Eliseo Guallar, MD, DrPH; Christine Laine, MD, MPH, Editor in Chief
Acknowledgment: The authors thank Jaya Rao, MD, MHS; Sankey Williams, MD; Cynthia Mulrow, MD, MSc; Darren Taichman, MD, PhD; Catharine Stack, PhD, MS; and Deborah Cotton, MD, MPH, for their critical review of drafts of the manuscript.
Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-0112.
Requests for Single Reprints: Eliseo Guallar, MD, DrPH, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, 2024 East Monument Street, Room 2-645, Baltimore, MD 21287; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Guallar: Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, 2024 East Monument Street, Room 2-645, Baltimore, MD 21287.
Dr. Laine: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106-1572.
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Andrew Miller, MD
Lenox Hill Hospital, PGY-2, Internal Medicine
February 19, 2014
Guideline In Excelsis Deo!
The author’s statement: "Reversal of prior practice can confuse health professionals and the public, who then question the wisdom of guidelines that withhold care *they* consider standard." (emphasis added) was an interesting way to frame this issue.
Take a moment and consider whom the authors have defined as "they." I’ll note, it is not “health professionals and the public" who create the notion of a "standard of care." Rather, a "standard" is created and handed down to the public by people and groups like these authors. It is only when the former "standard" is ignominiously invalidated by those who sit perched atop their ivory tower when the wrongness of the 'old' way is suddenly ascribed entirely to the ignorance of the unwashed masses. The audacity of that sort of thinking always astounds me. It exemplifies in the clearest possible way how we might better describe theirs as an ivory tower of Babel.
The editorial suggests there’s no need for the “noise” of open debate. It implies that “evidence” from a RCT, meta-analysis, or systemic review is somehow sacrosanct. No matter of course that a debate may be about the irony of replacing a prior untested lipid guideline in part with a new scoring system that is itself entirely untested. A 7.5% on such an unreviewed system might be accurate or it might simply be a nice number between 5 and 10.
No need to debate with useless noise the settled science of “evidence.” No matter of course that the JNC 8 guideline, though speaking quite highly about the importance of "evidence based medicine," ultimately published 6 of its 11 guidelines with the rating of "expert opinion."
The editorial authors' concluding sentence sums up this entire debate quite well: "If the goal is high-value health care for all, we must quiet the noise that accompanies guidelines so that we can hear the evidence speak." If one’s “evidence” is so weak that its supporters fear it may be shattered merely by a modicum of open debate and public scrutiny then I say bring on the debate! For the sake of creating the highest value health care for all of our patients, may we all continue to make noise. Evidence doesn’t speak, people do.
Andrew Miller, MD
Guallar E, Laine C. Controversy Over Clinical Guidelines: Listen to the Evidence, Not the Noise. Ann Intern Med. ;160:361–362. doi: 10.7326/M14-0112
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Published: Ann Intern Med. 2014;160(5):361-362.
Healthcare Delivery and Policy, Prevention/Screening.
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