Blogfinger

Graphic from the Journal of the American Medical Association

By Paul Goldfinger, MD, FACC   (Editor @Blogfinger)

When I practiced medicine, treatment and diagnostic guidelines were written to provide frameworks for doctors to use as non-mandatory evidence-based guides to patient care. But now it is apparent that the screws are tightening on the medical profession.

The new JNC 8  (Joint National Commission)  guidelines for the treatment of hypertension were made public on Dec. 18, 2013 in The Journal of the American Medical Association (JAMA,) but a wide-ranging debate has ensued over this document, just as we recently saw regarding cholesterol guidelines.

The debate is not only about clinical matters such as which BP number should be used to decide about starting drug therapy. But there are other questions having to do with how trustworthy these guidelines are, whether the writers have conflicts of interest, whether the scientific evidence is good enough, and whether the JNC 8 recommendations are practical enough that they can be integrated with guidelines  for other issues such as treating diabetes, cholesterol and obesity.

But what is the over-riding concern that underlies the angst?    Well, according to an editorial in that same issue of JAMA by Harold Sox, MD,   from Dartmouth Medical School, “Guidelines are increasingly driving the practice of medicine.”  Thus, in this concise sentence, he explains the growing concern regarding guidelines.

But how does this tie into Obamacare?   Well, mandatory guidelines will become a major tool to influence the practice of medicine. It will happen via the Obamacare surrogates–the insurance companies–who will pressure doctors via guidelines. Of course, guidelines will soon become an obsolete name for what is occurring  (see below).

This is what Howard Bauchner, MD, from Duke University said in the same issue of JAMA, referring to the way that practice guidelines have evolved in recent years:

” Over time, as guidelines have become more formalized, deviations from guideline  recommendations have become less tolerated. Furthermore, guideline recommendations have now been distilled into “performance measures,” which use rigid criteria to assess physicians’ quality of care. Rather than merely suggesting a course of action, performance measures define what a clinician should and must do to avoid a quality concern. As a result, performance metrics are increasingly linked to public reporting and pay-for-performance programs, providing powerful incentives for measuring performance.”

So, although such scrutiny may sound fine, and I do not oppose all scrutiny on the profession,  you can see how mandated rules can coerce doctors. These new guidelines for hypertension have loosened the requirements a bit on who gets treated, especially if you are over age 60, but among the biggest consequences of all this debate is to underline the fact that doctors must be in charge of decisions about their patients. It is all simply too complicated to boil down to a few guideline rules.

In Part III I will explain the new guidelines, and Part IV will be variations on a theme that I have learned from 30 years of treating hypertension. It’s all like jazz: you can work around a basic chord progression, but the end result needs to be played out differently each time. Each patient is unique, and you will want your doctor to conduct the band.