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It appears to me that many of the criticisms of guidelines
mentioned in this thread are things I wouldn’t necessarily think should
be directed at the concept of clinical guidelines, but rather they point out
the pitfalls of inappropriate use of guidelines. I think the wording that Carlos
quoted from the Pantell article is worrisome, in that the author appears (I
confess I haven’t read the full text yet) to contrast
individualized clinical judgment with guidelines. I would hope that guidelines would
be consulted to help the physician develop their best clinical judgment
individualized to a particular patient’s context, such that these two
sources of information should work in concert, not in opposition.
I also think that somehow penalizing physicians for lack of
adherence to published guidelines in the context of treating a particular
patient would be a significant misuse of guidelines in the name of quality
measurement. This could have the unintended(?) effect of paralyzing innovation
and turning all clinicians into technicians, rather than problem-solvers. On
the other hand, the application of quality measurement to practice patterns
does seem to have some potential value. If one consistently deviates from
practice guidelines and their patients consistently have poorer outcomes than
their peers, then I think we would do well to explore whether that pattern
might need to be changed. Perhaps that clinician’s patients are somehow
different from their peers. It does seem, though, that most good quality
measures provide for exclusion of inappropriate patients such as described by
Dr. Shaneyfelt. By assessing quality of care in patient populations, rather
than at the individualized patient level, hopefully confounders such as patient
refusal or non-compliance would even out. If not, then perhaps right there is a
problem that needs to be investigated further.
-Rob
Rob Mullen
Director
National Center for Evidence-Based Practice in Communication
Disorders
Washington, DC
United States
From: Evidence based
health (EBH) [mailto:[log in to unmask]] On Behalf Of Dr.
Carlos Cuello
Sent: Wednesday, September 02, 2009 1:51 PM
To: [log in to unmask]
Subject: Re: EBM and increasing requests for the use of consultants...
“An expert is a
man who has made all the mistakes which can be made, in a narrow field.”
- Niels Bohr
I once said to my students "clinical guidelines are for dummies"...
ie, if I am a rookie inexperienced physician in a rural area, taking care of a
2 month old baby with fever, I will go with the guidelines and I am pretty sure
I will do more good than harm following a good guideline than not following it.
On the other hand, if I am an experienced paediatrician I will rarely see the
guideline on EVERY patient with fever I see, perhaps only when it is recently
published and to see what is new and what the course of action
"should" be, as I know it is based on the best evidence available.
Difficult thing is how to make physicians (novice and experts alike) to be
up-to-date with clinical guidelines for every condition?
I quote an article by Pantell et al:
Pediatric clinicians in the
United States use individualized clinical judgment
in treating febrile infants. In this study, relying on current clinical
guidelines would
not have improved care but would have resulted in more hospitalizations and
laboratory
testing.
JAMA. 2004;291:1203-1212
Would this be true in other
areas?
If I am on a rural area (whatever the reason) and it happens that I have to
attend an acute myocardial infarction in a 60 y.o. man, I better follow a
clinical guideline, as I am not an expert on that field any more.
I like Ben´s idea about expertes in EBM (evidologists?)
On Wed, Sep 2, 2009 at 12:15 PM, Djulbegovic, Benjamin <[log in to unmask]> wrote:
thanks, Felice
it appears from your and other response that it is content (and context) that
matters. This is probably a reason why people do not consult guidelines outside
their fields. This is certainly true for me: I rarely consult guidelines
outside of my field, while I do consult hem-onc guidelines often (even those
that I helped develop!) particulary when I want to deviate from the guideline.
Time is a key factor, since I am so familiar with guidelines in my own field
and I can find what I am looking for within 1-2 minutes, while it would
probably take me 20-30 minutes to understand/consult the guideline outside of
my own specialty. I should also mention that (outside giving cancer-specific
treatments and some other treatments that are outside of purview of
generalists, e.g. treating hemophilia...) >90% cases in which I am asked to
give second opinion/consult relate to providing information/evidence to the
questions requested in the referrals. Since all available information to me are
equally accessible to anyone else ("there is no secret knowledge in
medicine"- I often tell to the referring docs and patients alike), in
theory docs could just dial EBM services and get the answers to the questions
asked? But such services will be devoided of the context/content. So, ultimately
content will always win...I think what EBM movement ought to do is to re-focus
effort from generalists and consumers to train suspecialists
("experts") in EBM methods...
ben
________________________________________
From: Evidence based health (EBH) [[log in to unmask]]
On Behalf Of [log in to unmask] [[log in to unmask]]
Sent: Wednesday, September 02, 2009 6:01 AM
Subject: Re: EBM and increasing requests for the use of
consultants...
Hi Ben and Others,
Very interesting discussion here.
I think that evidence based guidelines are not easy to develop and use. That's
why Ebguidelines production is not in CME and educational programs for health
care workers. EBguidelines need to be continuously updated and adapted. More
over there is no interest in health care managers and directors to use
Ebguidelines adopted in real practice as evaluation criteria for physicians,
consultants, referrals and so on. Is there no trust about Ebguidelines use is
correlated to better outcomes for patients?. There is no clear policy about
this.
So i do not think EBM rising (as EBguidelines use in real practice) can justify
requests of the use of "experts" . It is true the contrary.
Felice Musicco
Hospital Pharmacist in Rome, Italy
www.ifo.it
---------- Initial Header -----------
From : "Evidence based health (EBH)" [log in to unmask]
To : [log in to unmask]
Cc :
Date : Wed, 2 Sep 2009 08:09:21 +0530
Subject : Re: EBM and increasing requests for the use of consultants...
> Forwarding this message from Scot who is unable to register for this list
> but is responding to the discussion:
>
> Rakesh, I probably cannot post to the EVIDENCE-BASED-HEALTH group, so
please
> pass this along:
>
> *The need for information is often much more than a question about medical
> knowledge. Doctors are looking for guidance, psychological support,
> affirmation, commiseration, sympathy, judgment, and feedback. This
> "information need" is particularly poorly explored
> *
>
> I strongly agree with the above passage, find it quite novel and apropos,
> but foresee even greater difficulties "selling" this information
need to the
> IT and finance personnel who generally control information tools in the
> enterprise. For example, at the link below is what occurred at one
of the
> largest pharma research labs in the world, where selling the idea that
drug
> discovery scientists needed the best informatics tools fell flat.
Not
> intuitive, but that's the way it was.
>
> See:
>
> "Sure path to R&D failure: Conflation of IT with
information science in the
> pharmaceutical industry"
> http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=pharma
>
> Scot
>
> --------------------------------
> Scot M. Silverstein, MD
> Consultant in Medical Informatics
> Teaching faculty in Healthcare Informatics and IT (Sept. 2007-)
> Director, Institute for Healthcare Informatics (2005-7)
> College of Information Science and Technology
> Drexel University
> 3141 Chestnut St.
> Philadelphia, PA 19104-2875
>
> Email: [log in to unmask]
> Bio: www.ischool.drexel.edu/faculty/ssilverstein/biography.htm
> Common Examples of HIT difficulty:
> www.ischool.drexel.edu/faculty/ssilverstein/medinfo.htm
> ARS KU3E, member www.arrl.org
> ________________________________________
>
--
Carlos A. Cuello-García, MD
Director, Centre for Evidence-Based Practice-Tecnologico de Monterrey
Cochrane-ITESM coordinator. Professor of Paediatrics and Clinical Research
Avda. Morones Prieto 3000 pte. Col. Doctores. CITES 3er. piso,Monterrey NL,
México. CP64710
Phone. +52(81)88882154 & 2141. Fax: +52(81)88882019
www.cmbe.net
http://twitter.com/CharlieNeck
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