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Correspondence  |   January 2015
Old Guidelines or Methods Cannot Insure Quality or Progress
Author Affiliations & Notes
  • Paul M. Kempen, M.D., Ph.D.
    Weirton Medical Center, Weirton, West Virginia. kmpnpm@yahoo.com
  • (Accepted for publication September 23, 2014.)
    (Accepted for publication September 23, 2014.)×
Article Information
Correspondence
Correspondence   |   January 2015
Old Guidelines or Methods Cannot Insure Quality or Progress
Anesthesiology 01 2015, Vol.122, 218-219. doi:10.1097/ALN.0000000000000492
Anesthesiology 01 2015, Vol.122, 218-219. doi:10.1097/ALN.0000000000000492
To the Editor:
The recent article and editorial regarding the use of a proprietary Decision Support Tool extolled the need to quit memorizing data, favoring medical interactive applications in applying medical knowledge.1,2  The Decision Support Tool was designed to increase adherence to an outdated yet still “current” 2007 American College of Cardiology/American Heart Association perioperative evaluation consensus guideline (PECG). It is clear that perioperative β blockade (PBB) and cost containment played a very large role in the underlying assumptions of that guideline. It is also clear that in 2008, the POISE study (PeriOperative ISchemic Evaluation trial [ClinicalTrials.gov Identifier: NCT00182039]) completely transformed the premise of PBB, finding PBB stroke morbidity outweighed any cardiac morbidity prevention. PBB guideline revisions followed rapidly in 2009, without corresponding PECG changes. Furthermore, the reporting of Dr. Poldermans ethical violations, as a world proponent of PBB, further publically raised significant questions undermining the 2007 PECG validity. Cardiac guidelines experience particularly rapid turnover for multiple reasons.*01  Medical reversal is a rapidly emerging reality, indicating guidelines have limits to application, as well as potentially short shelf-lives, as PBB clearly demonstrated.3  This may directly compromise the usage of any Decision Support Tool, especially if failing to update rapidly while physician’s life-long learning does facilitate updates.
Assuming the PECG is “correct” in 2014, is a fundamental problem. Similarly, testing “correct answers” based on a Decision Support Tool adhering to the 2007 PECG, presents simply a false premise for contemporary knowledge. The guideline should also fit the patient and not vice versa. I would ask the researchers to publish their “defined as correct” answers to the already published questions, to facilitate assessment whether these answers are deemed correct by modern readers! Knowledgeable physicians may justifiably reject the guideline and the proposed “Correct” answers in modern practice, especially when tailored to the variable contemporary reality at hand (i.e., University vs. rural hospital). External realities further impose, where patients produce satisfaction scores and see themselves deserving EVERY consideration, test and therapy, regardless of cost, when rare complications produce 100% morbidity and mortality to them personally as “rare events.” The editorial goes even further, promoting the unproven utility of recertification. Similarly, transferring simulation and objective structured clinical examination applications for medical student/resident educations onto Recertification testing of practicing and competent physicians is yet another unproven leap of faith. Board certification, and especially recertification, have never been proven or demonstrated to clearly improve quality in care in outcome-based studies.
The real problem emphasized by both study and editorial, is that while both support the use of internet-based data acquisition in daily medical practice, certification, and recertification tests forbid it completely. Similar to old guidelines, simply believing that “certification or recertification matters,” may also be a mere historical relic, proprietary advertisement and/or simple false legacy assumption, having emerged before modern licensure and extensive regulation of residency training programs.4  These and other concerns have led to the significant opposition to maintenance of certification among physicians at large. It is time for an open discussion of the risks and benefits of the cost and unproven assumptions of recertification and maintenance of certification, as a Quality = Value/cost indicator. Blind, computerized, adherence to aging guidelines, however, requires short-term revalidation of underlying programs to insure patient safety.
Competing Interests
The author declares no competing interests.
Paul M. Kempen, M.D., Ph.D., Weirton Medical Center, Weirton, West Virginia. kmpnpm@yahoo.com
*Boyles S: Cardiac Practice Guidelines Have High Turnover, May 27, 2014. Available at: http://www.medpagetoday.com/Cardiology/CHF/46004. Accessed June 13, 2014.
Boyles S: Cardiac Practice Guidelines Have High Turnover, May 27, 2014. Available at: http://www.medpagetoday.com/Cardiology/CHF/46004. Accessed June 13, 2014.×
References
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Lockman, JL, Schwartz, AJ Learn it-memorize it! Better yet–open your smartphone and use the information!. Anesthesiology. (2014). 120 1309–10 [Article] [PubMed]
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Kempen, PM Maintenance of certification and licensure: Regulatory capture of medicine.. Anesth Analg. (2014). 118 1378–86 [Article] [PubMed]