The Dangers of Guidelines & Recommendations

Guidelines are wonderful. Guidelines are dangerous – – ROBERT CENTOR, MD | July 2017

Over the past decade, I have thought often about the benefits and the problems of clinical guidelines. The first concept that attracted my attention was reading about conflicting guidelines.  

Given the same data, different guideline committees would have significantly different recommendations.  At the least, this problem raises questions about guideline validity.

It makes clear that committee perspective could influence recommendations.  

This is exactly what happened when the CDC opioid prescribing guidelines were ghost written by addiction specialists from PROP.  

Guideline recommendations sometimes are clear and demonstrably evidence based, but too often recommendations reflect the committee’s view of the problem.

The problem here is a long tail problem.  As physicians, we strive to know when a patient’s presentation is not routine.  Our challenge comes from knowing when we should switch from system 1 (or automatic) thinking to system 2 (deliberate) thinking.  What clues must we consider prior to using a guideline?

Too often we see patients with diagnostic labels and “perfect” treatment for those labels — e.g., CHF or COPD.

But when we consider the patient more carefully we see that the patient does not carry to correct diagnosis.  The treatment (guideline directed) is wrong because the diagnosis is wrong.

Perhaps guidelines should start with a very careful inclusion definition.  

  • So for acute pharyngitis perhaps we would require short duration (at most 3 to 5 days), and no red flag symptoms.  
  • For systolic dysfunction, we might define an inclusion ejection fraction.  
  • For COPD we should require full PFTs (to define obstruction and exclude restrictive lung disease).

I submit this is not a trivial problem.  

Guidelines become recipes, but recipes do not work with the wrong ingredients.

Like opioid prescribing guidelines for addicts don’t work for pain patients. 

Guidelines should not suppress the physician’s thought process.

The CDC opioid guidelines are being codified into strict dosage limits that restrict a physician’s options and preclude careful thought and balancing of benefits and harms.

Perhaps a great guideline would define the warning signs (or “red flags”) that should induce more careful thinking.  

As an academic perhaps I worry too often about zebras, but then working at a community hospital and a VA hospital, I sure seem to see them.

I often say the diagnosis is job #1.  

We need our guidelines to clearly define the relevant patients for that guideline.  

The guideline should direct us to return to the diagnostic process when the patient’s problem representation does not fit the illness script that the guideline defines.

When patients are not addicted to opioids, they should not be prevented from using them at whatever dosage is effective.

Author: Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.


2 thoughts on “The Dangers of Guidelines & Recommendations

  1. taylo138

    Guidelines are not rules, policies, laws or replacement for medical experience and judgement.
    I don’t know how the MME’s were created but I’ll give you my recent history:
    Initially, my pain specialist prescribed:
    MS Contin 15 mg. BID=30 MME
    (I felt no pain. BUT, I was seeing double, unable to function, plus the full histamine reaction “like the worst case of hay fever, ever.”)
    After 3 doses, I called the office and requested another appointment ASAP and stopped taking MS Contin returning the remaining 57 pills.
    The doctor changed my prescription to:
    50 mcg./hr. Fentanyl patch + 3-10 mg. Norco pills/daily. = 150 MME
    (Pain relief has decreased by 80%, I can concentrate, read, I’m doing intensive physical rehab daily, side effect: mild fatigue.)
    If my pain specialist went strictly by the guidelines; he would have placed me on a 12.5 mcg./hr. Fentanyl patch = 30 MME
    (Then, I would have called the office complaining that the patch wasn’t effective.)
    He must have known that the MME’s are not equivalent from his experience treating patients and rather than follow a “guideline” he treated me with the experience aquired over years of treating chronic, intractable pain.

    Liked by 1 person

    1. Zyp Czyk Post author

      The MME for the patches seems ridiculously high. I tried the fentanyl patches and didn’t get anywhere near the supposed MME worth of pain relief.

      Also, because people metabolize drugs differently, each opioid can have very different effects for different people, so the MME isn’t valid in real life with real people.

      Our medical system is trying to standardize, but at the same time, we’re learning how different people really are. What a mess!

      Liked by 1 person


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