Consultations not Informed by Mutual Trust
Guidelines are set out by experts and specialists who focus exclusively on their own specialties. Other disciplines are not included in the considerations. The result is that, for example, multimorbid patients with five conditions (not rare in this era of the International Classification of Diseases (ICD), and diagnosis related groups (DRG)), would have to be given a minimum of 15 medications. Drug interactions and adverse effects are unpredictable in such a scenario, and that does not even touch on lacking compliance. In geriatric patients, prioritization is usually required. Only few guidelines exist for patients older than 75. Medications have usually not been tested in this age group.
The authors say: “Guidelines are one of the means by which health care organizations try to improve health care and lower its cost.” The likely problem will be that for GPs, the doctor-patient relationship will be dominated by considerations of how to meet externally imposed targets (“quality indicators”) rather than the confidential and trusting consultation with the patient.
It is true that in the context of evidence based medicine, randomized controlled studies are an essential instrument for the purposes of evaluation. But significance is not always the same as clinical relevance. What may apply for a healthy 20-year-old may not apply for a multimorbid 85-year-old. In spite of our ever increasing knowledge of molecular and genetic associations in the human body, in spite of our insights into receptors, ion channels, or signal transduction, we still apply the instrument of (medication) treatment practically “blindly” to the complex networks of body and psyche, without in any way recognizing the possible long-term consequences of such therapies.
Dr. med. Robert Hector
Conflict of interest statement
The author declares that no conflict of interest exists.
|1.||Karbach U, Schubert I, Hagemeister J, Ernstmann N, Pfaff H, Höpp HW: Physicians’ knowledge of and compliance with guidelines: an exploratory study in cardiovascular diseases. Dtsch Arztebl Int 2011; 108(5): 61–9. VOLLTEXT|