When you need medical help, how does your family doctor decide which diagnostic tests to order for you, and which treatments to recommend based on those test results? Physicians are trained to rely on a type of professional playbook called clinical guidelines to help them make those decisions. But as Dr. Michael Vallis, a professor of family medicine at Dalhousie University in Halifax, described the problem family docs face with clinical guidelines:
“There’s just no way they can follow every single guideline. One of the biggest impediments to physicians following new guideline recommendations is that they’re overwhelmed.” .
Sometimes, there are simply too many guidelines, or too many individual recommendations to be truly practical. And if a patient lives with a number of chronic conditions (like heart disease plus diabetes plus high blood pressure plus arthritis, for example), their family doctor may have to access several guidelines at the same time. And some of these guidelines may even seem contradictory.
Guidelines do in fact change over time to keep up with emerging medical research conclusions. So how do our doctors ever stay on top of every emerging new practice guideline?
An example of this change is Hypertension Canada – an independent organization of clinical and scientific healthcare professionals with expertise in treating high blood pressure. Their guidelines previously recommended that low-dose aspirin (ASA) should be considered in all adults with high blood pressure who are 50 years of age or older to help prevent cardiovascular disease in the future.
But – NEWS FLASH! – in light of newer research findings on the risks of taking aspirin every day (major bleeding) vs. benefits (lower chance of heart disease), Hypertension Canada determined that the risks actually outweigh the benefits – and they removed this guideline recommendation in 2020. So low-dose aspirin is no longer recommended for primary prevention of heart disease in adults over 50 with high blood pressure.
It’s likely that physicians who are still routinely recommending low-dose aspirin to their patients for this specific reason may not have read those 2020 guidelines yet.
So many guidelines, so little time. . .
Another new guideline that’s important for heart patients is called C-CHANGE.(1)
First established in 2008, C-CHANGE produces a guideline that’s a subset of recommendations from Canada’s cardiovascular-focused guideline groups. The newest update released this year is their fourth so far – and (here’s the good news!), the team of physicians and researchers who drafted this updated guideline actually sought feedback from heart patients.
Basically, the 2022 C-CHANGE update includes a total of 83 recommendations, of which 48 are new or revised. They focus on what’s called “multi-faceted care” for people who are at high risk of cardiovascular disease – from preventive strategies to screening, diagnostic tests and treatments.
Recommendations include appropriate medications, but also these cornerstones of lifestyle behaviour change:
- healthy eating
- regular physical activity and exercise
- healthy body weight
- stress management
- reduced alcohol intake
- smoking cessation
That’s a pretty long list of recommended lifestyle changes based on the family doc’s risk screening assessment of each adult patient. And imagine the time requirements for busy family doctors tasked with adopting dozens of new recommendations?
While Dr. Michael Vallis calls C-CHANGE “a well-organized overview of guidelines on cardiovascular medicine”, he was realistic about its practical usage in family practice – and more importantly, the response to guideline recommendations from patients themselves.
He suggests, for example, that the problem with guidelines like the new C-CHANGE update (and with chronic disease management in general) is that recommendations also tend to assume that patients will be immediately on board with these recommendations.
“Clinicians too often prescribe drugs, for example, without first addressing the critical question of whether the patient intends to take these medicines as directed. Clinicians may presume that a patient is ready (immediately upon receiving a new diagnosis) to adapt and make needed changes in lifestyle, including following complex drug regimens.
There are many reasons, each one personal and individual, that patients like this are rarely found. I wrote about the PURE study (Teo et al, JAMA, 2013), here:
These researchers followed over 7,500 heart attack survivors in 17 countries. They found that:
• 48% of smokers continued to smoke
• 65% did not exercise
• over 60% did not improve their diet
• 14% had adopted not one single lifestyle improvement
So it’s safe to conclude that, generally, most behaviour change advice from our doctors does not seem to be working. See also: Living with the “burden of treatment”
As Dr. Vallis reminded his colleagues in a recent Medscape interview, there needs to be greater realization of the stages of acceptance that patients must work through following a diagnosis for a chronic disease.
“Physicians may describe patients as being in denial of their medical conditions, when what they actually need is help in adjusting to them.
“They’re not in denial. They’re just struggling to accept the diagnosis. They don’t want to be sick. Nobody wants to be sick. They don’t want to organize their life around their illness. They just want to be normal.”
Although we’re on the same team, physicians and patients sometimes have surprisingly different goals.
One interesting difference in our goals is that doctors often recommend what behaviour scientists call avoidance goals (“Do this so your test numbers won’t rise“). These are apparently far less effective than approach goals (“Do this so you’ll feel better) For example, I could decide to head out in the sunshine today for a brisk walk to help me ward off a future heart attack someday (an avoidance goal) or I could go for a walk so I can enjoy a seaside view (an approach goal).
Your family doctor wants your test numbers and your chances of worsening future outcomes to improve. Patients generally don’t care about numbers.
Rahul Jain et al. Canadian Cardiovascular Harmonized National Guideline Endeavour (C-CHANGE) guideline for the prevention and management of cardiovascular disease in primary care: 2022 update. Canadian Medical Association Journal, , 7 Nov 2022.
Q: Have you experienced that struggle to adjust to a new diagnosis?
NOTE FROM CAROLYN: I wrote much more about why women are not just small men in my book, “A Woman’s Guide to Living with Heart Disease” . You can ask for it at your local bookshop, or order it online (paperback, hardcover or e-book) at Amazon – or order it directly from my publisher, Johns Hopkins University Press (use the JHUPress code HTWN to save 30% off the list price).