Chief Medical Editor`s Message:Guidelines of Care

T his issue of Skin & Aging focuses on acne and discusses consensus recommendations for acne treatment. These recommendations are not formally issued guidelines of care from the American Academy of Dermatology (the AAD is expecting to release an updated version of acne treatment guidelines by no later than early next year); however, these consensus recommendations are put forth by leading practitioners and researchers who specialize in treating this condition. The Pros and the Cons of Guidelines In general, guidelines of care can provide tremendous educational value to physicians. Guidelines have certainly helped me organize my thoughts when treating complex conditions with numerous treatment options — and acne is clearly such a condition. In their ideal, guidelines lead us toward the best and most appropriate treatment plans for patients. It’s too bad, however, that guidelines of care can be fraught with so many problems. The process of creating guidelines of care is inherently problematic. Whether based on clinical experience or more formal evidence, this creation process is ultimately subjective. People who formulate guidelines come to the table with their own biases that will affect what they think is best. The only potentially unbiased candidates for this job would be those with no clinical or research experience with the condition or its treatments, and these people are probably in an even worse position to judge what should be deemed appropriate care. Clinical interpretation of guidelines is also riddled with problems. Patients are diverse individuals, each having their own complex set of demographics, co-morbidities, family histories, genetic predispositions, social situations and personal preferences. It’s nearly impossible for guidelines of care to account for all these factors, especially a guideline that assumes that all patients meet the criteria of the average person enrolled in a clinical trial. The art of medicine is very much the adjustment of the standard approach to fit the needs of the individual patient. For me, that’s often the fun part of developing the treatment plan. The Biggest Problem The worst factor of all, however, is the abuse of guidelines. Insurance companies can utilize existing guidelines of care as a basis to avoid paying treatment costs, even if a physician believes the treatment regimen is in the best interest of a patient. Guidelines can also be twisted in the legal system by attorneys trying to suggest that a physician did not properly treat a patient. Still, I like guidelines and the help they provide me in organizing a good treatment plan — but I also recognize the problems with them. That conflict is so typical of the world in which we live. Steven Feldman, M.D., Ph.D. Chief Medical Editor

T his issue of Skin & Aging focuses on acne and discusses consensus recommendations for acne treatment. These recommendations are not formally issued guidelines of care from the American Academy of Dermatology (the AAD is expecting to release an updated version of acne treatment guidelines by no later than early next year); however, these consensus recommendations are put forth by leading practitioners and researchers who specialize in treating this condition. The Pros and the Cons of Guidelines In general, guidelines of care can provide tremendous educational value to physicians. Guidelines have certainly helped me organize my thoughts when treating complex conditions with numerous treatment options — and acne is clearly such a condition. In their ideal, guidelines lead us toward the best and most appropriate treatment plans for patients. It’s too bad, however, that guidelines of care can be fraught with so many problems. The process of creating guidelines of care is inherently problematic. Whether based on clinical experience or more formal evidence, this creation process is ultimately subjective. People who formulate guidelines come to the table with their own biases that will affect what they think is best. The only potentially unbiased candidates for this job would be those with no clinical or research experience with the condition or its treatments, and these people are probably in an even worse position to judge what should be deemed appropriate care. Clinical interpretation of guidelines is also riddled with problems. Patients are diverse individuals, each having their own complex set of demographics, co-morbidities, family histories, genetic predispositions, social situations and personal preferences. It’s nearly impossible for guidelines of care to account for all these factors, especially a guideline that assumes that all patients meet the criteria of the average person enrolled in a clinical trial. The art of medicine is very much the adjustment of the standard approach to fit the needs of the individual patient. For me, that’s often the fun part of developing the treatment plan. The Biggest Problem The worst factor of all, however, is the abuse of guidelines. Insurance companies can utilize existing guidelines of care as a basis to avoid paying treatment costs, even if a physician believes the treatment regimen is in the best interest of a patient. Guidelines can also be twisted in the legal system by attorneys trying to suggest that a physician did not properly treat a patient. Still, I like guidelines and the help they provide me in organizing a good treatment plan — but I also recognize the problems with them. That conflict is so typical of the world in which we live. Steven Feldman, M.D., Ph.D. Chief Medical Editor