This Blog has argued that, medicolegally if not medically. clinical practice guidelines often do more harm than good. There are many reasons why that is so, but one is that the experts who generate these recommendations often disagree among themselves. The abstract from a recent JAMA Internal Medicine article is enlightening:
Different professional societies and organizations continue to disagree over the optimal time to initiate and discontinue breast cancer screening mammography and the optimal screening interval. In October 2015, the American Cancer Society (ACS) revised its guidelines, encouraging personalized screening decisions for women ages 40 to 44 years followed by annual screening starting at age 45 years and biennial screening for women 55 years or older. The US Preventive Services Task Force (USPSTF) reissued its recommendations in January 2016 recommending personalized screening decisions for women ages 40 to 49 years followed by biennial mammograms for women ages 50 to 74 years. The American Congress of Obstetricians and Gynecologists (ACOG) recommends yearly mammograms for women 40 years or older. With physician recommendations the most important determinant for patients obtaining screening, we investigated physician recommendations in light of recent guideline changes in a national sample.
Archana Radhakrishnan, et al., “Physician Breast Cancer Screening Recommendations Following Guideline Changes: Results of a National Survey,” JAMA Intern. Med. Published online April 10, 2017. Here we have three highly respected organizations, all no doubt equally zealous in screening for breast cancer, all striving to offer sound advice to clinicians, and all disagreeing about the proper way to follow patients.
Equally informative is the analysis of actual physician behavior. Traditionally, the habits of one’s colleagues in the same specialty or discipline have defined the standard of care: the law’s metric for performance. In theory, doing what one’s peers do in similar circumstances means doing that which the law demands. So, what do clinicians do to screen for breast cancer, and why?
More than a quarter of physicians (26.0%) reported trusting ACOG guidelines most; 23.8%, ACS guidelines; and 22.9%, USPSTF guidelines. Physicians who trusted ACS and ACOG guidelines were significantly more likely to recommend screening younger women compared with those who trusted USPSTF guidelines (ACS guidelines, 86.5%; ACOG guidelines, 92.9%; USPSTF guidelines, 60.8% for women ages 40-44 years; and ACS guidelines, 94.7%; ACOG guidelines, 95.6%; USPSTF guidelines 72.4% for women ages 45-49 years) (Figure 2). This pattern was similar among women 75 years or older (ACS guidelines, 73.4%; ACOG guidelines, 78.3%; USPSTF guidelines, 44.2%).
Note the roughly similar levels of confidence in the guidelines published by each group. From a defense perspective, one could argue that adherence to any of these guidelines, then, conforms to the standard of care. Of course, if the defendant followed none, then the argument would be that guidelines do not establish the standard, and in any event are inconsistent. But while the authors do not explain it, only 72.7% of physicians surveyed weighed in; more than a quarter of respondents apparently offered no preference. Among patients 40-44, the gap between the most and least frequent screeners was about 22%. The difference was smaller, but certainly not zero, in the approach taken to screening older patients, except those 75 and older, where the gap was north of 30%.
Comment:
Thought leaders in pertinent disciplines come together to analyze the available literature and offer their own insights from years of experience in dealing with a specified clinical issue. They publish recommendations reflecting those thoughts and efforts. No one doubts that this exercise sheds light on important questions. The trouble is that, in our society, these publications are irresistible to those who often earn substantial incomes by suing doctors. The attraction is even more powerful when a second group of learned professionals comes together, does much the same thing as the first, and for many if not all of the same reasons, but reaches conflicting views. Plaintiff’s counsel will select whichever of these two is a better fit with his theory of the case and attempt to use it as a weapon against the defendant practitioner. When the profession is generous enough to provide opposing counsel with three or even more sets of conflicting guidelines, the opportunities for mischief grow proportionally.
Medicine thrived for generations, indeed centuries, without clinical practice guidelines. It can do so again. And barring some extraordinary change in either our law or our national fascination with litigation, it should.