Like many health publications, the UC Berkeley Wellness Letter and BerkeleyWellness.com often report on the release of major clinical guidelines from leading professional medical associations and government bodies. We recently looked at updated guidelines for managing cholesterol from the American College of Cardiology and the American Heart Association (ACC/AHA). In 2017 we reported on the controversial revised guidelines regarding blood pressure from ACC/AHA, which lowered the cutoffs for hypertension. We’ve also discussed many guidelines from the influential U.S. Preventive Services Task Force (USPSTF), an independent panel of experts appointed by the federal government to make recommendations about preventive measures, such as screening for cancer, osteoporosis, depression, and heart disease, as well as about aspirin or hormone therapy.
While I have great respect for the efforts of these groups, it’s impossible not to have mixed feelings about such guidelines and the role they play in medical care.
When I started practicing medicine more than 40 years ago, there were fewer official clinical guidelines and they were not such powerful influences on medical care. Such guidelines, devised by experts in particular fields, serve worthwhile purposes. They identify and evaluate the latest and best evidence about prevention, diagnosis, and treatment, taking into consideration risk/benefit ratios and sometimes cost-effectiveness. They answer key questions about clinical practice and often contain helpful decision algorithms. Many guidelines rank treatment options into categories (based largely on the strength of evidence) as a shortcut to help practitioners decide which ones to use.
Clinical guidelines are also meant to standardize medical care in ways that improve quality and reduce risks. But the idea of standardized medicine is problematic. No matter how many variables the guidelines try to take into consideration, the art and practice of medicine requires experience and clinical judgment—leading to individualized decision making. Guidelines can have a profound leveling effect, especially for practitioners who are less inquisitive or simply don’t have enough time or energy to keep up with the medical literature in all of the fields they deal with. They can also be used as a cudgel by, say, hospitals and insurance companies to maintain standards (good or questionable ones) and keep costs down. What’s more, guidelines largely represent the beliefs and opinions of their expert authors, who have to compromise to reach a consensus that their organizations will find acceptable.
As my colleague on the Wellness Letter Dr. William Pereira suggested to me, excessive reliance on guidelines seems to have “shifted us from a ‘doctors as cowboys’ to a ‘doctors as cattle’ paradigm.”
Clinical guidelines should be seen just as starting points. They are intended to help you and your health care providers make decisions, not to dictate them. They should be evaluated and compared to guidelines from other groups. When our editorial board reviews new guidelines in preparation for our articles, we often have divided opinions and sometimes end up questioning at least parts of the guidelines. I remember having a debate in 2012 about the USPSTF recommendation against PSA screening for prostate cancer, which we questioned in our article and which was softened in revised guidelines five years later. We have written about how cholesterol guidelines from ACC/AHA and USPSTF vary, and how mammogram guidelines differ among major expert groups (notably in terms of annual or biennial screening). Various expert groups continue to disagree with recent changes in the ACC/AHA hypertension guidelines—for good reason, as I discussed in this column.
Doctors should compare the various guidelines and pick and choose among the recommendations based on their own experience and judgment. Patients should also be aware of the influence exerted by guidelines and make sure that their doctors discuss them and take into consideration their specific circumstances as well as their values and preferences.
This article first appeared in the UC Berkeley Wellness Letter.
Also see Screening Tests: How Old Is Too Old?