What are the risks and benefits of adopting guideline-driven care?

Jeremiah Joyce is a third-year student at the Mayo Clinic School of Medicine. As part of his clerkship in family medicine, Mr. Joyce responded to a writing prompt meant to develop his thoughts about the role of a primary care physician. The prompt: “The ideas behind MDM or contextualized care ask us to respect the needs and circumstances of the patient before us as we construct our care plans. But that puts us in a weird spot, yes? Because just as MDM is this decade’s push, last decade’s push was evidence-based

Joyce

medicine: the idea that, through science, we can find a ‘best’ way to handle a problem, a ‘best’ treatment. It becomes our job to apply the evidence with less and less spin to it, if we dedicate ourselves to EBM purity. With that in mind, what is your opinion of the Minnesota Community Measures’ “D5” criteria (http://mncm.org/reports-and-websites/the-d5/)? What are the risks and benefits of adopting guideline-driven care? Do the D5 measures reflect a friendly contextualization of care?” Mr. Joyce’s response follows:

The Mayo motto “the needs of the patient come first” uses the singular noun; the patient is an individual. In practicing evidence based medicine, however, I think we often make the mistake of using population-based recommendations for individuals. There is an interesting precedent for the idea that a “one size fits all” model fits no one perfectly. In his book The End of Average, Todd Rose describes a U.S. Air Force study of pilot average body measurements, designed to tailor a cockpit that fit the average pilot. Out of over 4,000 pilots measured to determine the perfect dimensions, not a single one was within the average range in all of the 10 primary dimensions (Rose, 2016). This article is a fascinating physical example of a truth that undoubtedly applies to medical recommendations as well.

In practicing medicine, we should focus on tailoring the recommendations to fit the patient, rather than forcing the patient to fit the recommendation. We are all aware of the benefits of D5 recommendations on the long-term health of populations, but we also know some patients have ASA-induced asthma and others have statin-induced myositis. Still others haven’t been able to quit smoking despite their best intentions. We as future providers risk losing a therapeutic alliance with patients if we push too far or too hard. Someone with a recent diagnosis of diabetes may quickly be overwhelmed if we add on all the D5 as soon as their A1c is at 7.1%. As Rose describes in his book, the Air Force’s solution to their cockpit dilemma was increasing flexibility in the design, allowing pilots to adjust their planes. This approach resulted in a dramatic decrease in casualties. We may see the same effect when we work with patients to achieve the greatest benefit to their health. Across a panel of patients, we would be much more satisfied with a population of half-treated and gradually improving diabetics than we would be with losing many patients to follow-up due to frustration and disappointment with a rigid healthcare system.

(Rose, 2016) “When U.S. air force discovered the flaw of averages.” https://www.thestar.com/news/insight/2016/01/16/when-us-air-force-discovered-the-flaw-of-averages.htmlhttps://www.thestar.com/news/insight/2016/01/16/when-us-air-force-discovered-the-flaw-of-averages.html

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