CONFLICTING RECOMMENDATIONS: WHO SHOULD YOU BELIELVE?

So, you want to stay healthy?  Or maybe, you need to treat some condition you have developed.  It would certainly seem to make sense to follow authoritative recommendations from recognized groups of experts.  You would think this would be easy to do. Well, this is not always as easy as it should be. 

The problem is that the media trumpets new “official” recommendations on how to treat or prevent some dreaded disease or medical condition.  You see these recommendations, usually stated as if they were hard facts, on TV, in the papers, or on the internet.  Your friends will quote this advice solemnly, and perhaps your doctor will push it as definitive.

Then, often with months, a new report will hit the media with a totally different set of “official” recommendations from a different “authoritative” organization.  All too often, these recommendations conflict with the first set.  How can this happen? 

The first thing to understand is that in the US there is no single recognized “official” body to look to.  What we have is a collection of separate specialty societies, each of which feels obligated to issue its own set of recommendations.  Any condition you can think of will almost certainly be diagnosed or treated by several specialties.  If one organization issues a list of recommendations, the other societies will lose stature and be perceived as less important if they do not come out with their own.  Further, they cannot very well come out with recommendations from their group that say, basically, “Yeah, those other guys were right.  Do what they say.”  If they did, they would get zero press coverage and their committee members would be perceived as less authoritative than the others.  So, to maintain their status, they publish the second, or perhaps third, set of conclusions,

Complicating things further, we have to recognize that each group of specialists have their own prejudices and financial interests at stake.  After all, these specialties get paid to diagnose or treat these conditions, so not surprisingly, if there is more than one way to handle the problem, their recommendations always seem to be the ones that help their pocketbook.  I guess this is a sad commentary on human nature. 

Let’s look at a very simple example.  How often should a woman get a screening mammogram to look for an early cancer.  Doctors routinely, usually solemnly, pronounce “the” recommendation.  But whose are they using?  The CDC summarizes guidelines from seven different organizations, and there are differences. 

The American College of Radiology has for many years espoused the concept of annual mammograms.  It seems an article of faith.  They also recommend the annual mammograms start at age 40.  Surprise!  They are pushing for more mammograms than any other organization, and they are the ones getting paid to do the studies.  

At the other end of the spectrum, we have the US Preventive Services Task Force.  They do not recommend screening until age 50 (unless the woman asks for it) and after age 50 they recommend screening every other year.  However, the USPSTF is sponsored by the federal government, which has an obvious interest in limiting the cost to the medical care system.  Is it a coincidence that they give the least expensive guideline? 

The American College of Obstetricians and Gynecologists sides with the radiologists, but also adds an annual clinical breast exam, for which they get paid.  No other society includes a clinical exam in their guidelines.

The American College of Physicians and the American Academy of Family Physicians side with the USPSTF, with mammograms every other year after age 50.  The American Cancer Society guidelines fall in between with annual mammograms from age 45 to 55, and every other year thereafter.

Similar problems with conflicting recommendations can be found for a huge number for the problems we deal with commonly.  At what blood pressure should we begin treating?  What should our target be?  What cholesterol levels should be treated with the statin drugs?  The American College of Cardiology and the American Heart Association have come out with new recommendations that conflict with those of the American Association of Clinical Endocrinologists.  This will be the subject of another post.  When should the PSA (prostate specific antigen) test be done for men?  How about PAP tests in women?  All have conflicting recommendations.  The list goes on and on.

So, what do I do?  I try to objectively present the variable guidelines so people can make their own decisions, and I try to support whichever decision they feel comfortable with.  I also try to remain aware of the potential biases behind any recommendation I see published.  I think they all need to be taken with a grain of salt. 

They all say they are authoritative, but we usually do best if we apply some Real Common Sense.