Treatment guidelines help doctors and other health-care providers understand and follow the best clinical practices, but as a recent commentary in the New York Times points out, they also can undermine the best care for some patients.
In “Don’t Homogenize Health Care,” Dr. Sandeep Jauhar denounced the lack of flexibility for practitioners to diagnose and treat individual patients. “In American medicine today,” he writes, “’variation’ has become a dirty word. Variation in the treatment of a medical condition is associated with wastefulness, lack of evidence and even capricious care. To minimize variation, insurers and medical specialty societies have banded together to produce a dizzying array of treatment guidelines for everything from asthma to diabetes, from urinary incontinence to gout.”
There are good reasons, he acknowledges, for consistency and the universal application of certain factors to certain situations, and that varying from them not only is unwarranted, but sometimes, he says, “deadly.”
He cites the example of a class of drugs called ACE inhibitors, which enlarge blood vessels and reduce blood pressure, making the heart’s job of pumping blood easier. These drugs are prescribed to heart-failure patients, but Jauhar says that only 2 in 3 U.S. physicians prescribe them to such patients. About 57,000 Americans die each year, he writes, because their doctors are varying from the best clinical practice.
But there’s also real danger in the unwillingness to vary from what’s been proved to be the best approach in most situations. “The effort to homogenize health care,” Jauhar writes, “presumes that we always know which treatments are best and should be applied uniformly. Unfortunately, this is not the case. The evidence for most treatments in medicine remains weak. In the absence of good evidence recommending one treatment over another, trying to stamp out variation in care is irrational.”
Jauhar is not new to ruffling feathers within his profession. As an intern he wrote a memoir and followed up with “Doctored: The Disillusionment of an American Physician,” about his residency at a prestigious New York City hospital where he described a crisis in American medicine.
As a cardiologist, he calls his field “a paragon of evidence-based medicine” in which “most treatment recommendations are based on expert opinions, not randomized controlled trials. Rarely is there one best option.”
Patient preferences, he suggests, also must be considered. “Medical decisions necessarily involve value judgments, and who better to make those decisions than the patient?” he asks. “If a fashion model doesn’t want curative surgery because it will scar her face, that may make sense in the context of her priorities. As a doctor, I may not agree with her, but I have to try to understand her reasoning and abide by her decision.”
As we regularly write, the practice of the best medicine is a collaborative effort between patient and doctor, and sometimes the collaborators hold different values, opinions and hopes for the future. Both must respect the perspective of the other in order to get the best outcome for the individual patient.
Jauhar believes that when a treatment recommendation comes from relatively weak science, the patient’s preferences should hold greater weight, “and the more variation you should expect to see. This is a basic conflict in modern medicine: treatment uniformity, which aims to optimize population health, versus treatment variation, which aims to respect individual choice.”
He accepts that it’s a conflict without an obvious solution, but that it’s likely to shape medical care in the near future.
This changing balance, of course, requires the provider to be frank with the patient about what he or she and the body of medical knowledge, actually know versus what we think it knows.
Most people aren’t science geeks; they need their doctors to be their honest partners. If they are, and if something goes wrong, it has been demonstrated that patients are much more likely to accept a poor outcome.
Unlike many arrogant, God-playing doctors, Jauhar is refreshingly frank about the medical profession’s shortcomings. “After spending nearly two decades in medicine,” he writes, “I am still amazed by how spare the evidence is on which we doctors base our medical decisions. Treatment guidelines, often accompanied by a de facto mandate, are frequently reversed.”
Yeah, they are. Jauhar offers the example of beta-blocker drugs. Only a few years ago they routinely were recommended for almost all patients undergoing noncardiac surgery. But new research has shown that the drugs might increase significantly the risk of stroke at the time of surgery.
“I remember colleagues questioning the beta-blocker recommendation for certain patients and being admonished for not being ‘evidence-based.’ I shudder to think,” he says, “how many patients were left disabled by strokes because of the blanket adoption of this standard.”
There’s no shortage of these “never mind” medical recommendations. Hormone replacement therapy for post-menopausal women once was prescribed widely, and now isn’t. Taking a daily aspirin for heart health is an ongoing debate. Science is a dynamic, evolving practice, and medical professionals have to accept that what’s right today might be proved wrong tomorrow.
Or at least wrong for some people in some situations.
Big brother plays a role here, Jauhar says. Many physicians chafe against being forced to apply guidelines and checklists or risk not being compensated by insurers and public underwriters. “Instead of being allowed to deliver ‘patient-centered’ care,” he says, “many physicians feel they are being co-opted by regulations. Some feel pressured to prescribe ‘mandated’ treatment, even to frail older adults who may not benefit. Guidelines are supposed to assist and advise. But all too often, recommended care in certain situations becomes mandated care in all situations.”
If you like a uniform liquid consistency, homogenization is always good for milk. It isn’t the same for people.