4 ms·

> Many (I don’t have an exact number) clinical practice guidelines are based on expert opinion or observational studies, and are completely valid/evidence-based

> Many (I don’t have an exact number) clinical practice guidelines are based on expert opinion or observational studies, and are completely valid/evidence-based (it’s just weak evidence). A big problem is that humans have a preference for action, and a dislike of waiting for information. Many flawed guidelines are based on a desire to act even in the absence of evidence of benefit. "Primum non nocere" is probably the most accepted but least respected tenant of good medical practice.

haldujai 3y ago
> Many flawed guidelines are based on a desire to act even in the absence of evidence of benefit. Very true, I mostly intended to illustrate that many "good" or accepted guidelines are not necessarily based on randomized controlled trials as there seems to be a misconception (based on recent trending posts) that these are the only forms of "evidence" in medicine. Some guidelines are borderline pseudoscience but pertinently guidelines are not binding. You point out the correct approach - one is entirely allowed to deviate from guidelines for good reason (i.e. no/very weak evidence, questionable benefit). That's also the beauty of the EBM, you'll find grade & strength of recommendation in any modern guideline to help interpret them. We also have quality assessment tools like QUADAS-2 and the STARD reporting guidelines to help the reader assess quality. > "Primum non nocere" is probably the most accepted but least respected tenant of good medical practice. Also agree but I think EBM addresses this a lot more than the old days of science-based medicine where we did things because "they made sense" without looking at various outcome measures that sometimes reveal missed harm. > A big problem is that humans have a preference for action, and a dislike of waiting for information. Part of this is also by necessity due to the nature of patient encounters which have a need for decision-making. Where the guideline is clearly poor (e.g. adrenal nodules, homeopathic follow-up at best) I disregard them but sometimes you have to err on the side of caution. As an example I recommend pancreatic cyst follow-up per the ACR guidelines even though my (abdominal radiologist)/institutional expert opinion is they're overkill and unnecessary based on very weak and dated observational evidence. But what's the alternative, everyone just does what they want and a patient's follow-up will be variable depending on the reporting physician?

haldujai 3y ago

> Many flawed guidelines are based on a desire to act even in the absence of evidence of benefit. Very true, I mostly intended to illustrate that many "good" or accepted guidelines are not necessarily based on randomized controlled trials as there seems to be a misconception (based on recent trending posts) that these are the only forms of "evidence" in medicine. Some guidelines are borderline pseudoscience but pertinently guidelines are not binding. You point out the correct approach - one is entirely allowed to deviate from guidelines for good reason (i.e. no/very weak evidence, questionable benefit). That's also the beauty of the EBM, you'll find grade & strength of recommendation in any modern guideline to help interpret them. We also have quality assessment tools like QUADAS-2 and the STARD reporting guidelines to help the reader assess quality. > "Primum non nocere" is probably the most accepted but least respected tenant of good medical practice. Also agree but I think EBM addresses this a lot more than the old days of science-based medicine where we did things because "they made sense" without looking at various outcome measures that sometimes reveal missed harm. > A big problem is that humans have a preference for action, and a dislike of waiting for information. Part of this is also by necessity due to the nature of patient encounters which have a need for decision-making. Where the guideline is clearly poor (e.g. adrenal nodules, homeopathic follow-up at best) I disregard them but sometimes you have to err on the side of caution. As an example I recommend pancreatic cyst follow-up per the ACR guidelines even though my (abdominal radiologist)/institutional expert opinion is they're overkill and unnecessary based on very weak and dated observational evidence. But what's the alternative, everyone just does what they want and a patient's follow-up will be variable depending on the reporting physician?