Guidelines will rule the world

Craig-JosephEveryone knows medicine is an art not a science. Sure, fine, perhaps everyone doesn’t know this, but it’s an accepted fact. Ok, maybe it’s not a fact, per se, but lots of people think it, so its veracity should not be questioned. Geez, people, here’s my final statement: some people sometimes say that medicine is an art, not a science. Agreed? Fabulous! But what does this even mean: art, not science?

Physicians are trained to practice evidence-based medicine (EBM). In theory, this means that we are expected to keep up with the latest recommendations regarding effective patient care based on experiments that adhere to the scientific method. A major problem is that “science” isn’t always clear, and experimental results don’t always correlate with one another (see: COVID-19 pandemic for a reference). EBM is the shining star that physicians seek to ensure that we’re doing the best for our patients, but if the academic literature is not decided or, even more commonly, there is no data one way or another, what’s a physician to do?

Physicians are not automatons quoting scientific articles when recommending courses of action. Even if we were, it’s impossible to keep up with the number of studies that come out regularly. A report recently estimated that there are over 30,000 healthcare journals that publish greater than 2 million articles a year. Reading, interpreting, and changing the way we practice medicine in response to even just clinical articles is not realistic. Physicians seeking to practice EBM need help to keep their heads above the deluge of research.

We’ve established that science is an integral part of the modern practice of medicine. Yet the art of medicine cannot be ignored. Physicians are humans dealing with other humans, and we’re all complicated beings. The approach one takes to help similar patients may vary widely based on a panoply of factors, including both patient elements (e.g., history, age, other co-morbidities) and physician factors (e.g., training, experience, practice setting). EBM is often not perfectly clear, and the path to better health or less pathology needs to incorporate human factors, emotions, and situational awareness.

While the art of medicine takes time to develop, the science part can be overwhelming. To help point busy practitioners in the right direction, clinical practice guidelines have been created. These documents walk physicians through recommended courses of action for common patient problems. Want to know how to diagnose and manage asthma? Check this out. What’s to be done with benign prostatic hyperplasia (BPH)? Some expert, consensus-driven thoughts are here.

The National Institutes of Health (NIH) writes that clinical practice guidelines “… define the role of specific diagnostic and treatment modalities in the diagnosis and management of patients. The statements contain recommendations that are based on evidence from a rigorous systematic review and synthesis of the published medical literature.” They go on to emphasize a key point: “These guidelines are not fixed protocols that must be followed, but are intended for health care professionals and providers to consider. While they identify and describe generally recommended courses of intervention, they are not presented as a substitute for the advice of a physician or other knowledgeable health care professional or provider.”

Let’s dig a bit deeper into the concept that guidelines are not a substitute for physician advice. A clinical practice guideline is meant to highlight what the evidence shows to be the best course of action given an idealized or standard patient. Yet, most physicians don’t typically encounter such “perfect” patients. Hence, we are required to take into consideration the unique aspects of the patient in front of us and come up with a plan of action that acknowledges the guideline but may depart from parts of it or indeed all of it. We shouldn’t ignore all guidelines as “cookbook medicine,” but at the same time, we must use our training, experience, and insights to depart from recommendations that aren’t pertinent.

Maybe I’ve convinced you that medicine is both an art and a science. Now, I’d like to consider the future of healthcare in the United States. Today, the vast majority of clinical decisions are made by the physician and the physician alone. I’d argue that the future is team-based care, freeing the doctor of many decisions that they today probably don’t need to make (e.g., renewing prescriptions, filling out forms, approving referrals). Some posit that millennials will lead the way in seeking care on their own terms, via a combination of apps, specially-trained domain experts, and remote and in-person physician encounters. Under any circumstances, the physician may not be at the center of all decisions.

As we move into this brave new world, clinical practice guidelines will take on new importance. Less trained clinicians (or even untrained administrative folks) will be tasked with moving some patients through some parts of the healthcare system. They’ll lean very heavily on guidelines, and will by definition lack the education, experience, or authority to pick and choose which aspects of care that are available to the patient. This is not to imply that physicians will be totally out of the picture, but instead to acknowledge that many more decisions will be made on a sort of autopilot. Some will call this a good thing because it may lead to more evidence-based practice (as some docs aren’t as diligent as they should be). Others will see this as cookbook medicine on steroids. Either way, we should understand the future importance of guidelines in American healthcare and ensure that they’re as well-written and thoughtful as possible.

Topics: EHR, featured

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