Intended for healthcare professionals

Views And Reviews Taking Stock

Rammya Mathew: Three questions I ask before using a guideline

BMJ 2019; 364 doi: (Published 28 January 2019) Cite this as: BMJ 2019;364:l358
  1. Rammya Mathew, GP
  1. London
  1. rammya.mathew{at}
    Follow Rammya on Twitter: @RammyaMathew

Scenes of vehement nodding are all too familiar when someone proclaims that “clinical guidelines are just guiding principles, not a set of rules to be slavishly followed.” But equally familiar is the sense of unease that sits high in one’s stomach when choosing to actively ignore them. The worry that ensues, about our decision making being called into question, has probably plagued most of us at some point.

So, although the limitations of guidelines may be widely acknowledged, when it comes to making tough choices in medicine we often still succumb to the illusion of protection that guidelines offer. The ability to access vast reams of evidence that has been appraised, assimilated, and condensed into clinical guidelines is protective in many respects, both for doctors and for their patients. We know that guidelines have helped to standardise care and curb rogue, non-evidence based practice.1

Equally, we know that real life has so many permutations that can’t all be written into guidelines (and for which the evidence often doesn’t exist), yet we seem increasingly bound by guidelines. I can’t help but wonder whether guidelines now hold an unhealthy power over us.

We often still succumb to the illusion of protection that guidelines offer

Have guidelines taken front and centre stage—over-ruling clinical reasoning by the doctor and, worse, sidelining what matters to the patient? I’ve commonly seen patients who are quite clearly in their last year of life being referred for aggressive and invasive investigations, simply because that’s what the guideline says.

Never mind the fact that the patient doesn’t want more tests. Never mind that the decision makes little sense in the context of the patient’s overall health. Never mind that the guideline is derived from a population based study and may not apply to the patient sat at the other side of the desk. We could just dismiss this as bad medicine, but I suspect that the subconscious pull of guidelines is much stronger than we realise.

To counter this we need a better understanding of how to use guidelines—when they’re appropriate and when they’re not. I don’t recall ever being asked to unpick a guideline in my medical training despite using them almost daily. In a bid to resist the slow creep of guideline centred decision making, I’ve started to ask myself three questions:

  • Does the guideline apply to my patient?

  • Is the advice pragmatic?

  • Is it what my patient wants?

If the answer to any of those is no, I give myself the freedom to walk away from the guideline and to do what I think is right for the patient.


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