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Physician Compliance with Guidelines

Article  in  Annals of Internal Medicine · February 1996

DOI: 10.7326/0003-4819-124-1_Part_1-199601010-00032 · Source: PubMed

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Roben A. Pearlman. MD, MPH
Sealtíc Veterans Aífairs Medical Center
Scíittie, WA 98108
Nancy S. Jecker, PhD
University of Washington
Seattle, WA
Reference
I. Waisel UB. Truog RD. The cardiopulmonary rcsuscitation-not-indi-
cated order: fiilility revisited. Ann Iniern Mtd' l<4')5;]Z2-3()4-IA.
To the Editor: Although there is niueh to erilicize in the paper
of Waisel and Truog (I), we eonfine ourselves to one fundamen-
tal point. The authors echo the assertion that physiologic futility
is somehow free of "imposed value judgment" (2). By contrast,
we have pointed out (3) that making physiologic function the
objec! of medical treatment is not value free but rather ii value
choice, which, In our opinion, is about as far from a patient-
centered goal of medicine as it is possible to be, Waisel and
Truog do not say exactly why they consider physiologic futility to
be free of value judgments. However, their statement that "def-
initions of physiologic function (such as circulation and ventila-
tion) . . . are more technical in nature and do not involve sub-
stantial value judgments" suggests Ihat they have succumbed to
what Aivan Feinstein has called the "curse of Keivin,"" namely,
"the basic sentiment is: When you cannot express it in numbers
your knowledge is meager and unsatisfactory" (4). in other
words, it is easier to coun! heartbeats and respiration than to
determine when the patient no longer has the capacity to appre-
ciate these organ functions as a benefil. This ease of measure-
ment therefore provides the rationale for caiiing heartbeats and
respiration the goals of medical treatment. Lord Kelvin himself is
reported to have said, "All science is measurement but not all
measurement is science." Similarly, we submit that all medicine
represents outcomes, but not ait outcomes represent medicine.
¡Mwrence J. Schneidennan, MD
University of California, San Diego
La Jolla, CA 92D93-Ü622
Ntrncy S. Jecker, PhD
University oï Washington
Seattle, WA 9SI9,'5
Rtferences
t. Waisul I>B, Tniog RD, The cardiopulmonary rcsuscitation-not-incli-
cated order: futility revisited. Ann Inleni Med. i993; 122:304-8.
2. Truog Rl), Brett AS, Frader J, The problem with fulilily. N EngI J
Med. l942;32fvl5r)0-4.
3. Si'hneiderman LJ, Faber-Langendnen K, Jecker NS, Beyond futility to
an ethic of care. Am J Med. t994;96:l tl)-4.
4. Feinstein AR, On exorcising liic gliost of Gauss and ihe curse of Keivin.
in: Cliniciil Üiostatislics. Si. i_ouii;: Mosby: 1977:235.
To ¡he Editor: In their assessment of CPR-not-indicated pro-
posals, Waisel and Truog (1) conclude that "policies based on
anything other than physiologic futility are indefensible," adding
that physiologic futility "is a symbolic statemenf ¡hat "docs little
to advance current practice management." For the house ofñcer,
such conclusions have little value. As the person who must carry
out the word of any directives, the house officer is often eaught
in the middle of decisions on resuscitation.
Physiologic futility as a guideline for CPR-nof-indicated poli-
cies has several drawbacks. First, physiologic futility is difficult to
assess before implementing resuseitative measures. Second, when
the paticnl reaches a point at which further measures would not
restore physiologic function, the patient is already dead. Third,
physiologic futility already exists, permitting the physician to "'call
a code." Thus, for the house officer, physiologic futility is an
impractical approach.
In any policy for CPR-not-indicatcd orders, the direct relation
of the house officer to the resuscitation decision sets up the
possibiiity for eonflict between housestaff values and patient or
family wishes. Some of these conflicts are resolved by a "s!ow
code." a practical but unethical resolution of the conflict in which
1 January 1996 • Annals of Irttemal Medicine • Volume 124 * Number 1 (Part I)
physicians fail to inform families of their intention not to resus-
citate. Patients and families must be aware of our plans and must
be encouraged to seek alternate physicians when intentions dif-
fer. Housestaff should be involved in ali levels of discussion.
A role exists for unilateral do-not-resuscitate orders and co-
gent definitions of futility. Decreasing stays in the intensive care
unit will yield some eost savings. Public mistrust exists amid the
suspicion of clandestine deeision making. Concern for value judg-
ments should be tempered by ihe knowledge that physicians
make such judgments regularly when offering and withholding
Ireatments. In the final analysis, fidelity, nonmaleficence, and
utility supersede the concerns of paternalism in the deeision to
apply unilateral CPR-not-indicated orders.
.lonathan P. Kalz. MD
University of Pennsylvania Medical Center
Philadelphia, PA 19104
Rei'erence
I. Waisei Dli, Tniog RD, The cardiopulmonar>' resuseitation-not-indi-
cated order: luiility revisited, Ann Intern Med. 1995:122:3(14-8,
In response: We appreciate the thoughtful comments of the
readers. Several, however, seem to misunderstand our position.
We completely agree that '"physiologic futility" is not value free.
We also completely agree that "futility policies" that are based
on the concept of physiologic futility will be useful only in very
few cases.
Our centrai point is that iiny conccpi of futility implies an
objectivity and neutrality toward values that is misleading. Al-
though the notion of "physiologic futility" perhaps comes closest
to achieving these features, we recognize that it is also inherently
flawed.
We ceriainly agree with the readers that many of the treat-
ments currently provided to patients are inappropriate and
should not be used. We disagree, however, on the ways in which
these refusals to treat should be justified. As several of the
readers observe, after we acknowledge that these deeisions to
refuse therapy always involve competing values, ii becomes dear
that ¡hese conflicts must be resolved in a way that addresses
these diverse values. This approaeh requires societal involvement
and a dialogue between ihe medical profession and the commu-
nity. As a result of this process, the questions are placed within
a different framework. Instead of asking whether a treatment
"works" (the futility question), we more appropriately ask
whether providing a treatment is fair and reasonable under the
particular circumstances. The concept of futility does more to
muddle and confuse these issues than it does to resolve them.
David B. Waisel, MD
Wilford Hall Medical Center
Lackland Air Force Base, TX 7X23fi
Roberl D. Truog. MD
Children's Hospital
Boston, MA Ü2115
Physician Compliance with Guidelines
To the Editor: Ellrodt and colleagues' paper (1) highlights the
difficulty physicians have with guidelines. However, "noncompli-
ance" may not be an appropriate term to dehne physician re-
sponse. Such findings as the high rate (42%) of misclassification
and the lack of agreement among independent reviewers over
medical appropriateness in reeords reviewed suggest differences
in guideline interpretation.
Although Ellrodt and colleagues reported a similar distribution
of physieian mix between those who did and did not discharge
appropriately, they did not indicate how these physicians com-
pare with those in their respective specialties (for example, the
percentages of compliant and nonconipliant cardiologists). Were
internists more or less compliant than eardiologists? Did the 13
noneompliant physicians differ from those who appropriately dis-
77
charged the 151 patients? What types of physicians misclassificd
high-risk patients as having low risk, and the reverse?
Because comorbid conditions are a factor in delaying iliï-
chargc. would multiple physician management of multiple ill-
nesses contribuie to preexisting inefficiencies of the health cure
system? Could this explain why more cardiologists were nonconi-
phnnt? Research suggests ihat cardiologists view iniornisls iinil
family practitioners as lacking the knowledge and practice to
!reat acule myocardial infarction (2). Is this also ¡rue íor non-
cardiae conditions? Kassirer (3) has noted thai there is litilc
difference between generalists and specialists in terms of qtiality
of care.
If perceptions of what constitutes appropriate CÓTC arc spe-
cialty based, how effective is physician-to-physician feedback in
changing physician behiivior? Do physicians usually constiit with
those in their own specially when determining a course of (rctit-
ment for ihe diseases they routinely manage? If so. ireattnent
uniformity may be possible, bul would stich tmiformify cross
specialty lines?
Finally, is it feasible to expecl diagnosis-specific guidelines
from a consensus of different physician specialties? If differenl
specialties develop different guidelines lor the înanagenicn! of
the same disease, can positive outcomes result from diflcrenl and
equally efficacious treatments? if so. whom are guidelines lor?
More imp<irtantiy. how much weight should gtiidclincs have tor
assessing quality of cure?
Bt'Uy C. Jung. RN. MI'H
Guilford, CT 06437
Rclerentes
1. Ellnidt A(;, Conner U Riedinger M, Weingarten S. Meiisuring ;i[ul
improving physiciiin compliance with cliniciii practice gnidclincs. A
controlled intcrvciilional irial. Ann Intern Med. 1995:122:277-82.
2. Ayanian JZ. Hauptman P.|, Guadasnoli E, Antnian EM, Paslios <_'L,
McNeil B,l. Knowledge anti pniclices of gencralisi and specialist physi-
cians regarding drug therapy foi acute myocardial iiifari'lion. N Fiigl .1
Med, 1944:33hi 136-42,
3. Kassircr JP, Acœss lo speci;ilty care. N Engl J Med i W4:3.il:l LS?-.v
¡n response: Ms. .lung raises several important issues aboti!
physician compliance with clinical practice guidelines. We ptit-
posely used the term compliance because it is commonly applied
to "conformancc" with guideline recommendations. Our point
was that before one assumes that physicians simply refuse to
follow recojnmetidations and arc therefore "noncotiipliant." a
more in-dcpth review is required, i believe that Ms. Jung and we
are in complete accord on this issue.
Compliance rates for cardiologists, internists, and a conibin;!-
tion of these two significantly differed. Compliance with the
guideline was higher (84%) when internists lilonc cared for pa-
tients than when cardiologists alone (58'/r.) or internists with
cardiologists cared for the patient (5^^/r. P - 0.001) (I), We hiivc
no data to support or refute the idea that cardiologists might be
less adept at managing comorbid conditions outside their do-
main.
We believe our study suppi)rted the concept that physician-to-
physieian feedback wa.s effective. We cannot comment on whether
eardiologist-to-cardiologist or intemist-to-internist feedback would
be more effective.
If physicians are using the literature and an evidence-based
medicine approach to guidelines and pathways, substantial con-
sensus about best practice (in well-studied areas) is likely. An
evidence-based medicine approach should help avoid "biased"
guidelines, whether they are developed by subspccialists or other
groups. The issue of apparently equally efficacious treatnienîs is
best resolved by direct comparisons in rigorous clinical trials. In
addition, if a team is atîcmpting to develop guidelines and has
good evidenee supporting two difierent approaches, it is not
tinieasoniible to offer a choice of inanagemcnt strategies to the
caregivers and patients.
Finally, measuring outcomes of care coupled with optimal pro-
cesses according to guideline recommendations should provide
the best quality of earc.
78 1 Januarv 1996 • Annals of ¡mernal Mediane • Volume 124 • Number I (Part 1}
A. Cray Ellrodt. MD
Cedars-Sinai Medical Center
l,os Angeles, CA 90048
Referente
1 Weingarten SM, Riedinger MS, Cunner L, Lee 111, Hoffman I, Juhnsun
It, et al. Practice guidelines and remmders to reduce duration of
hospiial Slav lor patients with ehest pain. An intcrventionai iriiil, .\nn
liikTii Med'. lWl:120:2.^7-(.3,
Cali for Medical Quotations
Thu American Coiiege of Physicians ha,s asked .lock Murray,
preseni Chairman. Board of Regents, and me to serve as editors
tor a book of medical quotations. The book will illustrate the
hisUirical development of concepts and practice in tnedicine (dis-
eases, apparattis, procedures), represent the states of life—birth,
growlh. pain, death—that are concerns of the patient and the
physician, and iiluminittc the relations of paticnl and physician.
All fields of medicine are to be covered, noi solely internal
medicine.
We invite members of the College and other readers of Annals
to submif quotations to be considered for publication in this
collection,
A more detailed description of the aims for the book and of
the kinds of quotations sought, and forms for submission of
i|t]otati(>ns jrc available. Please address reqticsîs for these to
Kadilfcn Case. Publishing Division, American College of Physi-
cians, Sixth Street at Race, Philadelphia. PA 19106-1572, USA.
Faxed requests can be sent lo 215-351-2644, Requests shouid
indicate the number of copies of Ehe subtnission form requested:
each quotation must be submitted on a separate form.
Eílmml J Hiiih, MD
Editor Emerilus. Annals of ¡menial Medicine
Philadelphia. PA 19106
Correction: Vascular Causes of Renal Failure
A recent article on vascular causes of renal failure (i) coii-
Uiincil two crr()rs. On page hO3. the last sentence in the second
piiragraph should road "Salt-poor tirinc. clinical features, and lhe
absence nf hematuriii, proteinuria. and reital failure casts rule
out these other conditions." I'hc word "casts" was inadvertently
omitted from the printed sentence. In Table 5. the line ' Throm-
bdtic thronibocytopenic purpura" in the first column should be
aligned with the line ""Hemorrhage, weakness' in the second
column rather than with the line "bever, centrai nervous system
changes,"
Referente
I. Ahucio J(;. t)ia^nosii]g vascular causes ot renal taihire. Ann intern
Med. l'W5:12_";:<)(ll-4,
Correction: Updated Internet Information
Since the recent article on medical resources on the Intertïet
(1) was published, the filename for Mosaic for Windows has been
changed. The correct site/directory/fiiename is the following: ft-
p.ncsa,uitic.edu/Web/MosaicAVindows/w32sOI.H.exe. In addition,
the site of the National Center for Supcrcomputing Applieations
shouid contaiti the word "Metalndex" rather than '"Metainde.\,"
The following is the corrected, complete listing: http://www.ne-
sa,uiuc.t;du/SDG/Softwarc/Mosaic/MetaIndex,hltnl, Note that the
terminal periods are not part of the addresses.
Refert-nce
L Gl«»niak ,IV. Medical resources on the tnternot. Ann Inteiii Med,
 Copyright © American College of Physicians 1996.

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