Often in medicine, when physicians give advice, it is clear cut, precise and meant for a particular patient or group of patients. However, the message can be misunderstood or misused. Patients may have concerns when that advice may be different than it was from previous visits or not what they expected it to be. Are doctors changing their minds and their messages? Let’s examine this issue more closely.
In Canada and around the world, when medical guidelines are issued on a particular subject, they are the most up to date and most researched, outlining the most credible advice available on a subject. However, over time, research evolves; new studies are published and the guidelines evolve. That doesn’t mean physicians have “changed our minds,” but rather we are now sharing the most up to date information, even if it may contradict previous guidelines. That is sometimes hard to digest. But it is medical reality, reflecting the landscape of the present understanding.
Here is a quick example. When I was a medical student (a long time ago!), every patient, was required to have a chest X-ray before any surgery. At the time, concerns for tuberculosis and other infectious diseases were paramount. So, despite the radiation from X-rays, that was the guideline. We don’t do that anymore, even with smokers. Over time, it was shown that this intervention was no longer needed. As physicians, did we change our minds? No, we just received newer information.
As an example, let’s look at the evolving information on low dose acetylsalicylic acid (ASA), baby ASA. First, we no longer give baby ASA to babies. It can lead to a rare syndrome called Reyes Syndrome when given to an infant with a fever. So right from the get-go, the name is misleading. Second, the decision to take low dose ASA depends on many issues. Is it for primary prevention or secondary prevention of cardiac disease? Primary prevention refers to a patient without any cardiac disease and we are trying to prevent or lower the risk of developing it.
In secondary prevention, the patient already has some evidence of risk, perhaps changes on an ultrasound showing calcium in coronary arteries, or perhaps angina, chest pain with exercise. There is a big difference in these two patient profiles. In this example, there are other considerations. Does the patient have diabetes, previous blood clots, high blood pressure or worrisome family history? Clearly, the decision and the variables or issues are different for each patient and the guidelines may differ for individuals.
But as a consumer, perhaps you and your friend are talking, sharing health stories, and the question might arise about why a doctor treated one of you and not the other?’ It is all about context. What is the context for this individual, what is your risk profile? This is personalized medicine, what is right for you, based on guidelines, yes, based on your history, yes, based on our best advice today. And yes, that may evolve, that will evolve as we learn more and work to keep you up to date.