Practice Guidelines: Which Ones to Follow?
John A. Lombardo, MDTHE PHYSICIAN AND SPORTSMEDICINE - VOL 24 - NO. 6 - JUNE 96
Editor's Note: Because of increasing concern about practice guidelines, The Physician and Sportsmedicine takes the unusual step of publishing Dr Lombardo's editorial and two responses in the same issue, so that readers may consider their arguments together.
In the March issue of The Physician and Sportsmedicine, an article by David L. Herbert, JD, and an editorial by William O. Roberts, MD, detailed the need for and positive contributions of practice guidelines. I offer another opinion on the subject.
Three levels of recommendations have been amalgamated under the "practice guidelines" label: consensus papers of large groups such as the Bethesda Conference (1), guidelines and criteria prepared by groups or individuals based on opinions about and interpretation of the literature, and algorithms developed by managed care organizations. If these various documents were religious worshippers, they would not only sit in different churches, but would worship a different Supreme Being. However, the two authors have used the terms interchangeably, resulting in a quagmire in which physicians and their patients can only sink and attorneys and insurers can flourish.
Consensus papers that are the result of strict academic and clinical review of the available knowledge on a system or a particular problem, such as the Bethesda Conference or the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (2), offer the clinician state-of-the-art recommendations for patient care. These documents are collaborative works by respected scientists and clinicians and are a valuable resource for making decisions about the health and well-being of our patients.
The next group consists of papers and opinions published by groups or individuals based on their opinions and their interpretation of the literature. Examples of these include all the guidelines and criteria published on concussion (eg, the Colorado concussion guidelines (3)). These statements have not approached the sophistication or credibility of consensus papers, yet they seem to carry similar weight with both authors in the March articles. Rarely are these based on strong scientific evidence, and the conclusions often represent giant leaps of faith from the available knowledge. I consider these to be hypotheses and opinions open for discussion, not valid, substantive recommendations that set a standard of care.
The final and least valid of the practice guidelines are the algorithms, many of which were written for cost-efficient care. Algorithms do not represent a medical standard of care—they are the opinions of small groups of physicians under significant influence of the insurance industry. Algorithms represent specific opinions the value of which should be based on the qualifications, integrity, and diversity of the authors.
I believe that reliance on algorithm cookbooks exposes a basic fault of our education system and the selection system for medical school: The institutions develop, measure, and reward "matching-column minded" individuals who can regurgitate information and take standard tests. "Essay-minded" individuals, who absorb and understand information, then use it to deliver creative, individual solutions, are neither developed nor rewarded by our present systems. "Matching column minds" love algorithms and guidelines because they are comfortable with them. These people do not function well when thought and reasoning are required. There are few pure "matching column minds" or "essay minds"; most individuals have a percentage of both. It would be a travesty to reduce medical decision making and clinical judgment to an algorithm, further suppressing the development of the "essay mind."
Many groups are affected by practice guidelines. As group goals vary, their use of practice guidelines will also vary. Insurance carriers, who call themselves "payers" (not to be confused with consumers), wish for cost-efficient rules so that they can control costs and increase profits. Attorneys on each side of a malpractice suit wish for cut-and-dried standards with which an action can be compared so that they can win their cases. Physicians should be trying to find aids to help them make decisions and offer advice in the best interests of their patients. Athletes, who consistently push their physical limits, need sound information and advice to make intelligent decisions about their health. Physicians who deal with these "risk takers" need a fund of knowledge to provide them with such information and advice.
There may be no way to satisfy the needs and goals of all groups, but physicians must always remember that the primary responsibility and first priority is the health and safety of our patients. The interests of attorneys and insurance carriers should never influence our pursuit of this priority. As physicians, we must never relinquish our leadership in determining the significance, validity, and applicability of clinical recommendations.
Dr Roberts referred to the great chefs, and, again, I disagree with his opinion. Great chefs know how different meats, vegetables, sauces, and spices blend. By applying this knowledge, they create in much the same way as any artist. These great chefs write cookbooks for less gifted cooks. Physicians should strive to use their knowledge to think and create as artists, and not resort to painting by numbers.
DR ROBERTS REPLIES: Dr Lombardo has expanded on the major point of my editorial: A practice guideline is only as good as its authors. I apologize for not clearly distinguishing the practice guideline from empirical recommendations such as the Colorado concussion guidelines (3) (which I trust were developed by caring physicians with the best interests of community and student-athletes in mind) and from dollar-driven insurance mandates that have no place in the practice of medicine.
The practice guidelines that have been adopted by our family practice group were written by physicians in an attempt to make routine what is really routine. The variability in care from region to region and physician to physician is common knowledge among patients. Good, standard care for routine problems improves our credibility and enhances our ability to customize care when necessary, which is the true spice of medicine. Success in medicine still depends on our ability to build personal relationships with patients and thus overcome the financial pressures to switch providers for a few dollars saved.
The physicians involved in the writing groups came from large regional multispecialty groups and smaller local private groups. The documents are based on the scientific literature and combined clinical experience of the writing teams. It becomes apparent in the guideline writing process that much of our daily routine lacks solid scientific documentation. The best care for the patient, based on scientific discovery and documentation, should be the focus of these documents, with a secondary goal of providing the most cost-effective choices for evaluation and treatment. The guidelines are reviewed and modified on the basis of input from all the physicians in the network and the experience of the pilot sites that test the protocols before final adoption.
I think we all have the backgrounds to be the chefs. It will be up to us to write the cookbook or be forced to follow a recipe handed down by an insurance carrier.
MR HERBERT REPLIES: I was very pleased to see Dr Lombardo's comments about the article I wrote for the March issue of The Physician and Sportsmedicine. In part, Dr Lombardo directed his response to an accompanying editorial by Dr Roberts. Accordingly, I will only address the issues raised regarding my article.
First, there are many published statements that have been loosely lumped together under the broad heading of "practice guidelines." Some of these guidelines are indeed authoritative statements, such as the Bethesda Conference reports (1). Some, however, as Dr Lombardo points out, are based on the opinions of other groups of individuals. The Colorado concussion guidelines (3), which he mentions, may well be within this category. Dr Lombardo believes that these latter guidelines are somewhat below the "sophistication or credibility of consensus papers." However, the Colorado guidelines appear to have attained acceptance in sports medicine. They have been adopted and cited by the National Collegiate Athletic Association (2), among others (4). Therefore, it appears to me that even some of these group opinions can have considerable credibility and are very useful in considering issues related to the applicable standard of care.
Dr Lombardo also criticized certain practice guidelines that he characterizes as "algorithms," which in many respects have been established to contain costs. There is no question that practice guidelines that emphasize cost containment do not necessarily comport with the standard of care that sports medicine physicians should follow in caring for individual patients. Guidelines that are based principally or solely on cost containment should not rise to the level of consensus statements or group opinion statements that have gained widespread physician acceptance.
Lastly, I take exception to Dr Lombardo's statement that attorneys use standards statements to win their cases. No matter which side an attorney represents, his or her effort is to win the case for the client through a truth-finding process administered by the judicial system. I do not believe that attorneys concentrate their efforts on winning their case, but rather concentrate their efforts on advocating their client's cause or position.
Practice guidelines and standards statements can provide a reference for physicians to use in the course of rendering care and, secondarily, can facilitate the judicial truth-finding process. Such guidelines can only help physicians who may later be forced to address care issues in the legal arena.
Dr Lombardo is medical director of The Ohio State University Sports Medicine and Family Health Center in Columbus.