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Is the new professionalism and ACP's new ethics really just about following guidelines?

The Charter ( Medical Professionalism in the New Millennium.A Physician's Charter) did not deal with just the important relationship of ...

Friday, September 26, 2014

Another chapter in "were you wrong then doctor, or are you wrong now?" this time regarding stenting of non culprit lesions.

The American College of Cardiology recently retracted one of its magic five "Choosing Wisely" recommendations.In 2012 ACC had advised that in the setting of an acute coronary event one should only revascularize the "culprit artery".This is the artery thought to be responsible for the event and if other obstructions are detected the ACC said that there was evidence that the fix everything approach might be harmful.This advice was based on non randomized trials. Here is ACC's official statement.

Now apparently two randomized trials  suggest one should fix (place a stent in ) the other obstructions. Here is quote from ACC:

 “over the last two years, new science has emerged showing potential improvements for some patients in their overall outcomes as a result of complete revascularization.”

Larry Husten,prolific medical journalist whose Forbes article on this subject is linked above, really nailed it , quote:

" It seems to me that the medical organizations that produce guidelines should freely admit this lack of evidence for most recommendations. Then, instead of getting their panties all in a bunch trying to defend the indefensible– as we saw recently with the salt guideline– they could advocate for better evidence...So if they want to make the case for more data they will have to first acknowledge their ignorance.

Acknowledging ignorance seems the last thing  likely to emerge from the guidelines generating organizations.

In 1728, the three verdict system arose in Scottish Criminal cases.The accused could be found guilty,not guilty or not proven. So guilty, not guilty or admitting their ignorance and admitting we just can't say.

Being  a guideline author seems to confer immunity for having to say you are sorry.  The individual physician strives to do what is the right thing for his patient and hopes that what he does is right, the quality rule makers are able to summon up sufficient hubris to  presume to know what is good for everyone. Of course they frequently do not. Remember the beta blocker fiasco.


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