The Vital Role of Guideline Narratives

Kenneth Lin

Posted 12/1/11 on Common Sense Family Doctor

A few weeks ago, I presented Family Medicine Grand Rounds at Georgetown University School of Medicine on resolving conflicts between screening guidelines. During the question and answer session, Department Chair James Welsh, MD asked how evidence from carefully conducted clinical trials can possibly overcome powerful emotional stories of “saved lives.” I answered that evidence-based medicine’s supporters must fight anecdotes with anecdotes. For every person who believes his or her life was extended by a PSA test or a mammogram, statistics show that many more are temporarily or permanently injured as a result – and their stories matter too. As blogger Kevin Pho, MD wrote about the USPSTF’s recent prostate cancer guideline, “Task Force advocates will need to put a human face on the complications stemming from prostate cancer screening” in order to convince physicians and patients that it’s okay to stop. Indeed, news stories about PSA test-related complications such as this one by Associated Press writer Marilynn Marchione will go a long way in balancing the scales.

An insightful commentary published in JAMA last month took this point one step further by asserting that narratives deployed to support evidence-based guidelines should include not only patients’ stories, but the story of the guideline developers themselves:

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Primary Care Physicians and the Goldilocks Principle

Kenneth Lin

First posted 10/10/11 on the AFP Community Blog.

A recent national survey of internal medicine and family physicians published in the Archives of Internal Medicine found that 42 percent of physicians felt that their patients were getting “too much” health care, while only 6 percent thought that patients were receiving “too little.” These opinions contrast with multiple previous studies showing that primary care clinicians fall short when it comes to providing guideline-recommended care; a 2007 study, for example, found that children received less than half of indicated care.

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Experience is not the Answer

Bradley Flansbaum

First posted 8/25/11 on The Hospitalist Leader

I assume, incorrectly perhaps, that mechanics have a basic knowledge of their craft such that routine auto repairs require little effort. The tasks do not supersede the expected competency of the repairperson, and the customer can expect a car that operates at the time of pick up. A small percentage of jobs may stretch that assumption, but that is okay by me. Just like medicine, some mends are complicated. You need assistance from another mechanic or you refer the auto to a specialty garage. No one is superman.

How does this relate to the practice of medicine?

I frequently notice pharmaceutical ads on Sunday AM television broadcasts, as well as newspaper articles that advertise a medical product, or report on a new device, surgery, or therapy—usually of the latest and greatest vintage. As the data for these interventions is incomplete, or the costs unknown, the story concludes with a riposte conveying that the reader need not concern themselves with the alien facts—just “consult your health professional” and all will be well.

I also observe that politicians object to “meddling” when EBM-based policies from expert committees passively (or actively) affect the doctor-patient relationship, especially as it relates to decision-making and the counsel we provide. Just watch the nightly news—sound bites abound. This relationship is sacrosanct after all, and our advice is authoritative and 98.7% correct. Who would question a physician after all?

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Advocacy Groups Threaten Evidence-Based Guidelines

Josh Freeman

First posted on 7/13/11 on Medicine and Social Justice

Two recent “Commentaries” in the same issue of JAMA address different challenges to the implementation of evidence-based practice guidelines. One, “Direct-to-consumer cardiac screening and suspect risk evaluation,” addresses the challenges posed by the potential for profit that occurs when companies market screening tests directly to the consumer (DTC) that may not be indicated, may not be indicated for the people who it is marketing to, or may even be harmful to the recipients of such screening. This harm can be physical, as in untoward events, or in risks inherent in the further procedures for those who “screen positive” but turn out to have been “false positives.” The harm is also financial, for there is a cost to doing these tests – to the individual (sometimes) or to their insurer; in the latter case, whether that insurance is public (e.g., Medicare, Medicaid) or private, the cost is to all of us. And, of course, that cost is the reason for such marketing, as it is what translates into profit for the company selling the test.

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Clinical Practice Guidelines on Trial

David Cundiff

On March 23, the Institute of Medicine issued a report entitled, “Standards for Developing Trustworthy Clinical Practice Guidelines (CPGs).” The report noted that the National Guideline Clearinghouse accepted722 new guidelines to its database in 2008, bringing the total to nearly 2,700. Almost 1,000 CPGs have been updated because they didn’t quite get it right the first time. A staggering 1,978 CPGs were withdrawn from the database, presumably because they were just too wrong to be updated.

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More Can Also Be Less: We need a more complete public discussion about comparative effectiveness research.

JESSIE GRUMAN

Originally Published 12/1/10 on the Prepared Patient Forum

Jessie Gruman Media coverage of the government’s new investment in comparative effectiveness research leans heavily toward the effects of such research on new drugs and technologies: Will such evaluations lead to restricted access to the latest innovations? Will insurance no longer cover a drug that might give my aunt another year to live? Will such research hinder the development of a drug that could cure my nephew of type 1 diabetes?