Thankfully,more and more authors of medical journal articles are pointing out the obvious-single disease guidelines applied by role to complicated patients is not a good thing. Clinical judgment is actually required.
In the April 26.2006 issue of JAMA, Dr. Samuel C. Durso writes about the issues involved in using clinical guidelines for older patients with diabetes and complex health status.He referenced an article called "Guidelines for Improving the Care of the Older Person with Diabetes Mellitus." The JAMA article and by reference the "guidelines" he discusses seem to really be a permission to deviate from various single disease guidelines as the physician and patient attempt to do what seems best for the patient taking into consideration prioritizing goals and the patient values and wishes reminding me of Dr. Norton Hadler's "clinical truth".
There have been earlier articles critical of the rote use of single disease guidelines in patients with multiple diseases and this article's focus in on older diabetic patients and highlights problems in frail patients with short life expectancies.
Here are some quotes from Durso's article:
"Most clinical guidelines for common conditions are disease-focused and do not provide guidance for prioritizing multiple medical conditions including geriatric syndromes that are common in older adults."
"Nor do most guidelines make explicit provisions for addressing a patient's health care preferences when they differ from guideline recommendations."
The closing sentence is interesting:
"Clinicians also must be trained in complex decision making"
It that not what internists had been trained to do over the years?
I am a bit taken back that he seems to be talking about " guidelines for guidelines"(I do not believe there can be an algorithm for everything) but there is clear value in recognizing the importance of placing guidelines in the overall clinical picture and knowing when to hold them and when to fold them.