Practice guidelines: friends or foes?

As evidence-based medicine becomes established, the scope for individuality in the management of patients is decreasing. Not too long ago, reaching a diagnosis was often a challenge because of the absence of reliable diagnostic modalities. The accuracy, sensitivity, and specificity of many tests were so low that the results were often dismissed if they did not match the clinical diagnosis. Medicine at that time was much more an art than a science, and its practice was very individualistic. Seasoned diagnosticians frequently mesmerized their audience by their powers of observation and deductive reasoning. Grand Rounds were essentially a venue where astute diagnosticians exhibited their skills: they examined patients often with exaggerated theatrics, and then described the convoluted process by which they reached the final diagnosis, which often hinged on the detection of one or more obscure physical signs that most average clinicians missed.

Now, largely due to a vast array of diagnostic tools, an accurate diagnosis can be reached with relative ease in most instances. Even in conditions where there are no specific diagnostic tests, such as fibromyalgia rheumatica, scoring systems are available to help clinicians make or refute a diagnosis. Similarly, because of the enormous number of medications available, the treatment of most conditions is standardized. Treatment protocols are available, and clinicians are expected to follow them. There is little room for either individualistic thinking or initiative. Standards are available, and clinicians are expected to comply with these standards. Attorneys in court often ask clinicians accused of negligence why a particular test had not been ordered or why a particular medication had not been prescribed.

The point is that the practice of medicine is becoming more and more standardized. Technically a patient with a given condition should expect more or less the same management whether in a bristling academic center at the cutting edge of medical knowledge, or in a tiny rural community hospital. Given the volume of patients clinicians are expected to see, and the sometimes complex nature of their illness, one would think that clinicians would eagerly embrace practice guidelines generated by reputable organizations. So why have these guidelines had such a minimal impact?

In this issue of the Journal, Jackson et al (1) discuss some of the causes for this apparent lack of impact. Could it be that the sheer number of available guidelines is causing confusion by sometimes offering contradictory advice? Could it be that in the face of such confusion, physicians pressed for time just ignore them? Or could it be that the limited time physicians have for continuing medical education is preventing them from becoming familiar with these guidelines and from incorporating them in their daily practice?

Or could it be that most practicing clinicians still consider the practice of medicine to be more of an art than a science, and that it has to be as individualistic as possible? Could it also be that clinicians, who have a reputation for being fiercely independent, do not like to be told how things should be done? The concept of "cookbook medicine" is abhorrent to most physicians. Following guidelines, algorithms, and protocols is a form of cookbook medicine. An argument sometimes put forward is that one does not need to be a physician to practice "cookbook medicine."

Maybe this is precisely the point. Maybe we now have reached the stage when physicians are not needed to diagnose and treat the majority of patients, as this process has become so standardized for the majority of diseases. Maybe this could be effectively done by nurse practitioners or physician assistants. Maybe only complex patients should be seen by physicians, and the majority of patients could be seen and treated by nurse practitioners or physician assistants, who are managing more and more patients. Maybe the time has come for still more responsibility to be handed to non-MD health care providers, allowing them to manage the majority of patients, and to further restrict the role of physicians to only complex patients. This would lessen the workload of physicians, thus allowing them to get more involved in the care of complex patients, while ensuring that most patients are getting the standardized management as set forth in guidelines developed by reputable organizations.

Please see "Impact of National Low Back Pain Guidelines on Clinical Practice" on page 139 of this issue.

Reference

1. Jackson JL, Browning R. Impact of national low back pain guidelines on clinical practice. South Med J 2005;98:139-143.

Ronald C. Hamdy, MD, FRCP, FACP