What is the relationship between CPGs and the physicians’ individual clinical judgment?
I think it is very important to remember that we are not treating guidelines. We are treating patients. For example, treating an 85-year-old who has not previously been classified as having hypertension with an antihypertensive drug is probably not a wise clinical decision. The person might become symptomatically hypotensive, for example. We need to treat the reality that our patients live in.
It is also important to remember that guidelines are not rules or laws. Physicians should treat patients by using their best medical judgment. In fact, most clinical guidelines contain similar verbiage acknowledging the importance of a clinician’s medical knowledge and clinical experience. When we talk about the practice and art of medicine, that’s what it’s about—using the facts and knowledge you have acquired over the years, together with common sense, to pick and choose which guidelines apply best to a given patient. Each patient is unique and different. Guidelines are not a one-size-fits-all.
Communities are also unique. We may want overweight people to eat more fresh fruits and vegetables, but some people may have circumstances that make it difficult for them to get to a grocery store that carries these healthier options. They may not have a car, and the nearest store is ten miles away. They may have to catch two buses to get there and return with children in tow. It is important to craft treatment plans and apply guidelines that are realistic for the communities in which you practice and see if they are valid and reasonable for the patients you serve.
Do you have any further suggestions for clinicians?
I encourage clinicians to keep abreast of the news to whatever extent possible. Often, guidelines are embargoed before publication but released to journalists prior to being released to physicians or the public. I go into my office and my patient says, “I was watching Good Morning America and I found out there’s a new guideline on such-and-such that was published in today’s issue of New England Journal.” While it isn’t always possible, following the health news and reading the journals in which new guidelines appear is an important way to have meaningful conversations with patients about the newest recommendations.
It is also important to use common sense. You do not necessarily have to be the very first person to adopt every new guideline. You can adopt a guideline when you see that there are no unintentional negative consequences and explain your rational for hesitating to the patient. Patients should be part of your choices of which guidelines to follow. Have conversations and communicate, and then document the discussion and why you came to a particular conclusion.
- Manski C. Improving patient care using clinical guidelines and judgement. VOX Centre for Economic Policy Research (VOX CEPR Policy Portal), 2017. Available at: https://voxeu.org/article/improving-patient-care-using-clinical-guidelines-and-judgement. Accessed: July 29, 2018.
- National Academies of Science, Engineering and Medicine. Clinical Practice Guidelines We Can Trust. Available at: http://www.nationalacademies.org/hmd/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust.aspx. Accessed: July 30, 2018.
- Lugtenberg M, Zegers-van Schaick JM, Westert GP, Burgers JS. Why don’t physicians adhere to guideline recommendations in practice? An analysis of barriers among Dutch general practitioners. Implement Sci. 2009 Aug 12;4:54.
- Buffel du Vaure C, Ravaud P, Baron G, Barnes C, Gilberg S, Boutron I. Potential workload in applying clinical practice guidelines for patients with chronic conditions and multimorbidity: a systematic analysis. BMJ Open. 2016;6(3):e010119.
- Upshur RE. Do clinical guidelines still make sense? No. Ann Fam Med. 2014 May-Jun;12(3):202-3.
- Council of Medical Specialty Societies. (CMSS). Principles for the Development of Specialty Society Clinical Guidelines. Available at: https://cmss.org/wp-content/uploads/2016/02/CMSS-Principles-for-the-Development-of-Specialty-Society-Guidelines-September-20122.pdf. Accessed: August 21, 2018.
- Carey RM, Whelton PK; 2017 ACC/AHA Hypertension Guideline Writing Committee. Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Synopsis of the 2017 American College of Cardiology/American Heart Association Hypertension Guideline. Ann Intern Med. 2018 Mar 6;168(5):351-358.
This article originally appeared on MPR