Clinical Guidelines. Who are they guiding?

There are a plethora of clinical guidelines published around the world on various clinical presentations from low back pain to managing multiple medical conditions. The intent of a guideline is to offer clinicians evidence based information on the most effective way to diagnose, manage and implement treatment for the target condition. They are simply put, evidence summations and sign posts for the best current care. Ref: https://en.m.wikipedia.org/wiki/Medical_guideline

There have been many papers written on the lack of adoption or “adherence” to the published clinical guidelines amongst clinicians. Some of the lack of adoption is based on lack of awareness of the existence of the guidelines, but a lot of clinicians fail to follow them because they patients they see do not fit the inclusion criteria for the evidence base used to write the guidelines. It is common for RCT to exclude people with multiple co-morbidities, law suits, workers compensation claims, those undergoing current therapy, previous surgery etc. The average patient seen in daily practice, often has one or more of these exclusion criteria.

Useful reference: https://bmjopen.bmj.com/content/bmjopen/9/10/e032329.full.pdf

I have consistently suggested that clinical guidelines reflect a “perfect” world situation using the average outcomes from RTCs and Systematic reviews, where in everyday clinical practice patients come with complex issues, often with co-morbidities and related complex social determinants of health. It is obvious to most clinicians that no one necessarily needs what the average of all of us might need.

So what use are the guidelines if clinicians are not following them and the do not reflect the real world situation of everyday clinical practice?

A recent review by Lin et al looked at the best advice across the board from multiple guidelines and came up with 11 common recommendations. These recommendations are reasonable and can be applied across multiple clinical disciplines and seem to apply to most if not all patients. 👇

Source: https://bjsm.bmj.com/content/bjsports/54/2/79.full.pdf

As a clinician the paper is an important read, the recommendations are easy to apply in everyday practice.

It appears that a lot of clinicians don’t follow the guidelines because they are unaware, feel their patients aren’t represented, stuck in a treatment belief that they believe in but lacks evidential support, or (dare I say it), they believe they know better.

I have to admit, I’m not a guideline follower, but I do believe I am pretty close to the 11 recommendations from the Lin et al paper.

As always thanks for reading.

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