The Guideline-Care Barrier

Practicing medicine is an inexact science and it has never been easy. There is an undercurrent of disagreement that goes on in academic teaching centers between the professors and the local practicing physicians. As we discussed earlier, the Choose Wisely program was an attempt to use scientific data to compile a list of commonly ordered medical procedures, which may not benefit patients.

It is very easy to write the guidelines but, as a frontline physician, there are many barriers to implementing them. One of the ways that physicians make decisions is by intuition or by doing things the way they have always done it.

If you follow the guidelines presented by 10 specialty organizations, I suspect it will come directly in conflict with how you, your colleagues, or your residents practice. It may even come into conflict with your own belief systems which, as I pointed out earlier, may be adversely influenced by intuitive thinking and bias. Having said that, I am going to present some of the guidelines, which you may or may not agree with but should certainly give you reason to think carefully, investigate further, and discuss.

These guidelines were created from specialists in various medical organizations and might therefore be considered suspicious by local practicing physicians. This is a so-called town versus gown conflict. It goes both ways with some of the university physicians being the worst offenders of overtreatment and some of the community physicians being the worst offenders of either under or overtreatment.

I think, though, it is fair to say that one of the major problems in American medicine is not undertreatment but rather overtreatment.

Here is a sampling of recommendations from the Society of Orthopedic Medicine:

1. Do not obtain spinal imaging for patients with acute low back pain for at least 6 weeks in the absence of red flags. There is no evidence to suggest that radiologic procedures in patients who do not have obvious red flags aid in the diagnosis. Red flags might include progressive neurologic symptoms, events that produce traumatic thrusts to the spine, fever, cancer, and in patients with risks for osteoporosis.
2. Do not prescribe lumbar support braces for the long-term management or prevention of low back pain. While there may be some limited benefit in short-term treatment, numerous studies have found that there is limited value for this practice and may even make the patient weaker.
3. Do not recommend splinting postoperatively for carpal tunnel patients long-term.

From the American College of Cardiology comes following recommendations:

1. Do not perform stress cardiac imaging or advanced noninvasive imaging in the initial evaluation of patients without cardiac symptoms unless high risk markers are present. Asymptomatic low risk patients account for up to 45% of screening testing. Testing should be reserved for those patients with diabetes older than 40, peripheral artery disease, with high coronary artery scores.
2. Do not perform annual stress cardiac imaging or advanced noninvasive imaging as part of routine follow-up with asymptomatic patients. This practice may lead to unnecessary procedures, radiation exposure, and further tests that are not warranted. An exception to this rule would be a patient more than 5 years after bypass operation.
3. Do not perform cardiac stress imaging or advanced noninvasive imaging as preoperative assessment in patients scheduled to undergo low risk noncardiac surgery.
4. Do not perform echocardiogram as routine follow-up for mild asymptomatic native valve disease in adult patients with no change in signs or symptoms. An echocardiogram is not recommended yearly unless there has been a distinct change in symptoms
5. Do not perform routine EKG screening as part of preoperative preprocedural evaluations for asymptomatic patients with low perioperative risk of death or myocardial infarction. Studies have shown that most of these tests do not reveal anything and there is a high probability of false positive tests, which may counterbalance any potential benefit. The routine ordering of an EKG should be avoided.

From the American Academy of Neurology comes the following recommendations:

1. Do not recommend EEG in the routine evaluation of headache. EEG has no advantage over clinical evaluation diagnosing headache.
2. Do not perform imaging of the carotid arteries for simple syncope in the absence of other neurologic symptoms. Occlusive carotid disease does not cause fainting but rather causes focal neurologic deficits such as unilateral weakness. History is probably the most important factor in determining a diagnosis of syncope. An exception might be the rare patient who has bilateral highly significant stenosis of the carotid arteries.
3. Do not use opioids or butalbital treatment as the initial treatment of migraine. These drugs should be avoided because more effective migraine specific medicines are available and frequent use of these medicines can also lead to rebound headaches.

From the American Academy of Nursing comes following recommendations:

1. Do not let older adults lie in bed or only get up to a chair during their hospital stay. Up to 65% of adults who were previously mobile will lose their ability to walk during the hospital stay. Loss of walking independence increases the length of hospital stay, the need for rehab, and for nursing home placement. The deconditioning, which is caused by a week’s hospital stay, may take 6 months to undo.
2. Do not use physical restraints on older hospitalized patients. Restraints tend to cause more problems than they solve. It is better to involve family members or added staff members to keep the patient safe. Often the belligerence exhibited by some elderly patients is due to some distress they are having and discovering what that is may solve the problem.
3. Do not wake the patient up for routine care unless the patient’s condition or care specifically requires it. Studies show repeatedly that sleep deprivation in hospital patients affects circulation, immune status, and functional abilities. One the most absurd observations I have witnessed is waking patients up from sleep in order to give a sleeping pill or take a blood pressure reading.
4. Do not place or maintain a urinary catheter in the patient unless there is a specific indication to do so. When the catheter is placed, remove it as soon as possible.
5. Do not automatically assume that the patient who requests pain medicine is drug seeking. Painful conditions are better treated by the regular administration of narcotics rather than having patients wait long periods of time in order to receive them.

Some of these recommendations are common sense but some of them may be counter to hospital policy or how you were taught. Overall there were 245 pages of recommendations published and this is only a sampling. It is not always easy to do what you think is right. In order to know what you are doing is right, however, you need to study and learn about various procedures and how things change.

Do not just assume that the way you have always done things is the way they should be done. Lastly, do not assume that doing the right thing is always going to be the easiest thing to do.