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September 14, 2020

A Solution for Guideline Overkill—More Guidelines or Shared Understanding?

Author Affiliations
  • 1Family Medicine Residency, AdventHealth Winter Park, Winter Park, Florida
  • 2Institute of Applied Health Research, University of Birmingham, Birmingham, England
JAMA Intern Med. 2020;180(11):1508-1509. doi:10.1001/jamainternmed.2020.3969

Thirty years ago, the practice of medicine began a radical change of direction. As the pace of therapeutic discovery slowed in the late 1980s, many came to believe that the greatest benefit in the future might come not from innovative breakthroughs, but by the more consistent application of existing knowledge.1 If best practice could be identified by evidence from randomized clinical trials in a systematic way, and presented to clinicians as a set of recommendations, the general level of practice could be improved and assessed by objective criteria. Evidence-based medicine (EBM) became the accepted engine for medical progress, with systematic reviews and guidelines as the chosen instruments for promoting better and more standardized practice.2

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    1 Comment for this article
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    Phillip Shepard, MD | Retired FP
    As a Clinician and person that started in Family Medicine when it was unpopular I have always practiced "slow medicine". My attitude was that if a test or study did not make any difference in the diagnosis or treatment I didn't do it. I was not the favorite person at the hospital because I didn't order all sorts of tests and x-rays. My aim was efficiency and cost-effectiveness. Not a guesswork of "shot-gun" approach but heuristic. I took only medical history, three blood tests and one imaging study to diagnose a prolactinoma. It took me only history and a reflex hammer and one imaging study to diagnosis a glioblastoma. It took only history, examination of hands and a CBC to diagnose pernicious anemia. It took history, CBC and a hemoglobin electrophoresis to diagnose round worms and hemoglobin E. History and physical alone diagnosed Systemic Lupus. Another attitude I had was: Treat the patient not the lab tests. When a diabetic is overweight and hyperglycemic don't just keep adding to the poly-pharmacy. Find out why and get them to lose a few pounds. This business of over reliance on tests and poly-pharmacy is what we used to call "cook book" medicine. My diploma (1968) says I have a Doctorate in the Art of Medicine. Clinical practice is based upon Knowledge, Skill and Intuition; lab tests only support or reject diagnostic possibilities, they do not make diagnoses.