When Guidelines Don’t Guide

(From the E-i-C: Today’s guest post is from Mat Mercuri, a PhD researcher in the Division of Emergency Medicine, McMaster University. Mat’s post builds on a recent study he conducted that examined the influence of patient context on physician decision-making, suggesting that we must always consider the patient when applying “evidence” to a management plan.  Check out the original publication here.  COI – I’m a co-author.

  • Jonathan)

Medicine is technical, and effective patient management is determined by scientific principles, each of which is tested through rigorous laboratory or clinical trials – at least this is what we assume (or hope to be true) when we require medical care.  In reality, we find that management decisions are not so technical in nature.  Many factors go into determining what is the best course of care for a patient, most notably disease state and co-morbidities, available resources, and patient preferences.  But what about patient’s ability to adhere to the treatment plan suggested by the guidelines?  What if there is no one at home to take care of the patient after discharge?  What if the patient is leaving on a trip and will not be available for follow-up?  When I speak with physicians, they often tell me about circumstances where the evidence-based best option is not ideal, and where the patient may be better served by applying the “next best” option.

And yet, deviations from “scientific norms” (a.k.a. clinical practice guidelines) are somehow viewed as undesirable – the product of presumed lazy and uninformed physicians who are set in their ways.  I would argue that in some (and perhaps many) cases it is precisely the opposite.  That is, these deviations can reflect tailored care, which requires deep knowledge of the possible therapies for a given health status in conjunction with experience of what works in context.  Consider our recent study of Emergency Medicine physicians and residents.  When encountering “typical” patients, for example, a child with a sore throat or a young man with ankle trauma, guideline adherence for therapy or investigation was 80% (similar rates between experienced physicians and residents).  Clearly the physicians were knowledgeable of what “works best”.  Now, give them an anxious mother with 3 children in tow, 2 of which have been recently treated with antibiotics for a sore throat, and the third now has the same (with no positive culture), or present them with a professional hockey player with trauma to his right ankle – guideline adherence drops to 56%.  Is it not better to put the mother at ease, or not risk the hockey player’s career by forgoing a simple x-ray?  I imagine many clinicians would agree that the ability to effectively tailor care develops with experience, which is consistent with what we observed; guideline adherence in the “atypical” cases was higher among residents when compared to experienced physicians (67% vs. 56%).

Accepting that deviating from guidelines may be warranted has significant implications on how we assess competency and quality.  While it may be tempting to assume that all medical decisions are technical, and that science can provide us with a single solution for all patients who share a similar health complaint, patient circumstances are too complex and diverse for this to be the case.  Thus, we should avoid using adherence to guidelines as the standard for good physician practice – the best physicians may be those who know when it is appropriate to deviate from the guidelines for the betterment of the patient.

So, what do you think?

Image from patrisyu. via FreeDigitalPhotos.net