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Ben this is difficult - that's why its interesting but faced with a diabetic hypertensive asthmatic arthritic that is what we do - merge the data from guildeines and then discuss with the patient the options - (I had not forgotten the patient preference - just need to work out the options to present to them) This will remain a guide - but at least some of the options available to the more complex patient will be readily available, and possibly based on evidence - I love that story of having your own guideline coming back to bite you - a warnming message that is heeded! Martin ________________________________________ From: Djulbegovic, Benjamin [[log in to unmask]] Sent: 09 September 2009 08:28 To: Djulbegovic, Benjamin; Martin Dawes, Dr.; [log in to unmask] Subject: RE: Guidelines - we should only have one Somehow the original reply got cut in half.. -- Martin, even if your proposal is technically feasible, you are betting that the number of clinical presentations is FINITE- a questionable assumption, in my opinion, particularly if one can take into account patient preferences... It may, however, be possible to develop something along the lines you are proposing for limited number of conditions...For better or worse, the approach will also not succeed in developing "idiot-proof" guidelines, which is what the administrators want us to do...The problem of induction or applying of "averages" to individuals as highlighted in Frederico's and Liliya's post, will remain with us for ever, I am afraid... Ben Ps In less drastic example that in the one in case which started this thread, I remember the insurance company denying coverage for the treatment when I wanted to deviate from the guideline citing guideline that I developed! -----Original Message----- From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Martin Dawes, Dr. Sent: Wednesday, September 09, 2009 7:22 AM To: [log in to unmask] Subject: Guidelines - we should only have one I think we should stop using the plural for guidelines. I only have one patient in front of me - I need one guideline - asthmatic, colon polyps, diabetic, hypertensive with arthritis, an amputation of left lower leg, a prosthesis and complaining of problems walking her dog. I need to consider nutrition, obesity, exercise, ARB/ACE, aspirin etc etc - but I cant read and remember every guideline including all the cancer follow up ones. I need one guide for every combination of problems. Of course this may make no difference to outcome in primary care (scary thought) but I thought I would share that a group of us are working on this and have reached the stage of grant submission. It may seem an impossible task but if we look at all the recommendations, assess the evidence using GRADE looking at all the various patient subgroups (did they include diabetic amputees in their hypertension study for example?), and then come up with a single patient based guide maybe this might help me in my clinic with the one patient. This guide will probably be electronic but not necessarily. Will it work? Cannot be certain, but I do know that I don't even know where all the guidelines I should be using are in my office, let alone use them - so I think one guide will work better than 100. Am I serious - yes. After all what I do with my patient is exactly this process but in a far less robust way. I try and remember the 20 or so most relevant guidelines with their 100 or so steps in each while seeing my one patient. I think about aspirin, ACE/ARB, smoking, BMF, mammography, etc and try and cobble together some sort of primary screening, primary prevention, secondary screening, secondary prevention approach as well as dealing with the presenting complaint. I am in effect combining 20 or so guidelines into one 10 minute approach to care. This is why we need one guideline. Martin On 09/09/2009 02:27, "K. Hopayian" <[log in to unmask]> wrote: Definitions of guidelines usually contain a phrase that they do not replace practitioners' judgement, for example, the NICE definition "They are based on the best available evidence. Guidelines help healthcare professionals in their work, but they do not replace their knowledge and skills" Sounds good but I have always wondered how this fits in with NICE guidance on specific treatments (technology appraisals) which ARE binding on health care organisations. In the past, the director of NICE threatened that legal action would be taken against those who did not use approved technologies. Does anyone on this list see a difference between guidelines that tell you in which conditions a treatment should be used and guidelines that tell you which treatments to use in certain conditions? Kev Hopayian On 9 Sep 2009, at 04:41, Alejandro Piscoya wrote: Guidelines are quite interesting tools but they need to be used thoughtfully. This is why they just guide and are flexible, there is always room for individual cases where physicians need to think and take decissions taking into account their patientīs opinion. As EBM, guidelines are not cookbook recipes, this example shows that bluntly. The issue here is, assuming the news is not too biased, why this guideline is followed so rigidly and what to do to avoid this... Alejandro On Tue, Sep 8, 2009 at 12:08 PM, Ted Harding<[log in to unmask]> wrote: I know it's a Press story, but ... http://tinyurl.com/nojsbu If the main points in the stgory are accurate, then this is surely a disastrous example of adherence to guidelines. Ted. -------------------------------------------------------------------- E-Mail: (Ted Harding) <[log in to unmask]> Fax-to-email: +44 (0)870 094 0861 Date: 08-Sep-09 Time: 18:08:24 ------------------------------ XFMail ------------------------------