This week’s issue of The New England Journal of Medicine once again questions two practices that used to be almost the backbone of primary care.
One article is about the low likelihood that prostate cancer detected through PSA screening will shorten a man’s life, even if he chooses just to keep an eye on it.
The other article is about how repeated mammography screening mostly leads to the diagnosis of small and not very aggressive tumors, just like PSA screening.
These two common health screening issues, along with the disappearance of all scientific rationale for cholesterol targets, baseline EKGs, digital rectal exams, testicle exams and “routine” lab work, not to mention routine physical exams, have essentially forced primary care doctors to rethink how they spend their days.
CMS has plenty of other things for us to do, although they still want us to do some of the things the evidence has debunked, and much of their vision for doctors falls within the Public Health domain.
As a result of these changes, physicians today face a serious credibility problem. The more dogmatic we have been before about following the guidelines that are now relegated to the history books, the more ridiculous we look to our patients as we more or less enthusiastically make our required 180 degree course corrections.
Thank goodness I always spoke of the guidelines as just that, current expert opinion, not something carved on stone tablets, handed down to us from Mount Sinai. As my father used to say, “view everything a little von Oben”. That’s the German expression for “from above”. The full phrase is von Oben heraus”, which rings of superiority and can even mean snooty.
As a physician, I am not putting myself above the expert opinion of the day, but I see myself as a humble servant and disciple, not of the current guidelines but of the principles of my forbears, from Hippocrates to Osler. If I take them seriously, and always speak of today’s guidelines as something likely to be temporary, I don’t seem to have to feel embarrassed when the guidelines change, which they inevitably do.
I think this attitude requires knowing your caft and its science well enough to be able to tell why the guideline looks the way it looks. Without the proper depth of knowledge you can’t be “above it all”.
Seriously, whether we are making guideline related u-turns without explaining why suddenly our practice is changing, or reciting all the possible side effects of a medication we are about to prescribe, we are making ourselves look bad compared to other practitioners, whose research isn’t double blinded and who aren’t mandated to badmouth their own treatments the way we are.
With guidelines coming and going, promising new drugs suddenly disappearing from the market, and with so many of our favorite prescriptions barely more effective than placebos, we need to go back to the source for the physicians of yesterday and those of the future:
Know your science, view today’s guidelines from a historical perspective and don’t be completely immersed in today. Because the present is just the razor sharp boundary between the past and the future.
A Country Doctor Writes: 
How interesting it is that all these new “guidelines” just happen to reduce healthcare spending on patients, while doing nothing to reduce spending on administrators and guideline makers. We got paid less if we didn’t follow the old guidelines. Now we’ll get paid less if we don’t follow the new ones. The administrators and bureaucrats get paid just for coming up with new guidelines and enforcing them. Show me a new guideline that recommends that something be done involving spending money to improve an individual patient’s care, and I’ll entertain the notion that these parasites have some credibility.
It’s the new form of a death panel. Last week I had my first fecal occult in quite a few years. Until 2011, I had one each year, because I’m at risk-IBS-D, and family history of stomach cancer. My stool became black and very tarry. This is the first time in my life that I reported this in 74 years.
When I asked my old PCP about this, he said at my age, cancer care would be too involved for me at my age; I was 68 at the time.
I’m seeing my new GI next week. The old one retired.
well no. the NEJM article shows nothing about PSA screening. it also doesn’t show that watchful waiting is a good plan for prostate cancer either as the majority of patients randomized to that plan get more radical treatments anyway and they have more mets…..
i also fail to see why if science changes guidelines [assuming it does] why that in any way obviates the role of primary care physicians as compared with simply altering their behaviors….hopefully for the betterment of our patients.
50% chance no need to treat for the first ten years for prostate cancer identified through screening. So that adds to the notion that screening for something with that low a probability to “need” treatment, let alone kill you…..
A physician will have no credibility if he or she only speaks of the guideline and doesn’t explain current knowledge. One day we do this, the next day we do something else, but while we are doing whatever that is, we support it wholeheartedly – that is a ridiculous way to work. By speaking of current literature we can honor the scientific principles of medicine and show patients that the guidelines are becoming outdated and will likely change. That is how an intellectual, a professional, deals with information. We should act more like professionals and not robotniks.
On top of that, you find out the research is written by companies with a $$$ interest in the research going ‘their’ way, and loads of retractions due to falsifying data.
I feel sorry for you, the good docs. Such a sad and sorry state for people who truly went thru the years of training only to be stabbed in the back, a lot of times by your own. 😦
Vic-you missed the insurance companies. Just how many millions and billions does it take to make a CEO happy?