Good Guidelines, Worthless Guidelines
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Notice bibliographique
Résumé
I agree that there are likely a number of other reasons that physicians don't follow guidelines beyond the ones that I suggested. And I never meant to imply in any way that all guidelines are bad. For example, I think the Ottawa Ankle Rules are probably among the best guidelines likely to be devised for ease of use and accuracy. I do think that some mechanisms to induce physicians to use rules and guidelines are needed, but this assumes that the guidelines are well done, easy to follow, and will change outcomes in some positive way. Physicians don't respond well to punishment, and carrots always work better than sticks. That's the thrust regarding the extensive “pay for performance” initiatives we see currently being trialed. Under this mechanism, for example, physicians would be paid for ordering fewer ankle x-rays, and there would be an incentive to use the Ottawa Ankle Rules. ACLS is, in my opinion, a totally different matter. Except for early defibrillation and perhaps bystander CPR, I know of no compelling data that show that following the ACLS guidelines will change outcomes for a condition that has as miserable a prognosis from the start as cardiac arrest. I think it is important to note that it is, in my view, totally inappropriate to require residency trained, board certified physicians to earn a card, as noted by Dr. Acosta. One of the initiatives in which I take personal pride was the successful effort to have the California Chapter of ACEP develop its “anti-merit badge” policy statement some 20 years ago. Although I was an ACLS-affiliate faculty in the Mesozoic era, I have not had an ACLS card for at least 20 years, and I have never had an ATLS, APLS, you-name-it card. It is an embarrassment that emergency physicians succumbed to earning these merit badges as is the whole concept that you needed to have a “valid” unexpired card or you could no longer perform. Total bull. That's not to say that it isn't a good idea to take these courses and stay up on the topics — this is a totally different matter. What I objected to was the fact that we had to take them and others often didn't, like the cardiologists. In the “old days,” they were generally clueless how to run a code and intubate patients, yet nobody had the nerve to say that cardiologists needed to be ACLS-certified to work in the CCU. We saw more arrests than anyone, and had more experience at it, and they were absolved and we weren't. I think Dr. Acosta and I are largely in agreement. And, to restate my core premise: Not one more dollar should be spent on developing guidelines (especially using my tax dollars) unless it is demonstrated that use of the guidelines substantially changes some important outcome in a positive way and there is some reasonable mechanism in place to actively promote adopting the guideline.
Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.
Prédiction distillée sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Apprise à partir de 10 348 étiquettes directes de Codex et de 10 348 étiquettes directes de Gemma. Le mode candidate est l'union des têtes enseignantes seuillées; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont ni des étiquettes humaines ni des étiquettes directes de modèles de pointe.
Scores Codex et Gemma par catégorie
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,002 | 0,020 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,000 |
| Méta-épidémiologie (sens large) | 0,001 | 0,000 |
| Bibliométrie | 0,000 | 0,001 |
| Études des sciences et des technologies | 0,000 | 0,000 |
| Communication savante | 0,000 | 0,000 |
| Science ouverte | 0,000 | 0,000 |
| Intégrité de la recherche | 0,000 | 0,000 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,030 | 0,001 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découle