Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Can conflicting guidelines be good for patients?

Kenneth Lin, MD
Physician
June 17, 2014
Share
Tweet
Share

After I left my position as a staffer for the U.S. Preventive Services Task Force in November 2010, it was three years before I was tapped for another guideline post, this time at the American Academy of Family Physicians. Recently I joined the AAFP’s Commission on Health of the Public and Science, which formulates guidance for family physicians on a variety of topics, including clinical preventive services. My appointment coincided with the release of two high-profile guidelines on high blood pressure and cholesterol.

For most of my career in family medicine, nearly all physicians followed the same guidelines to manage these common risk factors for cardiovascular disease: JNC 7 and ATP 3, expert panels convened by the U.S. National Heart, Lung, and Blood Institute. After the JNC 7 blood pressure guideline was published in 2003, waiting for the release of the next iterations of these guidelines was like waiting for Godot. Then, in an abrupt move that was seen by some as wanting to avoid a public uproar similar to that caused by the 2009 USPSTF guideline on mammography, the NHLBI announced last year that it would no longer sponsor guideline development, and instead leave the process of translating evidence into recommendations to professional medical societies.

The result has been a fracturing of the longstanding primary care and subspecialist consensus on what to do for patients with high blood pressure and cholesterol. The new cholesterol guideline, published under the auspices of the American College of Cardiology and American Heart Association, quickly came under fire for recommending that clinicians base treatment decisions on a new cardiovascular risk calculator that could lead to a surge in statin prescriptions for older adults with normal cholesterol levels.

In contrast, the hypertension panel elected to skip organizational endorsement and publish their guideline directly in JAMA. JNC 8 endorsed looser blood pressure targets for older adults and rejected stricter targets for adults with diabetes and chronic kidney disease. Dissension within the panel became public when five members published a minority report that argued against abandoning the goal of a systolic blood pressure under 140 in older adults. As of this writing, it’s not clear which medical groups will decide to endorse or reject the new guidelines.

There has been much hand-wringing about the potential negative impact of conflicting guidelines. Whose guideline should doctors follow? How do we explain to our patients why guideline recommendations differ? When I worked for the federal government, these kinds of concerns engendered not-so-subtle pressure to harmonize or align existing discrepancies between official guidelines, such as those on screening for HIV and hepatitis B and C.

Now, the USPSTF and the Centers for Disease Control and Prevention concur on whom to screen for these infections, but to align their new recommendations, the Task Force arguably lowered its evidence bar and drew conclusions from a weak literature base. The same thing seems to have happened in lung cancer screening, where USPSTF recommendations for annual CT scans in heavy smokers harmonized with guidelines from oncology and pulmonology groups but were later rejected for “insufficient evidence” by the AAFP (though I agree, I was not involved in the AAFP’s decision process).

Sure, it’s easier for everyone when guidelines agree on what to recommend for a particular patient in a particular situation. But when “reaching alignment” is simply a euphemism for one guideline group exerting political pressure on others to fall into line, that isn’t good for medicine or for patients. After all, it wasn’t so long ago when medical groups marched in virtual lock-step to recommend menopausal hormone therapy to reduce the risk of heart attacks and strokes, and to drive blood glucose levels as close to normal as possible in patients with type 2 diabetes. Both of these recommendations now appear to have done much more harm than good. Patients’ interests would have been better served if at least one guideline group had had the courage to get off the bandwagon.

Kenneth Lin is a family physician who blogs at Common Sense Family Doctor. 

Prev

Be personable and make a huge difference in a patient's recovery

June 17, 2014 Kevin 0
…
Next

Health care is too nuanced for lengthy scripts

June 17, 2014 Kevin 5
…

Tagged as: Cardiology, Primary Care

Post navigation

< Previous Post
Be personable and make a huge difference in a patient's recovery
Next Post >
Health care is too nuanced for lengthy scripts

ADVERTISEMENT

More by Kenneth Lin, MD

  • How to recruit more students into family medicine

    Kenneth Lin, MD
  • When should you prescribe statins for older adults?

    Kenneth Lin, MD
  • Clinical practice guidelines have problems, but they’re not broken

    Kenneth Lin, MD

More in Physician

  • The gift we keep giving: How medicine demands everything—even our holidays

    Tomi Mitchell, MD
  • From burnout to balance: a neurosurgeon’s bold career redesign

    Jessie Mahoney, MD
  • Why working in Hawai’i health care isn’t all paradise

    Clayton Foster, MD
  • How New Mexico became a malpractice lawsuit hotspot

    Patrick Hudson, MD
  • Why compassion—not credentials—defines great doctors

    Dr. Saad S. Alshohaib
  • Why Canada is losing its skilled immigrant doctors

    Olumuyiwa Bamgbade, MD
  • Most Popular

  • Past Week

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • How New Mexico became a malpractice lawsuit hotspot

      Patrick Hudson, MD | Physician
    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
    • A world without vaccines: What history teaches us about public health

      Drew Remignanti, MD, MPH | Conditions
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • How the 10th Apple Effect is stealing your joy in medicine

      Neil Baum, MD | Physician
  • Recent Posts

    • From Founding Fathers to modern battles: physician activism in a politicized era [PODCAST]

      The Podcast by KevinMD | Podcast
    • From stigma to science: Rethinking the U.S. drug scheduling system

      Artin Asadipooya | Meds
    • The gift we keep giving: How medicine demands everything—even our holidays

      Tomi Mitchell, MD | Physician
    • The promise and perils of AI in health care: Why we need better testing standards

      Max Rollwage, PhD | Tech
    • From burnout to balance: a neurosurgeon’s bold career redesign

      Jessie Mahoney, MD | Physician
    • Healing the doctor-patient relationship by attacking administrative inefficiencies

      Allen Fredrickson | Policy

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 3 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • How New Mexico became a malpractice lawsuit hotspot

      Patrick Hudson, MD | Physician
    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
    • A world without vaccines: What history teaches us about public health

      Drew Remignanti, MD, MPH | Conditions
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • How the 10th Apple Effect is stealing your joy in medicine

      Neil Baum, MD | Physician
  • Recent Posts

    • From Founding Fathers to modern battles: physician activism in a politicized era [PODCAST]

      The Podcast by KevinMD | Podcast
    • From stigma to science: Rethinking the U.S. drug scheduling system

      Artin Asadipooya | Meds
    • The gift we keep giving: How medicine demands everything—even our holidays

      Tomi Mitchell, MD | Physician
    • The promise and perils of AI in health care: Why we need better testing standards

      Max Rollwage, PhD | Tech
    • From burnout to balance: a neurosurgeon’s bold career redesign

      Jessie Mahoney, MD | Physician
    • Healing the doctor-patient relationship by attacking administrative inefficiencies

      Allen Fredrickson | Policy

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Can conflicting guidelines be good for patients?
3 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...