Practice Guidelines: A Positive Perspective
William O. Roberts, MDTHE PHYSICIAN AND SPORTSMEDICINE - VOL 24 - NO. 3 - MARCH 96
Practice guidelines are a healthcare reality of the 1990s and beyond. Though practice guidelines have their negative side, they offer some important benefits: They can improve medical care and reduce clinical error.
In my practice setting, we have adopted more than 50 guidelines on subjects as diverse as the common cold and the length of postpartum hospital stays. Our goal is to implement 80 practice guidelines. The guidelines we use have been written by teams of practicing physicians who have volunteered their time to develop cost-effective, medically sound approaches to common medical problems. These guidelines, developed by practical people with the best interests of the patient in mind, represent the group consensus on the clinical approach to a problem. I hope that clinical guidelines represent the best in medical care, and that most of us will find them useful.
The difficulty in adopting guidelines is the large volume of material that must be assimilated into an individual's practice style. In my practice, adopting the guidelines has been relatively easy; I have found few differences between the guidelines and the protocols I have been using for patient care.
A common objection to guidelines among my colleagues is that they detract from the art of medicine and set the legal standard of care as outlined in Herbert's article in this issue (see "Practice Guidelines Take Center Court: How to Limit Liability") Working with guidelines, however, is nothing new to physicians. We constantly work with a set of protocols that we learned in medical school and in residency training. In our practices, we have modified these protocols with new information and through personal experience.
Guidelines can be used as an educational tool to keep us current regarding the myriad problems we face on a daily basis, and on treatments that have changed dramatically since I was a resident. To be an effective tool, guidelines must reflect the state of the art and must be developed by physicians who are involved in the day-to-day delivery of healthcare. The crucial questions to be asked are: Who developed the guidelines? Whose interests are the guidelines protecting? Are the guidelines current from the scientific and practice perspectives?
Guidelines can help shield practitioners from clinical error and malpractice risk. The most recent guideline I have received is for the early management of acute myocardial infarction. The guideline starts with the initial phone advice for the patient, then progresses through the hospital and immediate posthospital decision sequences. No step is cast in stone and alternative suggestions are included in the pathway. The art of patient education, relieving anxiety, and discussion of the future lifestyle and medical care need to be delivered with a physician's own bedside manner. Although the Colorado concussion guidelines (1) were not developed in our practice, many physicians use them as the basis for care of athletes. I use a different guideline for mild brain injury that would probably be accepted by an equal number physicians.
These and the other guidelines we have adopted are current, scientific, and cost-effective, and were obviously written by physicians who are practicing medicine at a high level of excellence. The challenge will be to keep the protocols current and cost effective.
If guidelines are "cookbook medicine," remember that even the best chef starts with a cookbook. The difference between the good and the best is often the subtle use of spices. The spice of medicine-intelligent reasoning and clinical intuition-and the art of medicine will not be supplanted by guidelines.
Dr Roberts is a family physician at MinnHealth SportsCare in White Bear Lake, Minnesota. He is an editorial board member of The Physician and Sportsmedicine and medical director of the Twin Cities Marathon. He is editor-in-chief of Your Patient and Fitness.