Do guidelines guide, goad, or beguile?

In the March 2 issue of the NEJM Sean Palfrey (“Daring to practice low-cost medicine in a high –tech era”) makes a good case for using common sense and clinical skills in place of technology. Although he mentions practice guidelines as providing some guidance in achieving those goals, the guidelines can be more of a hindrance than a help.

Guidelines do not take into account one of the most valuable tools that physicians have—intuition. Particularly for doctors who have known their patients for years and are well acquainted with their histories, guidelines can be obstacles to physicians’ exercising their clinical judgment.

Chest pain for example is more often than not, non-cardiac. Yet, physicians, even when, for good reasons, they have a very low index of suspicion, are almost forced to embark on expensive cardiac workups “just to be sure" that they are following the guidelines.

Are guidelines, because they are disconnected from the individual patient, over-rated? Do they guide or goad or beguile?

Ed Volpintesta MD