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When the U.S. Task Force on Preventive Services spoke out last week against the routine use of aspirin for prevention in people over 60, citing the risk of bleeding, that didn’t change. one iota of my clinical decision making and instead reminded me of a basic truth in medicine, patients should be seen and treated as individuals, guidelines are meant to guide and are not meant to be converted into mandates or in sayings.
Don’t get me wrong, a smart clinician should be aware of the risk of bleeding when recommending aspirin, and that risk certainly increases with age, but so does the risk of you building up sticky plaque that could lead to a sudden heart attack or stroke, and a good doctor can weigh the risk/benefit ratio of any drug, including aspirin, much better than a guideline.
It’s reminiscent of another time the USPSTF tried to change the practice of clinical medicine with a superimposed guideline, when they discouraged the routine use of prostate-specific antigen in men over 70. , despite the fact that PSA had led to earlier diagnosis of prostate cancer leading to more surgical treatments.
DOES A DAILY ASPIRIN HELP PEOPLE OVER 60 AVOID HEART DISEASE AND STROKE? EXPERT RECOMMENDATIONS JUST MODIFIED
Yet this august group pointed to the instinctive biopsies and surgeries that frequently resulted from high PSA, which did not prolong life. While I and many urologists and primary care physicians disagreed, arguing that the PSA was a useful tool and the information it gave you was valuable. It wasn’t a PSA who ordered a biopsy, it was a clinician.
To this day, I routinely check the PSAs of many men over 45 and act on the result based on many factors including genetics. No good doctor shakes anything.
The guideline problem has been compounded during the COVID pandemic, when lockdowns, closures, vaccine and mask mandates have directly followed the guidelines.
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The public has now lost the sense of guidelines guiding physicians and is reacting rather negatively to the new standard of guidelines leading directly to warrants. Politicizing the guidelines is not good for public health, whether it applies to vaccine mandates with no exclusion of natural immunity or negative tests like Israel and the European Union have done, or to shutdowns from expensive schools, or to mask mandates without attention to what type of mask, whether or not they are effective, and whether removing them to eat or drink erodes the essence of public health strategy.
This lack of public health consistency was highlighted by Florida federal court judge Kathryn Kimball Mizelle’s ruling against the CDC’s transport mask mandate on planes, trains and buses, on the basis of disagreement over the term “sanitation” as well as the fact that the CDC did not call a public referendum before instituting the rule. This lawsuit has opened a Pandora’s box that will likely end up in the Supreme Court and could fetter or restrict the powers of the CDC.
Population studies have indicated apparent efficacy for appropriate mask use in areas of high viral spread, but due to onerous mandates, as soon as they are lifted, there is virtually no mask in sight. .
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This type of relighting, extinguishing or red light/green light is hardly compatible with a good public health policy. I can choose to continue flying with an N95 mask, but now I’m pretty much the only one at the airport or on the plane wearing one.
We need to return to a time when guidelines simply guide, not mandate, while at the same time the digital age can be used to help inform these guidelines with up-to-date information. The key to successful public health is flexibility, not dogma.
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