Physicians' reasons for resisting adoption of clinical guidelines aren't good enough. Guidelines and rules seem, even by their appellation, to oppose the practice of medicine with liberty. What's wrong with them? Physicians want the freedom to autonomously choose the best approach for each patient. Knowing the guideline, its clinical setting, and components is not always easy.[1,2] The San Francisco Syncope Rule was elegantly derived and predicts those with a poor outcome within 7 days, but perhaps this endpoint isn't adequate.[3] Guidelines become outdated.[4] Conflicting rules are published, and I don't know if Pittsburgh's or Ottawa's rule can better judge who needs a knee x-ray![5,6]
Another legitimate concern is the risk of liability for a physician who breaches a guideline. Realistically, this issue exists regardless of how the standard of care is communicated; it's just that guidelines or rules crystallize the standard and make it easier to delineate deviation.
Let's distinguish between guidelines and rules. A committee of august colleagues often creates a guideline after meticulous evaluation of the medical literature.[7] “Rules,” in contrast, are more likely a single study with a derived algorithm – a clinical prediction instrument. Thus, guidelines are generally weightier than rules. More researchers should call their rules what they are – clinical prediction instruments.
The reality is that guidelines and prediction instruments ultimately rely on the scientific method. They are not immune to bias and limitations. Both should be subjected to clinical scrutiny by measuring outcomes. Such testing frequently demonstrates good performance, showing that lives can be saved,[8] outcomes improved, and medical costs reduced by their adoption.
Physicians should take the time to be familiar with the most important guidelines in their specialty. They should adopt the best guidelines because they represent the best practice and are best for the patient.
That's my opinion, I'm Dr. Jonathan Adler, an emergency physician at Massachusetts General Hospital.
Footnotes
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References
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