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Oh dear!
- Bob Bury (11 July 2008)
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Guidelines : handrails, not handcuffs
- Silvio Canino, Piero Baglioni, Consultant Physician - Prince Charles Hospital, Merthyr Tydfil CF47 9DT (12 July 2008)
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Bob Bury, Consultant radiologist Leeds General Infirmary LS1 3EX
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Des Spence's articles are one of the first things I turn (electronically) to each Friday morning. So it was disappointing to see him regurgitating the tired old complaints about clinical guidelines - you know the ones I mean - stifling clinical freedom, imposing straightjackets blah blah....... I chair the Clinical Guidelines Committee at one of the largest Trusts in the country (and already I sense you smirking in that slightly tired and ironic way we all do when we hear about the latest addition to the festering heap of pointless committees that blight the life of GP and hospital doctor alike)so I suppose I'm not a disinterested observer. We set the committee up for two reasons; first to ensure that guidelines in use within the Trust were eveidence-based and had the support of all interested parties, and secondly to try and ensure that we didn't have several guidelines in use for the same clinical condition, causing confusion for the end user. We frequently encounter the 'clinical freedom' argument, and the response is always the same. Guidelines are just that - guidelines. They won't apply to all patients in all situations, and the good clinician will know when to depart from the guidance, and will be able to justify that departure. What guidelines do is to help less experienced practitioners to follow best practice (and you can only have a guideline where there is agreement on what consititutes best practice). Of course, in every area of medicine, there will be those (usually not clinicians) who believe that blind adherence to guidelines is required, and who will attempt to point the finger of blame at anyone departing from them. The correct response is to raise one or two fingers of your own and explain to them the facts of clinical life. Still, at least Des resisted the temptation to trot out the old adage that guidelines, like rules, 'are for the guidance of wise men and the obedience of fools'. Which is a pity in a way, as it happens to be true. Sort of. Competing interests: Chairman, Clinical Guidelines Committee, Leeds Teaching Hospitals Trust. |
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Silvio Canino, Haematologist Ospedale San Giovanni Battista - Foligno 06043 (Italy), Piero Baglioni, Consultant Physician - Prince Charles Hospital, Merthyr Tydfil CF47 9DT
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We share many of the views expressed by Des Spence in his commentary. Guidelines, started as an attempt to decrease unacceptable variability and cost inefficiencies in clinical practice, are at risk of losing their direction and with it some of their usefulness to doctors. This is in part because they are usually written by people whose recognized expertise is tainted by the economic interests they share with the industry (1). Moreover, guidelines can be only as good as the sum of the individual studies they derive from, and even NICE guidelines contain a majority of grade D recommendations, which are based on expert consensus in the absence of evidence (2). Practice of medicine based on acritical application of guidelines can lead to grotesque estimates of risk and excessive medicalization of society (3). Guidelines tend also to be disease-specific and may fail to embrace the needs of individuals with complex health status, such as the elderly (4). Finally, adherence to guidelines disjointed from proper clinical judgment of the individual case, may fail to protect against legal persecution in the event of litigation (5). Guidelines do have a role, but they should remain what they were supposed to be : handrails, not handcuffs, and certainly not a substitute for the provision of robust leadership in clinical care. 1) Taylor R, Giles J - Cash interests taint drug advice - Nature 2005 vol. 437 : 1070 2) Pearson M, Ingham J - Audit, assessment or performance management ? - Clin Med 2005 vol. 5 : 7 3) Getz L, Sigurdsson JA et al - Estimating the high risk group for cardiovascular disease in the Norwegian HUNT 2 population according to the 2003 European guidelines : modelling study - BMJ 2005 vol. 331 : 551 4) Tinetti M, Bogarous ST - Potential pitfalls of disease specific guidelines for patients with multiple conditions -New Engl J Med 2004 vol. 351 : 2870 5) Colbrook P - Can you ignore guidelines ? - BMJ Careers, 9 April 2005 : 143 Competing interests: None declared |
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