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On Being a Doctor |

The Tyranny of GuidelinesThe Tyranny of Guidelines

George A. Sarosi, MD
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From Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota.

Requests for Single Reprints: George A. Sarosi, MD, Minneapolis Veterans Affairs Medical Center, One Veterans Drive, Minneapolis, MN 55417; e-mail, george.sarosi2@va.gov.

Ann Intern Med. 2015;163(7):562-563. doi:10.7326/M15-1202
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Fans of the “Prairie Home Companion” probably believe that Minnesota is densely populated with Norwegian bachelor farmers. However, I never met one until Mr. O was admitted to my medical service.





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Posted on October 7, 2015
Brian Pollak
WellSpan Health
Conflict of Interest: None Declared
This story is unfortunate on multiple levels. The timing and presentation certainly suggest that aggressive medical management was a disservice to this gentleman and resulted in his fall, fracture, and loss of independence.

It is hard to say that the persuit of quality metrics was what drove the medication adjustments. A1c control measures usually focus on ages 18 - 75, and blood pressure control measures usually focus on ages 18 - 85. This patient's age is outside of the measures' specifications.

We often recall cases similar to this supporting the idea that quality measures don't apply to our patients. I'm not trying to say that they do, but our recall bias is strong. We just don't know how fair the quality measure is until we know our patients as a population. Get a list of your patients who are not meeting a quality measure. Review that list and ask if there are legitimate reasons that the measure does not apply. When we do this we certainly find people who should not be aggressively managed, but we find more people in whom the disservice is our clinical inertia or unreliable systems.
Agree with Brian
Posted on October 8, 2015
Bradley Flansbaum DO, MPH
Lenox Hill Hospital, NYC
Conflict of Interest: None Declared
It's easy to condemn in hindsight.

What about the commentary Annals didn't publish? The 80 yo guy, whose HbA1c went from 8.5 to 7.6 and whose BP now hovers around 140/85. He's still waking up every day milking the cows and having his daily drink at the corner bar. Maybe he will avoid a vascular event, won't become dependent on the state and enjoy life for a while longer.

Can we quantify the risks and benefits? I grin--tongue and cheek--at the accounts of MSM deferring "to your doctor," when the decision to begin meds comes up in equivocal scenarios.

Out of 100 people, can you say a particular regimen might prevent five bad outcomes and cause 3? I can't.

The best guidance I can give: chronologic age does not equal physiologic age. Do the best you can. This case had flubs for sure, and I am speaking in general terms--as the case has general lessons--but attending to BP, DM, and BPH in a healthy guy who might live another 15 years has merits.


About Tyranny of Guidelines
Posted on October 12, 2015
Ivan Vucina MD-FACP
U. of Chile-CLC
Conflict of Interest: None Declared
I know that Guidelines are only *Guides*.You must use their indications with cautioun and wisdom , depending of the very good and complete diagnostics of the patient.That means, that in many cases, you have to choose between better recomendations and to use your better criteria, according with the reality of this special patient.
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