Sunday, April 6, 2014

Why I don't Always Follow Guidelines, My Response To Barron Lerner

Barron Lerner thinks he understands doctor's motives.  In his recent article in the Atlantic he laments that physicians act on tradition and emotion over adopting new science.  In defense of his position, he sites the example of how cardiologists use angioplasty and coronary artery bypass to treat coronary disease.  He states:

cardiologists have been remarkably slow to abandon the old hypothesis, continuing to perform hundreds of thousands of bypass operations and angioplasties annually not only in the setting of heart attacks (when they are appropriate) but also to try to prevent them.

He, of course, makes this statement without acknowledging that scientific data has only become more clear on such issues in the last ten or so years.  He ignores the fact that this has been an area of great controversy in which experts and the not so scientific guidelines disagreed over decades.  In other words, it's not that greedy doctors were just breaking the rules as a ploy to make money, there were actually highly respected leaders on both sides making persuasive arguments.  And furthermore, just because a cardiac intervention isn't in the setting of an acute heart attack, doesn't mean it is not appropriate.  

Lerner then pivots to discuss the new cholesterol and hypertension guidelines.  

In the case of cholesterol, the new guidelines, promulgated by a joint American College of Cardiology-American Heart Association task force, discourage the standard practice of checking patients’ cholesterol counts and choosing among a series of medications to lower them to specific levels. Instead, the group recommends treating all patients who fall into specific risk groups with a particular agent—the statins—and not following their levels.

What he fails to mention is that these guidelines have changed over the years based not on any new evidence, but more on the whims of the so called "experts" chosen to give their opinions.  These are the same experts who told us to shoot for an ldl of 70, treat low hdl with niacin, and use non statin lipid lowering drugs like Zetia.  All of which have fallen out of favor.  These are also the same experts who often make an income consulting for pharmaceutical companies who stand to benefit from such guidelines.  

The same can be said from the hypertension guidelines.  It seems every year some group is telling us what we should be shooting for which is often a new, random number.  The data, however, most of the time is lacking.

The problem is, the latest scientific data/theory is often wrong.  Their are countless examples of this in the literature.

Many anti arrythmics killed people.
Raising HDL cholesterol did not benefit anyone.
Vitamin E is useless.
Measuring homocysteine and CRP are rarely helpful.
Vitamin D does not treat heart disease!

The job of a physician is to evaluate the data and use this information to benefit his patients.  We are not expected, or required, to blindly follow guidelines.  So you'll have to excuse me if I'm not jumping to follow the new cholesterol dictates.

I didn't when I was told to get every one's LDL down to seventy.  I didn't when I was pushed to use gemfibrozil and niacin.  And I sure as hell won't now, until the scientific data that went into such decisions makes sense.


Anonymous said...

The problem is that there is a lot of time I've seen myself and others misdiagnosed because the medical literature was right and they didn't know it.

The medical community should be able to explain why these new guidelines were created by the "experts" for the reason you stated above: not on a lot of solid data.

What I don't understand is why the medical community doesn't want to accept several years of solid evidence from various double blind or the like studies (no matter how new or old it is) but it is ok for one doctors' "experience" to be used to determine someones' fate.

This also begs the question: how is the medical community learning when they're not trusting their own literature? How does one persons' experiences, if they have no experience in something, diagnose or treat someone? Do you just dump them, let them suffer? I see that a lot.

Anonymous said...

WOW "anonymous"

I think the major misconception is that you don't see experience as a valuable tool. The point of the blog was just how much experience matters. You mention "solid evidence from various double blind or like studies" implying that this is equal to TRUTH. The point of the article is that many studies over the years contradict themselves, even the all-powerfull, 1billion% correct "double-blind." An MD must evaluate every study with a critical eye and determine if his patients could benefit. People are not widgets. As of yet, we can't run them as clones to refine experiments & treatments. So in the end, it is the MD that has to make the call. It is his/her experience. Medicine is an art, not a science. Even for the super-super specialist, it is an art.

james gaulte said...

When I see the latest study or guideline proclamation I cannot help but say, at least to myself, the old attorney question to an expert witness when he has been caught in an apparent contradiction; Doctor, were you wrong then or are you wrong now?