Recommendations vs. Guidelines

Link post

Medicine loves guidelines. But ev­ery­where else, guidelines are still un­der­ap­pre­ci­ated.

Con­sider a recom­men­da­tion, like “Try Lexapro!” Even if Lexapro is a good med­i­ca­tion, it might not be a good med­i­ca­tion for your situ­a­tion. And even if it’s a good med­i­ca­tion for your situ­a­tion, it might fail for un­pre­dictable rea­sons in­volv­ing ge­net­ics and in­di­vi­d­ual vari­abil­ity.

So medicine uses guidelines – al­gorithms that even­tu­ally re­sult in a recom­men­da­tion. A typ­i­cal guideline for treat­ing de­pres­sion might look like this (this is a very over-sim­plified ver­sion for an ex­am­ple only, NOT MEDICAL ADVICE):

1. Ask the pa­tient if they have symp­toms of bipo­lar di­s­or­der. If so, ig­nore ev­ery­thing else on here and move to the bipo­lar guideline.

2. If the de­pres­sion seems more anx­ious, try Lexapro. Or if the de­pres­sion seems more an­er­gic, try Wel­lbutrin.

3. Wait one month. If it works perfectly, de­clare vic­tory. If it works a lit­tle but not enough, in­crease the dose. If it doesn’t work at all, stop it and move on to the next step.

4. Try Zoloft, Re­meron, or Effexor. Re­peat Step 3.

5. Cy­cle through steps 3 and 4 un­til you ei­ther find some­thing that works, or you and your pa­tient agree that you don’t have enough time and pa­tience to con­tinue cy­cling through this tier of op­tions and you want to try an­other tier with more risks in ex­change for more po­ten­tial benefits.

6. If the de­pres­sion seems more melan­cholic, try Anafranil. Or if the de­pres­sion seems more atyp­i­cal, try Nardil. Or if your pa­tient is on an ear­lier-tier med­i­ca­tion that al­most but not quite works, try aug­ment­ing with Abil­ify. Re­peat Step 3.

7. Try elec­tro­con­vul­sive ther­apy.

The end re­sult might be the recom­men­da­tion “try Lexapro!”, but you know where to go if that doesn’t work. A psy­chi­a­trist armed with this guideline can do much bet­ter work than one who just hap­pens to know that Lexapro is the best an­tide­pres­sant, even if Lexapro re­ally is the best an­tide­pres­sant. When­ever I’m hope­lessly con­fused about what to do with a difficult pa­tient, I find it re­ally re­as­sur­ing that I can go back to a guideline like this, put to­gether by top psy­chi­a­trists work­ing off the best ev­i­dence available.

This makes it even more in­furi­at­ing that there’s noth­ing like this for other ar­eas I care about.

Take diet­ing. Every­body has recom­men­da­tions for what the best diet is. But no mat­ter what diet you’re recom­mend­ing, there are go­ing to be thou­sands of peo­ple who tried it and failed. How come I’ve never seen a diet guideline? Why hasn’t some­one writ­ten some­thing like:

1. Try cut­ting carbs by X amount. If you lose Y pounds per week, the diet is work­ing. If not, you’re prob­a­bly re­sis­tant to cut­ting carbs be­cause [two hours of mum­bling about in­sulin] and you should move on to the next tier.

2. Try cut­ting fat by X amount. If you lose Y pounds per week, the diet is work­ing. If not, you’re prob­a­bly re­sis­tant to cut­ting fat be­cause [two hours of mum­bling about lep­tin], and you should move on to the next tier.

And so on un­til Step 7 is “get a gas­tric by­pass”.

I agree no­body can ever make a perfect al­gorithm that works for all even­tu­al­ities. But still. Surely we can do bet­ter than “Try the Pa­leo diet! I hear it’s great!”

What in­for­ma­tion do guidelines carry be­yond a recom­men­da­tion?

First, they have more than one recom­men­da­tion. It may be that the Pa­leo diet is the best, but the guidelines will also in­clude which is the sec­ond-best, third-best, et cetera.

Se­cond, be­cause they have more than one recom­men­da­tion, they can tai­lor their recom­men­da­tion to your spe­cific cir­cum­stances. The per­son with de­pres­sion and co­mor­bid anx­iety may want to start with Lexapro; the per­son whose main symp­tom is tired­ness may want to start with Wel­lbutrin. Since I love bread, does that mean I should avoid carb-cut­ting diets? Does that mean it’s ex­tra-im­por­tant that I cut carbs? Does it not mat­ter, and re­ally it de­pends on whether I have a fam­ily his­tory of di­a­betes or not?

Third, they ac­knowl­edge that some peo­ple might need more than one recom­men­da­tion. If you hear “try the Pa­leo diet”, and then you try it, and it doesn’t work, you might be­lieve you’re just a bad dieter, or that all diets are scams, or some­thing like that. Guidelines im­plic­itly ad­mit that ev­ery­one is differ­ent in con­fus­ing ways, that some­thing that’s ex­pected to work for many peo­ple might not work for you, and that you should ex­pect to have to try many things be­fore you find the right one.

Fourth, be­cause they ad­mit you may need to try more than one thing, they con­tain (or at least nod at) ex­plicit crite­ria for suc­cess or failure. How long should you try the Pa­leo diet be­fore you de­cide it doesn’t work? How much weight do you need to lose be­fore it qual­ifies as “work­ing”? If it’s been three months and I’ve lost four pounds, should you stick with it or not?

Fifth, they po­ten­tially con­tain in­for­ma­tion about which things are cor­re­lated or an­ti­cor­re­lated. The de­pres­sion guidelines make it clear that if you’ve already tried Lexapro and Zoloft and they’ve both failed, you should stop try­ing SSRIs and move on to some­thing with a differ­ent mechanism of ac­tion. If I’ve tried five carb-cut­ting diets, should I try a fat-cut­ting diet next? If I hate both Mex­i­can food and Chi­nese food, is there some other cat­e­gory of food which is suit­ably dis­tant from both of those that I might like it? Guidelines have to worry about these kinds of ques­tions.

My im­pres­sion is that once you un­der­stand a field re­ally well, you have some­thing like a Guideline in your mind. I think if no­body had ever writ­ten a guideline for treat­ing de­pres­sion, I could in­vent a de­cent one my­self out of ev­ery­thing I’ve pieced to­gether from word-of-mouth and com­mon-sense and per­sonal ex­pe­rience. In fact, I think I do have some per­sonal guidelines, similar to but not ex­actly the same as the offi­cial ones, that I’m work­ing off of with­out ever re­ally be­ing ex­plicit about it. Part of the con­fu­sion of ques­tions like “What diet should I do?” is sort­ing through the field of nu­tri­tion un­til you can sort of imag­ine what a guideline would look like.

So why don’t peo­ple who have more knowl­edge of nu­tri­tion make these kinds of guidelines? Maybe some do. I can’t be sure I haven’t read diet­ing guidelines, and if I did I prob­a­bly ig­nored them be­cause lots of peo­ple say lots of stuff.

But I think that’s a big part of it – mak­ing guidelines seems like a re­ally strong claim to knowl­edge and au­thor­ity, in a way that a recom­men­da­tion isn’t. Some idiot is go­ing to fol­low the guidelines ex­actly, screw up, and sue you. I just re­al­ized that my sim­plified-made-up de­pres­sion guidelines above didn’t have “if the pa­tient ex­pe­riences ter­rible side effects on the an­tide­pres­sant, stop it”. Maybe some­one will fol­low those guidelines ex­actly (con­tra my plea not to), have some­thing hor­rible hap­pen to them, and sue me. Un­less you’re the Amer­i­can Psy­chi­a­tric As­so­ci­a­tion Task Force or some­one else suit­ably im­pres­sive, your “guidelines” are always go­ing to be pretty vague stuff that you came up with from hav­ing an in­tu­itive feel for a cer­tain area. I don’t know if peo­ple re­ally want to take that risk.

Still, there are a lot of fields where I find it re­ally an­noy­ing how few guidelines there are.

What about nootrop­ics? I keep see­ing peo­ple come into the nootrop­ics com­mu­nity and ask “Hey, I feel bad, what nootropic should I use?” And sure, even­tu­ally af­ter do­ing lots of re­search and try­ing to sep­a­rate the fact from the lies, they might come up with enough of a vague map of the area to have some ideas. But this is an area where “Well, the first three things you should try for anx­iety are…” could be re­ally helpful. And I don’t know of any­thing like that – let alone some­thing that tells you how long to try be­fore giv­ing up, what to look for, etc.

Or let’s get even broader – what about self-help in gen­eral? I don’t re­ally be­lieve in it much, but I would love to be proven wrong. If there were a book called “You Are Willing To Devote 100 Hours Of Your Life To See­ing If Self-Help Really Works, Here’s The Best Way For You To Do It”, which con­tained a smart per­son’s guidelines on what self-help things to try and how to go about them, I would ab­solutely buy it.

No nominations.
No reviews.