A recent issue of the New England Journal of Medicine once again questions two practices that used to be almost the backbone of primary care.
One article is about the low likelihood that prostate cancer detected through PSA screening will shorten a man’s life, even if he chooses just to keep an eye on it.
The other article is about how repeated mammography screening mostly leads to the diagnosis of small and not very aggressive tumors, just like PSA screening.
These two common health screening issues, along with the disappearance of all scientific rationale for cholesterol targets, baseline EKGs, digital rectal exams, testicle exams and “routine” lab work, not to mention routine physical exams, have essentially forced primary care doctors to rethink how they spend their days.
CMS has plenty of other things for us to do, although they still want us to do some of the things the evidence has debunked, and much of their vision for doctors falls within the public health domain.
As a result of these changes, physicians today face a serious credibility problem. The more dogmatic we have been before about following the guidelines that are now relegated to the history books, the more ridiculous we look to our patients as we more or less enthusiastically make our required 180-degree course corrections.
Thank goodness I always spoke of the guidelines as just that: current expert opinion, not something carved on stone tablets, handed down to us from Mount Sinai. As my father used to say, “view everything a little von Oben.” That’s the German expression for “from above.” The full phrase is von Oben heraus,” which rings of superiority and can even mean snooty.
As a physician, I am not putting myself above the expert opinion of the day, but I see myself as a humble servant and disciple, not of the current guidelines but of the principles of my forebears, from Hippocrates to Osler. If I take them seriously, and always speak of today’s guidelines as something likely to be temporary, I don’t seem to have to feel embarrassed when the guidelines change, which they inevitably do.
I think this attitude requires knowing your craft and its science well enough to be able to tell why the guideline looks the way it looks. Without the proper depth of knowledge, you can’t be “above it all.”
Seriously, whether we are making guideline related U-turns without explaining why suddenly our practice is changing, or reciting all the possible side effects of a medication we are about to prescribe, we are making ourselves look bad compared to other practitioners, whose research isn’t double blinded and who aren’t mandated to badmouth their own treatments the way we are.
With guidelines coming and going, promising new drugs suddenly disappearing from the market, and with so many of our favorite prescriptions barely more effective than placebos, we need to go back to the source for the physicians of yesterday and those of the future:
Know your science, view today’s guidelines from a historical perspective, and don’t be completely immersed in today. Because the present is just the razor sharp boundary between the past and the future.
“A Country Doctor” is a family physician who blogs at A Country Doctor Writes:.
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