybe care can't be standardized." Without a third-party convener, such as the National Institutes of Health, "you'll increasingly see disagreeing guidelines," said Lin.

Williams, the geriatrician, said he sees widespread conflict. "Most of the subspecialty guidelines end up being shamelessly self-serving," said Williams. The recommendations "are never presented in a way that is balanced, and that's the problem—there's always an agenda," he said. Many thought leaders who put together guidelines "admit to either conflicts of interest or direct working for the industry," said Williams.

A 2016 study in PLOS Medicine [15]  adds some credence to Williams' assertions. It found that the majority of medical organizations that produce clinical guidelines do not disclose the organizations' ties with biomedical companies, and only about one half of the guidelines included disclosure statements from guideline committee members.

Even the JNC8[14] was not conflict-free. Panel members were required to disclose any potential conflicts; those with conflicts were allowed to participate in discussions as long as they declared their relationships, but recused themselves from voting on evidence statements and recommendations relevant to their relationships or conflicts. Four panel members (24%) had relationships with industry or potential conflicts.

Ende said that primary care physicians are not immune, but adds that ACP guideline committees are carefully vetted for conflicts. Writing committee members recuse themselves if conflicts do arise.

O'Gara took umbrage at the suggestion that societies might be motivated by self-interest or financial gain. "Speaking on behalf of writing committees and reviewers and people who put the evidence review together, that does not adequately recognize the effort put into something like this," he said.

"Our job is to make doctors better doctors, and to improve patient care. If other people disagree with how our experts interpret evidence, that's where we are with that," said O'Gara.

Guidelines Are 'Not Commandments'

Most of the clinicians interviewed said that colleagues had a tendency to take guidelines too literally. Improving care means interpreting guidelines through the lens of the individual doctor and the individual patient, they said.

"Clinical guidelines are guides, not commandments," said Stephen Devries, MD. Guidelines can provide useful treatment recommendations, but they "can be abused when interpreted as mandates," Devries told Medscape. Devries is executive director of the nonprofit Gaples Institute for Integrative Cardiology, Deerfield, Illinois, and associate professor at Northwestern University Feinberg School of Medicine in Chicago.

Ende believes that to determine what's best for patients, "clinicians need to become vigorous consumers of guidelines." But decisions have to be individualized, in conjunction with patients, he said.

"The guides are only recommendations! They are never objects of intellectual imposition!" said an internist, commenting on Medscape's article about the stroke guideline reversal. "Patients are not recipes in which you can apply a specific guide and follow it to the letter. The appropriate clinical judgment must always be implemented...Medicine is a science and an art!"

Even if guidelines do not carry the heft of law, primary care physicians are inevitably held more accountable than specialists for meeting them—because of the nature of the practice itself, and quality metrics and reimbursement schemes, said Lin. He said he did not feel it was right to "fire" a patient, even if they were not getting to a guideline target. "I know I'm probably leaving some money on the table by not being strict with them, but I feel that being a good doctor is not just slavishly adhering to guidelines, but recognizing the whole patient," he said.

Williams, the geriatrician, said guidelines are useful tools for synthesizing the now vast quantities of information and evidence—"as long as they're not meant to pollute the doctor/patient relationship."

But, from his point of view, healthcare is "getting more and more templated, more and more guideline-driven, and is less personal."

The individual patient's needs should be the driver of care decisions—"where two people come together to solve a given predicament," said Williams.

Dr Lin was the chair of the AAFP's clinical practice guideline subcommittee from 2015-2017, and authored an opinion piece for Medscape Medical News that was critical of the ACC/AHA hypertension guideline. Dr Stafford disclosed that he was an investigator on the Systolic Blood Pressure Intervention Trial (SPRINT), which was heavily emphasized in the ACC/AHA hypertension guideline.

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