The worst 4 words you can hear coming out of your doctor’s mouth are “well, the guidelines say…” Actually, “the consensus guidelines say” may be even worse. What this is code for is, we do not have data, so I am instead going to quote what a room of a bunch of physicians and researchers decided on. I have been part of many consensus committees. It ain’t pretty. Lots of fighting, lots of financially conflicted individuals, and the worst, indoctrinated and philosophically conflicted individuals. (Don’t believe me – ask yourself if you will get an animal rights activist who has spent his entire life denigrating anyone who eats meat to recommend high nutrient dense and high protein sources from animals, even to someone deficient in both). Or perhaps you are on a consensus guideline committee with one of several Haaaaaavahhhhddd researchers whose pockets were getting filled by the sugar industry to push any blame to fat. Get ready to fight them to the death, but since they are from Harvard, prepare to lose or be kicked off the board. Or maybe you are sharing the board with some members of the Global Energy Balance Network; now you are fighting against the incredibly deep pockets of Coca Cola…
The greatest trick the devil ever pulled was convincing the world he didn’t exist.
– Roger “Verbal” Kint (or Keyser Söze), The Usual Suspects
But I digress. The key here is, when approaching data-free zones, we should be totally transparent with patients. Covering up data-free zones with guesses masquerading as evidence, particularly when swimming in a sea of conflict, is the worst possible scenario, often leading to the false view that data exist, both in our eyes and our doc’s. The latter may simply be regurgitating something they never had the time or desire to research—if you repeat something enough times, you start to believe it. Just ask the docs who are still recommending over ten servings a day of bread, rice, and pasta to their diabetic and obese patients whose pancreases threw in the towel years ago and have almost no residual ability to digest carbohydrates. Or wait until the paper mask wearers start donning them this winter despite the evidence (both inside and out, to really hammer home a lack of evidence-based action).
I am proud to say that of the two last consensus committees I was part off, one removed all their dietary recommendations and the other—nutritional recommendations during cancer treatment—kicked me out after I refused to agree to their 1970’s recommendations that I would have only recommended to a Steeler’s offensive lineman in the off-season to help put on weight. You may not even recognize the guidelines as they are so close to the past, but let’s just say Bravo’s and Olive Garden may not be too happy with them as the endless breadbaskets may bankrupt them.
I now refuse to join any guideline committees, mostly because when docs, nutritionists, and exercise personnel use the word “guidelines,” I run for the hills. I say this all with utmost respect for my physician colleagues as guidelines bestowed upon us from the gods in their ivory towers often cause considerable conflict in our practices, particularly with well-informed patients who can smell the fecal aroma emanating from some of these so called guidelines and follow up with questions that quickly pick them apart (my favorite patients). And of course, I am not saying that all guidelines are bad (or good). I certainly refer to guidelines in my practice, but they are merely a starting point for a deep discussion as to whether one should proceed with a treatment or not, not the endpoint.
Some personal “guidelines” I would consider when your physician regurgitates recent medical guidelines are:
- Who was on the committee?
- What are their conflicts (are the participants sponsored by a company that owns ad space on every television channel available)?
- Do the guidelines always ultimately recommend treatment?
- Were these guidelines mandated upon the committee, particularly by the government?
- Ask your doc what is his or her personal opinion of the guidelines (assure them you are not recording the conversation).
- What are the potential side effects from following the guidelines (i.e., do not just tell me about the potential benefits.)?
These 6 simple questions usually tell you all you need to know. And last but not least, if the guidelines quote a relative benefit (i.e., this will cut your risk of flu in half), as opposed to an absolute benefit (i.e., this will cut your risk from 2 to 1%), be worried. And be even more suspicious if they then use an absolute number to quote the side effects (i.e., this will cut your risk in half and the side effects are only experienced in 5% of people). This is a dirty way of saying, your are trading a 5% risk of side effects for a 1% risk of benefit. Always ask for absolute numbers.
Would you agree to that shot or pill or lab recommendation if there was no data to back it, but rather the opinion of a room of scientists compensated by the companies who make the pill? What if your absolute potential benefit is a fraction of the potential side effect? The answer is up to you as the informed patient, but being informed is the most important first step.
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