Tuesday, May 21, 2013

Who's guiding the guidelines?

How does everyone feel about guidelines?  I have recently started working with a physician who disputes these guidelines.  He has some very valid points and he has been in practice for many years, so these points are intelligent and well thought out.  The problem comes in where my training is based primarily on following the guidelines.  If you don't follow the guidelines, then you may be held accountable in a law suit.  I was trained, if you follow the guidelines, they will set you free (with in reason).

 As I look at the hard data, the guidelines also make sense.  I feel that the future of medical care in America has to look at the risks and benefits of having or not having certain tests done.  They also have to look at cost effectiveness.   Is educating the patients regarding the guidelines enough to allow them to make their own decisions? Is an expected life span of 10 years or less enough reason to encourage people to stop screening?  I would think that if I could get 10 more years with the people I love, that would be a good thing, but is it good enough for the government to approve payment for your testing?  Is a lifetime worth more than a healthcare spending budget or the other way around?

From a medical standpoint when the numbers are showing that testing 100, 000 we will catch only a small percent, then why bother, it doesn't sound so bad.  However, when you are sitting across from a patient that landed in the 1-10% and you have to tell them that they are going to die because we didn't screen for this, it doesn't seem so rational now.  My employer has some stories like this.  He has tested patients outside the guidelines and caught quite a few prostate cancers in the early stages in men under the age of 45.  He has many years in Medical Practice, looks at the research and the numbers, but he has been in that chair across from patients that would otherwise not have been screened.

My collaborator and I are constantly debating about the new gynecology guidelines and whether to pap or not.  He disagrees with the 21 and up first time pap smears for sexually active women and young girls.  Should they be subjected to a screening exam because they are being responsible and seeking birth control methods?  Does the birth control effect the changes in cervical cancer or the progression of HPV into invasive cancer enough to withhold until further testing is sought and that would include further invasive procedures?  Furthermore the guidelines never suggest discontinuing OCP usage in women who do test positive with HPV high risk or otherwise.

As I struggle with the decision to base my practice on guidelines or not, I wonder who will be "set free."  I started this article 2 months ago and as I struggle to get tests ordered for my patients and insurance companies are arguing with me. They insist on negotiating to get more tests done instead of just covering the test that I am ordering, now I begin to see the light that is "guiding" my collaborating physician.  I know better than to challenge him on most subjects, because he has 25 years of practice over me, but that doesn't mean that I'm going to stop trying.

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