Clinical practice guidelines (CPGs) have increasingly become institutionalized as ways to provide guidance to clinicians regarding patient care.1 CPGs are “statements that include recommendations intended to optimize patient care.”2 They are “informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.”2 According to the Institute of Medicine (IOM), “Trustworthy CPGs have the potential to reduce inappropriate practice variation.”2
While a guideline may be regarded as a mere “suggestion for behavior,” clinicians have “strong incentives to comply with these guidelines when they are issued, making adherence to them almost compulsory.”1 Additionally, adherence to guidelines may be used as evidence of due diligence in the event of a malpractice claim.1
Despite their advantages, many clinicians do not necessarily agree with the centrality or content of CPGs.3 Others — especially primary care physicians (PCPs) — are overwhelmed by the vast and ever-increasing numbers of guidelines issued by multiple societies, which they are expected to master and incorporate into practice, especially because the guidelines issued by specific societies focusing on specific conditions do not address the realities of patients with multiple comorbidities.4,5
To shed light on the role of CPGs in primary care practice, MPR interviewed Gary L. LeRoy, MD, a family physician in Dayton, OH and a member of the board of directors of the American Academy of Family Physicians (AAFP). Dr LeRoy is also the associate dean for student affairs and admissions and associate professor of family medicine at Wright State University, Boonshoft School of Medicine, Dayton. Dr LeRoy serves the Dayton community through Reach Out Montgomery County, Dayton Public Schools, American Red Cross and Saint Vincent’s Homeless Shelter. He is the president of Dayton and Montgomery County Public Health.
What are your perspectives on the role of CPGs in primary care?
Dr LeRoy: Today’s guidelines are overwhelming in number and almost impossible to master. As a personal family physician, if I were to read every single guideline issued by every society or medical institution, along with my other daily responsibilities, it would be like reading all 8 volumes of Harry Potter every single day. It is virtually impossible for PCPs to read and master all of these recommendations, so as in other areas of medicine, one must triage the guidelines based on what is most immediate and relevant to one’s practice.
How do you suggest ‘triaging’ the guidelines?
One suggestion is to prioritize the guidelines that are most relevant to your practice. For example, if I look at my practice over the last 26 years, I have gone from a population consisting of mostly pediatrics to young adults and now, many of my patients are in the geriatric range. So I spend more time with the geriatric guidelines and less with the pediatric guidelines.
I also urge physicians to keep up with their CME requirements. CME activities will often discuss guidelines that are recent and relevant to your practice.
Does the AAFP issue or recommend specific CPGs?
Yes, the AAFP develops CPGs that are informed by a systematic review of evidence and assessment of the benefits and harms of various care options. The guidelines are developed in adherence with the standards of the Institute of Medicine (IOM)2 as well as the Council on Medical Specialty Societies.6 The guidelines are designed to be specifically relevant to family physicians. (Further information about the development of the AAFP guidelines can be found here.)
In addition, AAFP evaluates and often endorses CPGs issued by other societies. Sometimes, the AAFP’s guidelines differ from those of other societies—for example, the AAFP does not endorse the recommendations of the American College of Cardiology, the American Heart Association, and several other societies on the management of hypertension in adults.7 (The AAFP Guidelines can be found here.)
Were you yourself involved with authoring the AAFP guidelines?
I have been involved with many AAFP commissions, but not this one. On the other hand, I am the president of the Board of Healthcare in Dayton, Montgomery County, and am very familiar with clinical guidelines and guidelines in other areas of public health. We have a task force on the Board of Health that is in charge with looking at guidelines and disseminating them through social media and printed or electronic media so that people are aware of what is and isn’t valid. The Public Health commission is doing something similar to what the commission at AAFP is doing—weeding out information and seeing what is practical for our communities and citizens.
Do you think that adherence to guidelines is protective against malpractice litigation?
I think that physicians should adhere to community standard of care, and that there is no absolute way to shield against all potential litigation. I recommend trying to follow, to your best extent, the clinical guidelines as they become the community standard.
This article originally appeared on MPR