The intent is admirable: Give doctors guidelines so they can be sure to cover what needs to be discussed with patients and help select options. Let’s talk about your diet and any problems you might have sleeping. Are you getting enough exercise? If not, here is some advice. You are due for colon cancer screening. Do you prefer a colonoscopy or a fecal test? Here are the pros and cons of each.
But there is a problem. There are just not enough hours in a workday to discuss and act on all the guidelines.
Suppose an American doctor wanted a gold star when seeing patients and followed all of the guidelines for preventive, chronic and acute disease care issued by well-known medical groups. That could require nearly 27 hours per day, a team of doctors wrote in a study last year for the Journal of General Internal Medicine.
No one could actually do that, so imagine a doctor shrugged off the chronic and acute care, as well as administrative work, and merely followed the preventive care checklist recommended by the U.S. Preventive Services Task Force, an independent panel of health experts. That would be 8.6 of the doctor’s hours each day, according to a study in the American Journal of Public Health.
As anyone who has been sped through a 15-minute annual wellness visit knows, doctors cannot be so exacting. That the guidelines are so thorough yet so often glossed over prompts questions about their usefulness. At the same time, doctors’ pay often depends on checking off guideline boxes.
“Is this an issue? Absolutely,” said Dr. Michael Pignone, a former member of the Preventive Services Task Force and chairman of the department of internal medicine at the University of Texas at Austin’s Dell Medical School.
“Suffice it to say that what has been incentivized isn’t always what delivers the most health or benefit,” Dr. Pignone said.
Guidelines have become “a constant frustration,” said Dr. Minna Johansson, a general practitioner in Uddevalla, Sweden, who also directs the Global Center for Sustainable Healthcare at the University of Gothenburg. She worked with doctors in other countries on an analysis of the issue that was published last month in BMJ. “A lot of guidelines may seem reasonable when considered in isolation,” Dr. Johansson said. “But the cumulative burden of all guideline recommendations combined is absurd.”
Dr. Johansson was inspired to study the issue working in a small town on Sweden’s west coast.
“I have a yearly visit with my patients,” she said. Spending that precious time discussing a lifestyle prescription that, however well meaning, is unlikely to change a patient’s habits, is of dubious value, she said. And, she added, it “crowds out more important discussions.”
“Maybe the patient smokes or has suicidal thoughts,” she said.
And, she added, many guidelines, like those for extensive discussions about improving exercise habits or diet, have not been shown to result in important health benefits.
Dr. Johansson worked with Dr. Gordon Guyatt of McMaster University in Hamilton, Ontario, and Dr. Victor Montori of the Mayo Clinic in Rochester, Minn. They argue that this problem affects medical systems throughout North America and Western Europe.
In Norway, for example, guidelines for assessing and treating high blood pressure apply to the nearly three-quarters of adults with pressures above the goal of 120/80. If the guidelines were strictly adhered to, patients would need so many regular follow-up visits that accommodating them would require more general practitioners than are currently working in Norway.
And implementing all the British guidelines for improving patients’ lifestyles could require more doctors and nurses than are practicing in the entirety of Britain.
The researchers say that guideline makers should consider what the study calls “the time needed to treat” — how much time it takes to implement a guideline.
For example, they say, the British guideline on assessing a patient’s physical activity would take 15 percent of a doctor’s visit to implement, but there is no evidence it would improve long-term health. That, they say, might suggest the guideline should be jettisoned.
Dr. Carol Mangione, chair of the U.S. Preventive Services Task Force, said the task force considered the time guidelines take. And nowhere is it suggested that doctors try to tick off each guideline recommendation in a single visit.
“Clinicians do not — and would never be expected to — implement all of the suggested screenings, counseling services, and preventive medications in a single patient visit,” Dr. Mangione wrote in an email. “When caring for patients, clinicians use both their judgment and the information obtained during conversations with each patient to prioritize which preventive services should be offered during each visit.”
Even that is not easy, said Dr. Daniel Jonas, director of the division of general internal medicine at Ohio State University.
Guidelines can serve a purpose, Dr. Jonas said. “I think they’re incredibly helpful,” he added. But, he said, “deciding what to prioritize in a busy primary care practice is a big challenge.”
Dr. Montori added another complication.
“To assume that patients and clinicians can sort and prioritize recommendations over multiple visits,” he said, “wishes away the fundamental problem that many patients cannot get primary care, see the same clinician or have unhurried consultations.”
Dr. Pignone said that some of the burden should be shared with other professionals, like nutritionists, who can talk to patients about healthy diets. But, he said, that is only a partial solution. He’d like to see current recommendations prioritized by their impact on health and on their cost effectiveness. As examples, he said, childhood immunizations would rank high but existing guidelines to give tetanus boosters to adults who already had tetanus shots would rank lower.
Dr. Guyatt said guidelines should be held to the same standard as new drugs. Before they are implemented, there should be evidence that they are helpful.
“Somebody might say, ‘Oh, a new drug has side effects but what harm is there in this guideline?’” he said. “But yes, there is real harm. There is a trade-off between doing things that are actually useful and spending time on things that are useless.”
Gina Kolata
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