Sunday, May 10, 2015

"Best practice" guidelines

For all their talk about evidence-based medicine, a lot of doctors don't follow the clinical guidelines set by leading medical groups...

So, even in the midst of good science and a clear consensus on what should be done, a lot of physicians don't follow the "best practice" guidelines.

Now, imagine what happens when the science isn't clear...

"There's really a lot more ambiguity about what is the right thing — what's appropriate [and] what's not appropriate," says Dr. Albert Wu, an internist and professor at the Johns Hopkins Bloomberg School of Public Health.

In cases like these, Wu says, doctors are more likely to follow their gut instincts. And when that happens, fear often comes into play.

Imagine, for example, that a healthy, 40-year-old woman walks into your office and asks about a mammogram.

"If that woman were to develop breast cancer or to have breast cancer, you can imagine what might happen to you if you didn't order the test," Wu says. "Maybe you'd get sued."

Doctors often hear stories like this, he says, and that can affect their judgment.

"Emotion and recent events do influence our decision-making," he says. "We are not absolutely rational, decision-making machines."

See:  Oliver D. Schein, M.D., M.P.H., Joanne Katz, Sc.D., Eric B. Bass, M.D., M.P.H., James M. Tielsch, Ph.D., Lisa H. Lubomski, Ph.D., Marc A. Feldman, M.D., M.P.H., Brent G. Petty, M.D., and Earl P. Steinberg, M.D., M.P.P. for the Study of Medical Testing for Cataract Surgery.  The Value of Routine Preoperative Medical Testing before Cataract Surgery,  N Engl J Med 2000; 342:168-175


  1. Great advice from Dr Jarvinen. His is one of those landmark studies that should change the world. Patients beware before accepting the knife. Insurance companies take note in establishing standards for reimbursement. Guideline makers insert watchful waiting and rehab before recommending surgery. And surgeons, adjust your practice.

    Everyone talks about evidence-based medicine, but often there is a long time lag before compelling evidence actually has an impact on clinical practice. This is bad for the patient, bad for the health care system, and bad for society.

    We shouldn’t continue doing senseless, expensive, and potentially harmful procedures just because they produce a strong placebo effect.

    My knees are aching a bit as I write this and certainly make themselves known every time I climb up a flight of stairs. None of my body parts works as well as they once did. And my mind seems increasingly to be out to lunch.

    Aging will do that to you. There is not a medical or surgical solution to the wear and tear of life. If you have bum knees, think exercise and weight loss before submitting to the knife.

    See today's (5/11/15) comment on Placebo March 20, 2015.

    See more at:

    Sihvonen R, Paavola M, Malmivaara A, Itälä A, Joukainen A, Nurmi H, Kalske J,
    Järvinen TL; Finnish Degenerative Meniscal Lesion Study (FIDELITY) Group.
    Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med. 2013 Dec 26;369(26):2515-24.

  2. People who go to the doctor for headaches are increasingly likely to be sent for advanced testing and treatment, a study finds. That testing is expensive, it may not be necessary and it could even be harmful, says lead researcher Dr. John Mafi, of Beth Israel Deaconess Medical Center in Boston.

    Mafi looked at the rates of advanced imaging like CT scans and MRIs in people with headaches, as well as referrals to other doctors, presumably specialists. He found that from 1999 to 2010, the number of diagnostic tests rose from 6.7 percent of all doctor visits to 13.9 percent. At the same time, referrals to other doctors increased from 6.9 percent to 13.2 percent. In other words, almost double what it was a decade ago.

    Mafi says this isn't because more people are suffering headaches. The headache rate has remained virtually the same over the past decade. But what has changed is supply and demand. Today there are a lot more advanced diagnostic machines than there were a decade ago, and more patients are asking to be tested.

    "Patients are more assertive than ever before," Mafi says. "They do research online, are more informed and sometimes go to the doctor demanding, 'I think I need an MRI.' "

    And while an informed patient is a good thing, Mafi says sometimes the patient gets it wrong. "I think there's a subconscious perception that more is better, and that fancier, more expensive tests are better and that equals better care."


    Mafi JN, Edwards ST, Pedersen NP, Davis RB, McCarthy EP, Landon BE. Trends in the Ambulatory Management of Headache: Analysis of NAMCS and NHAMCS Data 1999-2010. J Gen Intern Med. 2015 May;30(5):548-55.