"Some doctors say that however
reasonable guidelines may seem, their cumulative burden causes “constant
frustration” to medical practice.
The intent is admirable: Give
doctors guidelines so they can be sure to cover what needs to be discussed with
patients and help select options. Let’s talk about your diet and any problems
you might have sleeping. Are you getting enough exercise? If not, here is some
advice. You are due for colon cancer screening. Do you prefer a colonoscopy or a
fecal test? Here are the pros and cons of each.
But there is a problem. There are
just not enough hours in a workday to discuss and act on all the guidelines.
Suppose an American doctor wanted a gold star when seeing
patients and followed all of the guidelines for preventive, chronic and acute
disease care issued by well-known medical groups. That could require nearly 27 hours per day, a team of
doctors wrote in a study last year for the Journal of General Internal
Medicine.
No one could actually do that, so imagine a doctor shrugged
off the chronic and acute care, as well as administrative work, and merely
followed the preventive care checklist recommended by the U.S. Preventive
Services Task Force, an independent panel of health experts. That would be 8.6 of the doctor’s hours each day, according to
a study in the American Journal of Public Health.
As anyone who has been sped through a 15-minute annual
wellness visit knows, doctors cannot be so exacting. That the guidelines are so
thorough yet so often glossed over prompts questions about their usefulness. At
the same time, doctors’ pay often depends on checking off guideline boxes.
“Is this an issue? Absolutely,” said
Dr. Michael Pignone, a former member of the Preventive Services Task Force and
chairman of the department of internal medicine at the University of Texas at
Austin’s Dell Medical School.
“Suffice it to say that what has
been incentivized isn’t always what delivers the most health or benefit,” Dr.
Pignone said.
Guidelines have become “a constant
frustration,” said Dr. Minna Johansson, a general practitioner in Uddevalla,
Sweden, who also directs the Global Center for Sustainable Healthcare at the
University of Gothenburg. She worked with doctors in other countries on an
analysis of the issue that was published last month in BMJ. “A lot of guidelines may seem reasonable
when considered in isolation,” Dr. Johansson said. “But the cumulative burden
of all guideline recommendations combined is absurd.”
Dr. Johansson was inspired to study
the issue working in a small town on Sweden’s west coast.
“I have a yearly visit with my
patients,” she said. Spending that precious time discussing a lifestyle
prescription that, however well meaning, is unlikely to change a patient’s
habits, is of dubious value, she said. And, she added, it “crowds out more
important discussions.”
“Maybe the patient smokes or has
suicidal thoughts,” she said.
And, she added, many guidelines,
like those for extensive discussions about improving exercise habits or diet,
have not been shown to result in important health benefits.
Dr. Johansson worked with Dr. Gordon
Guyatt of McMaster University in Hamilton, Ontario, and Dr. Victor Montori of
the Mayo Clinic in Rochester, Minn.
They argue that this problem affects medical systems
throughout North America and Western Europe.
In Norway, for example, guidelines
for assessing and treating high blood pressure apply to the nearly
three-quarters of adults with pressures above the goal of 120/80. If the
guidelines were strictly adhered to, patients would need so many regular follow-up
visits that accommodating them would require more general
practitioners than are currently working in Norway.
And implementing all the British
guidelines for improving patients’ lifestyles could require more doctors and
nurses than are practicing in the entirety of Britain.
The researchers say that guideline
makers should consider what the study calls “the time needed to treat” — how
much time it takes to implement a guideline.
For example, they say, the British guideline on assessing a
patient’s physical activity would take 15 percent of a doctor’s visit to
implement, but there is no evidence it would improve long-term health.
That, they say, might suggest the guideline should be jettisoned.
Dr. Carol Mangione, chair of the
U.S. Preventive Services Task Force, said the task force considered the time
guidelines take. And nowhere is it suggested that doctors try to tick off each
guideline recommendation in a single visit.
“Clinicians do not — and would never be expected to —
implement all of the suggested screenings, counseling services, and preventive
medications in a single patient visit,” Dr. Mangione wrote in an email. “When
caring for patients, clinicians use both their judgment and the information
obtained during conversations with each patient to prioritize which preventive
services should be offered during each visit.”
Even that is not easy, said Dr.
Daniel Jonas, director of the division of general internal medicine at Ohio
State University.
Guidelines can serve a purpose, Dr.
Jonas said. “I think they’re incredibly helpful,” he added. But, he said,
“deciding what to prioritize in a busy primary care practice is a big
challenge.”
Dr. Montori added another
complication.
“To assume that patients and
clinicians can sort and prioritize recommendations over multiple visits,” he
said, “wishes away the fundamental problem that many patients cannot get
primary care, see the same clinician or have unhurried consultations.”
Dr. Pignone said that some of the
burden should be shared with other professionals, like nutritionists, who can
talk to patients about healthy diets. But, he said, that is only a partial
solution. He’d like to see current recommendations prioritized by their impact on health and on
their cost effectiveness. As examples, he said, childhood immunizations would
rank high but existing guidelines to give tetanus boosters to adults who
already had tetanus shots would rank lower.
Dr. Guyatt said guidelines should be
held to the same standard as new drugs. Before they are implemented, there
should be evidence that they are helpful.
“Somebody might say, ‘Oh, a new drug
has side effects but what harm is there in this guideline?’” he said. “But yes,
there is real harm. There is a trade-off between doing things that are actually
useful and spending time on things that are useless.”"
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