Dr James Schaller
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The Folly of Practice Guidelines

A lawyer phrase best describes practice guidelines: Garbage Science.

Paper shufflers, partisan hacks for HMO's, entirely devoid of credibility, collect studies based on statistics using the bell shaped curve (parametric statistics). These paper shufflers have half the clinical experience of clinicians, because, by contract, they spend half their time shuffling papers.

A desperate clinician faces a desperate patient. By dumb luck, some different treatment works. That spreads throughout the clinical community in weeks. Years later, the out of it, paper shuffler hears about it. He writes a grant, carries it out, writes it up and publishes it. Seven years have passed. Meanwhile, above desperate clinician has had a full turnaround in practice, doing little the same way as seven years ago.

Next, a committee of inexperienced paper shufflers, with tremendous time on their hands or in the pay of the enemies of clinical care, meets. They gather the parametric studies published years ago. These studies do not even represent the larger population. Any exclusion criterion keeping patients out that a clinician would not have kept out violates one of the key assumptions of the statistical test. Parametric statistics, if patients are truly randomly selected, represents the larger population. (The opinions expressed in 1500 random phone calls to voters come close to the election result, if done the same day.)

Clinical care is not of a larger population, but a series of on/off experiments in individuals. The statistics that describe this practice have binomial curves (like flipping a coin). You cannot apply studies with parametric distributions to a series of patients described by a binomial distribution.

  1. No statistical validity.
  2. Describes the practices of seven years ago.
  3. Written by the inexperienced, possibly with hidden adverse agendas to promote drugs or to restrict access to care to increase HMO profits.
  4. Always used as a spear against the doctor, never as a shield. This aggressive use will explode in any health court regime. The "health expert" judges will parse the guidelines word for word like a statute. "Ah, he missed this step. Guilty."

That is enough for me. If a doctor faces these guidelines during a medical malpractice claim, he should ask the defense lawyer to file a cross claim against all guideline authors as individuals, their employers, for their failure to supervise, and all publishers, and all republishers. They have a duty to do no harm, says an appellate decision upholding a verdict against guideline writers (Meneely v. S.R. Smith, Inc., 5 P.3d 49, 2000 Wash. App. LEXIS 1379 (2000)). Failing that, guideline writers have a duty to warn, "Not Scientifically Valid, for Entertainment Purposes Only." I would like to see judges, especially "health" judges, lose their unjust immunity. They should be made to pay double all costs from personal funds if they ever allow the use of guidelines in a case.

A cross claim would deter, and defend clinical care from its vicious enemies.

An anonymous professional

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