January 28, 2014
News Review From Harvard Medical School -- Navigating Changes in Treatment Advice
Changing guidelines for treatment of several common conditions can be confusing for doctors and patients, a doctor writes in a new blog posting. The writer is Suzanne Koven, M.D., an internist. The Boston Globe published it January 27. Dr. Koven writes about how recent guideline changes have affected her and her patients. The guidelines include those for high blood pressure, cholesterol and cervical cancer screening. Some of them make big changes to the way she has practiced medicine for decades. For example, the new guidelines say no treatment is needed for some older patients who might have been treated for high blood pressure in the past. Changes like these can make patients uneasy and shake their trust in their doctors, Dr. Koven writes. But they are based on evidence and the goal is better care. And the changes also show that medical science is not a perfect process and knowledge is never complete, she says. "The long perspective teaches that even when we’re certain we know the right answer in medicine, it’s best to maintain our curiosity -- and our humility."
By Lori Wiviott Tishler, M.D.
Harvard Medical School
What Is the Doctor's Reaction?
Every Friday afternoon, I oversee several resident doctors who are learning to practice primary care. After we care for people, we study primary care topics together. For the last couple of weeks, we’ve discussed changes in guidelines for care of high blood pressure, high cholesterol and cervical cancer screening.
New doctors are always a little surprised when the guidelines change. More experienced doctors expect it!
As Dr. Koven notes in her blog, guidelines have changed during the last couple of years for some people with high blood pressure. New advice for certain patients, particularly those who are older, suggests that a safe blood pressure may be higher than we used to think. Drugs may be started in different combinations.
Just a few years ago, we treated low bone density with drugs -- potentially forever. Now, we treat only osteoporosis or its equivalent. Sometimes treatment lasts only five years!
Usually new guidelines come from well-respected organizations. The sources include the Centers for Disease Control and Prevention, the U.S. Preventive Services Task Force, the American College of Cardiology and others. Groups derive their guidelines from:
- New research
- Careful study of previous research
- Expert opinion
Why do guidelines change? Is it change for change's own sake? Medical research is actually growing and changing all the time. One research study may lead to many more questions than it answers. As we try to answer those questions, we learn new things.
Many times, later studies confirm a first study. Sometimes they show the opposite. In addition, the quality of the study makes a difference. The groups that create guidelines look at all the data. They also consider the size, the quality and the methods of the studies.
Sometimes the data are very clear. When we first started recommending Pap smears for women, we didn't know about HPV, the human papilloma virus. Now we know that this virus causes almost all cases of cervical cancer.
Knowing the science helps doctors ensure that we don't miss cervical cancer. But it also helps us avoid over-testing our patients. Women who test negative for HPV virus infection can now get Pap tests less often. As a practicing doctor, it's easy for me to make sense of this advice. It's easy to implement, and easy to explain to patients.
Sometimes the data and recommendations are less clear. I have spent the majority of my career nagging patients about their cholesterol levels. Now the new guidelines suggest that we don't have to measure the number at all. What matters in these guidelines is the intensity of treatment based on people's overall risk. Since, frankly, this is much harder for me to grasp, I'm finding it harder to explain to patients.
I always look forward to learning about new guidelines. They keep me clinically alive and active. They remind me that medicine is vibrant and changing, art and science. The best guidelines have aspects of both. They challenge me to think about what is best for my patients and how to best use that knowledge to teach them and help them.
Sometimes I adopt them wholeheartedly. Sometimes I take them with a grain of salt. The only thing that I take for granted is that they will -- sooner or later -- change again.
What Changes Can I Make Now?
If you get routine preventive care or if you have a chronic condition, you should be aware that there are guidelines for your care. Examples of chronic conditions include high blood pressure, diabetes and high cholesterol.
When your doctor recommends a test or a new treatment, you might ask him or her what the guidelines are. If your doctor is following the guidelines, that's wonderful. If not, ask why not. Many times, if I am not strictly following a guideline, I have a good reason and I can explain what I think is better. New guidelines can be controversial. Your doctor should be able to explain both the controversy and her opinion about it.
Be aware that guidelines change. Sometimes my patients and I decide that "we'll both be keeping an eye on the news" as things change. This is particularly true, in my experience, with guidelines about vitamins and nutrition.
Don't assume that guidelines are changing for political reasons or that your doctor is trying to cheat you out of care. In many cases, less may be better for your health.
What Can I Expect Looking to the Future?
If we are doing our job as practicing doctors, scientists and medical researchers, then guidelines will continue to change. And as they change, they should continue to improve the care that we can offer to all patients.