Guidelines: When Satan Reads the Bible

Clinical guidelines are a mixed blessing. Wise clinicians know that they offer a general pattern of doing things that usually results in favorable outcomes. They also know there are lots of situations when guidelines can’t be applied because of unique patient characteristics.

Guidelines can be dangerous if we apply them indiscriminately. Education and experience teaches us when and when not to follow them.

The problem with guidelines is that people without our knowledge or experience have placed themselves in positions where they judge physicians by whether we follow a particular guideline or not. Never mind that there are competing guidelines, and that the web repository of them shut down a month ago.

That reminds me of a colorful Swedish analogy my grandmother often used, “som fan läser Bibeln”, translated “like Satan reads the Bible”.

One of many American Christian authors writes about it this way:

“What makes Satan happy is when he can get Christians to believe that Proverbs 15:6 justifies the accumulation of wealth in a world of hunger; that 2 Thessalonians 3:10 abolishes charity; that Romans 9:16 makes evangelism superfluous; that 1 Timothy 2:4 means God is not sovereign in conversion; that John 10:28 means a “Christian” can do whatever he wants and still be saved; that Hebrews 6:4–6 means there is no security and assurance for God’s elect.”

If Satan can pick and choose Bible phrases to confuse, tempt or mislead earnest and well meaning Christians, imagine what someone with ill will or authority without wisdom can make out of clinical guidelines.

That is the reality of today’s Quality Quagmire in health care.

We sometimes get judged if we don’t have diabetics on ACE inhibitors, even if they don’t have microalbuminuria. According to UpToDate, there is insufficient evidence for this practice.

Regarding statins, the American College of Cardiology writes: “Five major North American and European guidelines on statin use in primary prevention have been published since 2013. Guidance on use in the growing elderly population (age >65 years) differs markedly…The main goal of primary prevention with statins is to achieve net-benefit from treatment. Potential harm(s) is a crucial part of appropriate decision making. As frailty, comorbidity, and polypharmacy may increase the risk for adverse statin-associated symptoms, the “risk-benefit” balance in the elderly could theoretically tip in favor of withholding statin therapy if such conditions are present.” So much for following guidelines there.

Another striking example of how crazy this system is:

A doctor sees a patient with bronchitis. Guidelines discourage antibiotics. That is a Quality indicator. On the way out of the office, empty handed, so to speak, with no antibiotic but a lengthy diatribe about the uselessness of antibiotics and the looming threat of multi resistant superbugs, the patient is asked to rate his physician. Such ratings are an increasingly large part of provider evaluations and even compensation formulas. Will that patient give the doctor a favorable rating?

This what I do: Some patients, like those with chronic lung disease, get antibiotics right away. Others get a thorough explanation of why I’m not prescribing them. And a few get a “backup prescription”: “If this, this or this happens, fill it”.

Guidelines and doctor ratings shouldn’t tie our hands. We are the professionals here. We must apply our knowledge to every clinical situation we encounter. In some cases, the people who dangle guidelines or popularity ratings over our heads are simply being ignorant bullies.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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