Why it is important to ask your Doctor WHY??

"Trust me I'm a Doctor"
“Trust me, I’m a Doctor”

We all want to believe our Doctor’s know best. But if our knowledge is doubling almost every year, how can a busy and dedicated Doctor keep up on all the medical knowledge needed to treat their patients???

In reality, Doctors and hospitals use guidelines established by well know associations and groups such the American Heart Association (AHA) and the American College of Cardiology (ACC) to treat patients.

But what if these medical associations and groups are using data that is as scientific as you would think. Especially, if a loved ones health is being based on it. Well, that is what a study in the Journal of American Medical Association (JAMA) has reported when it looked at cardiovascular treatments.

Currently, there is a rating system that the ACC/AHA use to evaluate the evidence behind a recommended guideline (available at http://www.acc.org and http://www.aha.org). One is based on the level of evidence behind the study (Level A, B, C) and another based on a grading of the types of studies supporting the recommendation and expert consensus/opinion (Class I, Class II, IIa, IIb IIc and Class III)

The evidence or Level A, B and C based grading is as follows:

  • Level A: including multiple randomized trials or meta-analyses.
  • Level B: single randomized trial or non-randomized studies.
  • Level C: recommendations based on expert opinion, case studies, or standards of care.

Level A is viewed as the best because it encompasses more information and testing before the recommendations are made to Doctors.

The class of recommendations  (Class I, II, IIa, IIb IIc and Class III) are as follows:

  • Class I: conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective.
  • Class II: conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.
  • Class IIa: weight of evidence/opinion is in favor of usefulness/efficacy.
  • Class IIb: usefulness/efficacy is less well established by evidence/opinion.
  • Class III: conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful.

The Class of recommendations requires the guideline writers to make a judgment about the relative strengths and weaknesses of the study data AND to make a value judgment about the relative importance of the risks and benefits and based on the the evidence they have and to “synthesize conflicting findings among multiple studies“.


"Um are you sure?"
“Uuuummmm are you sure?”

That with 16 guidelines for reporting levels of evidence, only 314 of 2711 recommendations were are classified as Level A with the higher evidence to back them.  But that the Level A recommendations were mostly concentrated in Class I where there is evidence and/or general agreement that a given procedure or treatment is useful and effective.

However, only 245 of 1305 Class I which indicate a general agreement about a treatment or procedure by the guideline writers had a Level A evidence to back them.

They found that the BIGGEST increase in recommendations has been in Class II, where there is “conflicting evidence and the usefulness/efficacy of the guideline is less well established by evidence/opinion.”

Simply put, a lower standard overall.

The article concluded that the medical research community needs to streamline clinical trials, focus on areas of deficient evidence while expanding the funding for clinical research.

More telling is the last line in their conclusions “Finally, clinicians need to exercise caution when considering recommendations not supported by solid evidence.”

Not good, right?? It doesn’t help when you look at who funds the American Heart Association.

  • AstraZeneca LP
  • Sanofi-Aventis
  • Bayer Corporation
  • Bristol-Myers Squibb Company
  • Centocor Inc.
  • ConAgra Foods
  • CV Therapeutics
  • GlaxoSmithKline to name JUST a portion.

    Who did you say you worked for again?
    Who did you say you worked for again?

While I could not find who funds the American College of Cardiology, on their web page the reoccurring ad was for AMGEN the world’s largest independent biotechnology firm.

I am not saying we should ignore our Doctor’s advice but we should definitely be our own and our family’s BEST advocates. Sometimes being a better advocate means simply asking WHY?

Or even go a step further and ask to read the studies or do some research on your own about a particular drug or treatment.

Here are some other similar articles you might find helpful:

Clinical Practice Guidelines: Still Miles to Go…

Systematic Analysis Underlying the Quality of the Scientific Evidence and Conflicts of Interest in Interventional Medicine Subspecialty Guidelines. 


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