Sharon Begley
Senior Correspondent, Health and Medicine,
Reuters
Evidence-Based Guidelines Affecting
Policy, Practice and Stakeholders
New York Academy of Medicine
December 11, 2012
(Some) Doctors
Resist Guidelines
The majority of doctors continue to recommend annual
cervical screening for women in which guidelines
suggest waiting 3 years between negative Pap tests.
[Roland et al. American Journal of Obstetrics & Gynecology, 2011]
Although guidelines for acute low back pain call for advice
and analgesics, 80% of 3,533 patients in a 2010 study were
not given advice and 82% were not given analgesics. Many
got harmful drugs not recommended in guidelines: 37%
got anti-inflammatory drugs, 20% opioids.
[Arch Int Med 2010: 170(3)]
Guidelines? What guidelines?
 Nearly 30% of physicians reported routinely ordering
ovarian cancer screening for women at low risk for the
disease, despite recommendations against routine
screening.
 Incidence of ovarian cancer is low, and screening tests
have high false-positive rates and low positive
predictive values. In addition, there is no proof that
screening affects morbidity or mortality rates of
ovarian cancer.

[Baldwin LM. Ann Intern Med. 2012; 156: 182-194]
Why do doctors resist guidelines?
Not because they’re unaware of them.
“A growing number of doctors and patients have begun to chafe under
the absolute one-size-fits-all view of disease inherent to guidelines.
Most guidelines assume the presence of only a single condition or risk
factor, recommend unwavering cutoff points for treatment and are
based on averages derived from large groups of patients. But real
patients are rarely average.’”-- New York Times, May 19, 2011
The US has a pay-for-service healthcare system
What the press likes
 Personal stories, anecdotes—that is, individuals over
statistics
 The surprising & unexpected
 Controversy
 Skepticism/contrarianism
Personal (and Contrarian)
 Prostate cancer survivor: PSA test 'saved my life'
(News 9, Denver, October 8, 2011)
 Officer: Colonoscopy saved my life (Jacksonville
Action News, March 29, 2012)
 Any number of similar quotes, stories and testimonials
can be found instantly by searching the internet. The
stories usually drive home the message, “get the test,”
and are seen by their publishers as essentially Public
Service Announcements—regardless of guidelines.
Controversy: Sex Sells
 The inevitable social controversy over guidelines on
“hot” topics like Plan B for teenagers and vaccination
for HPV almost guarantees extensive coverage.
 Plan B guidelines announced last month generated to
643 news stories, including major newspapers, TV
networks, wire services, magazines (Google News
search 12/4)
 HPV vaccination guidelines received similar wide
coverage (644 stories, Google News search 12/4)
Unsurprising?
Six organizations issue new clinical recommendations in
November 2012 for diagnosing and treating stable ischemic
heart disease (IHD)
 “Patients with chest pain should receive a thorough history
and physical examination to assess the probability of stable
IHD prior to additional testing. Choices regarding
diagnostic and therapeutic options should be made
through a process of shared decision making between the
patient and physician to discuss the risks, benefits, and
costs to the patient.”
 These definitely non-shocking guidelines received almost
no news coverage. (Google News Search: 3 stories)
Watchdogging
 The press likes to sniff out potential conflicts of
interest and be a “consumer watchdog”
 When an interest group takes a position against its
perceived own financial interest, the story is likely to
get more favorable coverage
 “Choosing Wisely”
Cervical Cancer Screening
 In 2009, the American College of Obstetricians and
Gynecologists said get fewer Pap tests (women over 30
who have had three or more normal annual Pap tests
can be screened every 3 years instead of annually).
 Extremely favorable and extensive coverage, mostly
because a group that would be expected to take a
different view (i.e. ACOG should want women to get
PAP tests every month) recommended ‘doing less.’
Cholesterol
 Abundant controversy about cholesterol, including
about what level means you should be on a statin and
who should be screened
 November 2011, a panel assembled by the National
Heart, Lung and Blood Institute issued
guidelines calling for universal screening of all 9 to 11year-olds with a non-fasting lipid panel. Previous
recommendations called only for children considered
at high risk of elevated levels to be screened with a
non-fasting total cholesterol test.
Consider the Source
 The press follows the ‘consider the source’ doctrine,
and if the source has a financial interest in the
guideline then coverage is often more skeptical.
 The NHLBI panel chair and members disclosed
extensive financial relationships with companies
making statins and lipid tests, including paid
consultancies or advisory board memberships with
Merck, Pfizer, Astra Zeneca, Bristol-Myers Squibb,
Roche and Sankyo.
. . . And consider the evidence
 August 2011: A study in Obstetrics & Gynecology, the
journal of the American College of Obstetricians and
Gynecologists, found that barely one-third of the
group’s clinical guidelines meet the Level A standard
of “good and consistent scientific evidence.” The
majority of ACOG recommendations for patient care
rank at Levels B and C, based on research that relies on
“limited or inconsistent evidence” and on “expert
opinion.”
The Modern Media Environment
 'In the relativistic haze of participatory media, it's all just a
matter of opinion. You are entitled to yours and I am
entitled to mine. . . . The Internet welcomes everyone into
the conversation. An op-ed in the New York Times may as
well be a column on the Huffington Post. . . . Everyone's
opinion may as well matter as much as everyone else's,
resulting in a population who believes its uninformed
opinions are as valid as those of experts who have actually
studied a particular problem." [Douglas Rushkoff, 'Present Shock']
 'In this era of exploding media technologies there is no
truth except the truth you create for yourself." [Richard Edelman, PR
guru]
Trusted No More
 In part because of this proliferation of sources, the
media are not trusted.
 In turn, relying on the media to “get the word out” and
educate the public and practitioners about medical
guidelines may not be the best strategy.
Gallup Poll, Sept 21, 2012
Key Gallup Findings
 “Americans' distrust in the media hit a new high this
year, with 60% saying they have little or no trust in the
mass media to report the news fully, accurately, and
fairly. Distrust is up from the past few years, when
Americans were already more negative about the
media than they had been in years prior to 2004.”
 In the 1970s 72% expressed high trust in the media
Gallup Poll, December 2, 2010
Most Americans Take Doctor's Advice Without
Second Opinion
 Despite the advent of health websites and other widely
available sources providing medical research and
information, 70% of Americans feel confident in the
accuracy of their doctor's advice, and don't feel the
need to check for a second opinion or do additional
research. Americans' confidence in their doctor is up
slightly from eight years ago.
Reporters or doctors?
 The best strategy is likely to be one that focuses on
physicians and other health professionals, not the
traditional media