Perspective: Practice guidelines, Part II – Who do “guidelines” actually guide?

By Charles A. Pilcher MD FACEP

Related to this newsletter’s earlier “Perspectives” essay on the value of “Guidelines,” David O’Dell MD JD writes his own nice summary of the topic in Medical Economics, January 10 edition. He discusses the relationship between malpractice claims and “guidelines.”

Dr. O’Dell agrees that most guidelines carry little weight in the form of solid evidence. Guidelines are published using two levels of supporting information: 1) “Classes of Recommendations,” ranging from I (something is clearly useful and effective) to III (something is not useful and may be harmful) and 2) “Levels of Evidence” rated from A (multiple randomized trials support the recommendations) to C (supported only by opinion and case reports). Thus a level I-A “guideline” is clearly useful and the evidence comes from solid science, while a level III-C guideline, based on is little more than one person’s opinion, and may not even be useful.

Dr. O’Dell notes that in a series of 1973 recommendations found in 16 current guidelines,  only 19% of the Class I recommendations are based on Level A evidence. He then reminds physicians (apparently those using “Guidelines” as a defense against malpractice claims) that juries may remain unimpressed with guidelines and may rely more on their own “common sense” and “personal standards” when evaluating care options. He closes by noting that a compassionate, remorseful and likeable physician will always fare better before a jury than one who is arrogant and unrepentant, regardless of the role played by guidelines.

This is just another reminder that attorneys, both plaintiff and defense: quoting a  “guideline” in a case of alleged malpractice is not enough. You must know the science from which that guideline is derived, for if it is controversial, your guideline could come back to bite you on cross-examination.

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