This is my first ever blog! Before I talk about the topic at hand, I should say this is a very invigorating feeling to have one's own blog. I don't remember the last time I wrote something that wasn't for educational or occupational purposes. No one will be marking my blog, there is no deadline to finish this blog and I can say what I truly feel without too many repercussions (hopefully). I now appreciate how writing one's own thoughts can be a therapeutic exercise. I feel empowered and energized already and I've only written a few sentences so far. I may become a brand new person by the end of this blog! Yikes!
I have entered the world of Clinical Practice Guidelines (CPGs) and I am not coming back. Over the past year and a half, I have been exposed to the intricacies of clinical guideline development and worked with some of the top minds in the world in this realm. Creating a guideline is a difficult process that requires a multitude of factors before the final product is ready to be published. It requires financial resources and many hours from expert physicians, family doctors, epidemiologists, methodologists, statisticians, policy makers, IT experts etc. So it's a shame when I meet doctors and discuss guidelines and the first thing they say is 'guidelines are useless' or something similar. I, of course, immediately ask them why and I get a myriad of answers - 'Grade D or expert consensus is not good enough', 'The study or trial that the recommendation is based on does not represent my individual patient', 'Pharmaceutical companies are behind it all and so I don't trust the guideline', 'I have been doing this for awhile, I don't need a guideline to tell me what to do', 'I have no time to read a guideline, I am busy seeing real patients' , ' I don't like cookbook medicine' and I can go on and on.
These comments drive me nuts! Guidelines are not magical documents that are suppose to solve every little problem a doctor may have. They are what the name suggests, documents that GUIDE your clinical judgement. I admit, some clinical guidelines are more helpful than others and there are things that can be done to make guidelines more actionable, feasible and user-friendly. But some of these complaints I simply do not agree with.
'Grade D or expert consensus is not good enough'
You can't do a Randomized Control Trial(RCT) for everything! It is simply not possible. If 20 expert physicians who have been practicing medicine for over 25 years sit at a table and decide that Vitamin D should be taken by most adults on a daily basis, I am willing to follow their advice. I don't need an expensive RCT to convince me.
'The study or trial that the recommendation is based on does not represent my individual patient'
Of course it doesn't!! Would you like every trial ever done to include the entire patient panel at your clinic? Trials do their best to represent the general population. A trial cannot take into consideration patient values, religious beliefs, co-morbid conditions and the genetic variants your patient may have. This is why a guideline is not a rigid gold standard.
'Pharmaceutical companies are behind it all and so I don't trust the guideline'
This is a little tricky because even I am a little skeptical of this. But I am not paranoid and think pharmaceutical companies control every recommendation out there. Guidelines just need to be more transparent about the development process.
'I have been doing this for awhile, I don't need a guideline to tell me what to do'
I can see more experienced physicians using guidelines less then someone who just recently graduated from medical school. But how can you completely ignore guidelines? You aren't a historian. The renaissance era rarely changes and so a historian can afford to learn once and do his job perfectly. Doctors do not have that luxury.
'I have no time to read a guideline, I am busy seeing real patients'
' I don't like cookbook medicine'
Guidelines are not meant to be used as rigid documents with strict rules, so don't categorize them as such.
So I shall conclude by saying guidelines are simply the starting point for a physician. It should be used as an educational resource to learn principles that you may have forgotten or discover new principles based on the most recent literature. After this knowledge is obtained FROM THE GUIDELINE, the physician can incorporate his own values, patient preferences and any other factor before using it in practice. Does that sound reasonable?
11/22/2012 05:41:52 am
Guidelines provide the structure for patient care whether you are a physician or a nurse. Guidelines are not set in stone and nor are they meant to be. Once we are aware of the structure, only then we can mold them in a way which would best fit our patients and lead to optimal health outcomes.
11/26/2012 10:15:30 pm
Constructing guidelines is difficult. Applying them is like playing jazz; you improvise based on your patient's characteristics.
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Ananda Chatterjee MD
I am Family Medicine graduate of Michigan State University and currently work at AC/VC Wellness Clinic in Portland. My clinical interests include obesity medicine, lifestyle medicine and clinical lipidology. My hobbies include travel, fine dining, watching sports and binging movies and TV shows.