Gold standard, guidelines, and… money!

Medical practice must be based on data, statistics, and outcomes. All these factors must work together to determine which medical attitude offers the best patient outcomes. Is this true in today’s practice and recommendations?

The gold standard should be the best procedure or exam to treat or diagnose a specific disease, meaning the one that offers the best results. This should be independent of costs. Cost-effectiveness and availability should be evaluated separately from the gold standard classification, I think. Are doctors thinking this way?

Additionally, guidelines and recommendations should be based on pure scientific results. Trials and studies analyzing outcomes independently of costs should be prioritized. Do you think this is the reality?

Reading a book about colonic polyps, the authors said the length and periodicity of the surveillance are being decreased, meaning fewer colonoscopies. The reason? The health care system was not able to respond to the previous recommendations. So, periodicity and length of surveillance were changed not because colonoscopies were being performed in excess (without benefits for the patients) but because the health care system failed. The new surveillance recommendations are not better for the patients, they are better for the system. Is this evidence-based medicine?

Another similar topic comes from my daily clinical practice, and is about preoperative localization of a parathyroid adenoma in the setting of a PHPT (primary hyperparathyroidism). The gold standard approach is a target surgery, performing a small incision directly over the adenoma and conducting a minimal neck dissection. This has very good results with less morbidity and faster recovery than the classical neck exploration. To do this, a reliable preoperative localization is mandatory (two concordant image exams). Otherwise, the adenoma may not be found, the patient will not be cured after the first surgery, additional image tests will have to be performed, and another neck exploration will be necessary. Nowadays we know that PET-CT Choline has huge advantages over the classical MIBI. It is better to find small adenoma, better to find multiglandular disease, better to find adenoma near the thyroid, and gives much better images that will help surgeons. However, doctors keep saying PET-CT Choline is expensive and because of that should be a second-line test. Why? If it is the best test why should we use it only after the other tests fail or the first surgery fails? Why do guidelines insist on not recommending PET-CT Choline as first line? Once again, money is the possible reason. Once again, doctors may be making recommendations based on money not science.

Is this correct? I know some will say money is important because someone has to pay for it. Correct. But doctors and recommendations should not be the reason for someone to refuse to pay for that procedure or exam. People are using recommendations as an excuse to not pay for the best procedure, and this is negatively influencing medicine and patients. At least this is my idea…

A doctor’s work is to offer the best treatment to the patient, not the cheapest. Doctors are supposed to treat patients aiming for the best outcomes, not the least money spent. Always remember, in the end, outcomes will be only the doctor’s responsibility. No one (those who tell you not to spend money) will back you up in a legal litigation. Doctors must always decide based in good and strong science. Doctors’ responsibility is to the patient, not in health care management (that is for politicians, who do anything to run away from it).

The cheaper medicine is the best medicine.

Dr. Carlos Eduardo Costa Almeida

General Surgeon

#guidelines #recomendations #money #responsibility #medical_responsibility