variations in variability

Elias Peter pheski69 at GMAIL.COM
Tue Nov 1 18:04:54 UTC 2016


If there was anything I have learned from 40 years in primary care, it is that guidelines represent the opinions of a group of people who have read and are informed by the evidence. The evidence is always incomplete and always changing, often not applicable to individuals who differ from study groups, and sometimes biased. Neither the evidence nor the guidelines can incorporate the values, preferences or resources of individual patients.

For me, this was both one of the great challenges and one of the great joys of primary care: using the guidelines and the evidence) to start a conversation with a patient about what decision we should make. I never see the guilders as an answer, always as an opening statement.

Sorry for the rant, but many years of being admonished or punished by administrators, insurers, QI committees because of carefully considered individual decisions (made collaboratively with patients) that were deemed ‘out of compliance’ or 'poor care' has left me with a very sensitive and exposed nerve.

Peter

> On 2016.11.01, at 1:30 PM, Twest54973 <000000040134e744-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG> wrote:
> 
> Guidelines are ideally based on prospective data not just opinion or biologic plausibility
> When adequate data doesn't exist ( as is the case for VTE prevention in pregnancy), then different people and organizations create different "guidelines" based on their beliefs and biases
> 
> Its a shame (but not unexpected) that different professional associations act independently of each other : this  results in confusion in clinicians and even sometime active conflict between clinicians 
> 
> A contrary editorial accompanied the Natl Partnership article ...
> 
> Good luck to the bedside clinician trying to provide good clinical care!
> 
> Thomas Westover MD
> Asst Professor Maternal Fetal Med and Obgyn
> Cooper Medical School 
> NJ
> 
> 
> Sent from my iPhone
> 
> On Nov 1, 2016, at 10:13 AM, Tom Benzoni <benzonit at GMAIL.COM <mailto:benzonit at GMAIL.COM>> wrote:
> 
>> A topic for awareness/discussion is guidelines.
>> They need to support the person on the sharp end of the process, the practitioner advising the patient.
>> So is it acceptable that there is variation among guidelines for the same condition?
>> Would this be acceptable in other high risk industries?
>> An example crossed my desk this morning:
>> Comment
>> 
>> The variability among professional societies' recommendations for VTE prevention in pregnancy has hampered attempts at quality improvement. The NPMS challenges obstetric units to adopt all the features of this bundle in an endeavor to reduce the burden of maternal morbidity and mortality, both of which are disproportionately borne by poor women and those of color. Ideally, efforts to streamline recommendations and encourage measurement of important outcomes will promote equity and excellence in maternity care.
>> 
>> http://www.jwatch.org/na42624/2016/10/28/another-maternal-safety-bundle-obstetric-venous?ijkey=VLA13UO7mZVBs&keytype=ref&siteid=jwatch&variant=full-text <http://www.jwatch.org/na42624/2016/10/28/another-maternal-safety-bundle-obstetric-venous?ijkey=VLA13UO7mZVBs&keytype=ref&siteid=jwatch&variant=full-text>
>> Is it not abrogation of responsibility to push this off onto the practitioner?
>> 
>> How do you reconcile this?
>> 
>> (There are legion examples of this in medicine.)
>> 
>> tom
>> 
>> 
>> 
>> 
>> 
>> 
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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