A note on Clinical Practice Guidelines

Have you ever been annoyed at a change in your clinical practice guidelines? Have you ever been frustrated because of moving goal posts? Want to understand your clinical practice better? Start here.

 

1.  No-one knows what “right” is. 

Occasionally I hear people complain about changes in paramedic guidelines. “I can’t keep up!”. “They’re always changing the guideline!” “Why can’t they leave things as they are?”

Apart from acknowledging that “they” are hard-working paramedics like themselves, there’s a very simple reason for this: science. The truth is that we often don’t know what the right way to manage a certain condition is. We have to try things and see whether they work. No-one has a crystal ball, and changes aren’t being made to frustrate anyone. They’re just our best guess at the moment.

Often a study will be done or new medication will be developed which radically changes how we approach a certain pathology. The recommendations will change to match the best available evidence, and sometimes that makes for an ugly guideline. I’m sorry, but there’s nothing much we can do about that.

We used to use leeches and laudanum to treat pretty much all medical complaints. Then we phased out the leeches and refined laudanum to morphine. Now leeches are back in a limited capacity.  No-one was wrong, we were just doing the best we could. And millions of medical leeches are no longer unemployed, so that’s good.

 

2. Medicine is statistics

Let’s say that you have a favourite intervention. You’ve seen it work a number of times and perhaps save someone’s life. But then it’s removed from your clinical guidelines and you’re no longer authorised to practice it. Injustice!

Maybe. But maybe not.

These days, medicine is statistics. The days of doctors and paramedics experimenting and following their gut feelings is on its way out. This is not due to lack of ability – it’s down to the large numbers involved. Anecdata just isn’t reliable enough.

Perhaps your intervention worked for a few patients. But without using some biostatistics to model whether it’ll work at a population level, we can’t be sure that it’s a good idea. Unfortunately we don’t have individual, genetics-based medicine quite nailed down yet. Until we do, we’ll have to rely on ideas like “the greatest good for the greatest number”, informed by statistical analysis of probably flawed studies.

 

3. Sometimes the best option isn’t the best option. 

Sometimes a guideline is in use which is clearly not the best thing to be doing. It might have been shown to be overkill, or unnecessary, or just plain wrong.

Understandably this upsets some paramedics. If Medication X is clearly superior in every clinical respect to Medication Y, then why aren’t we using it? Y indeed?

Unfortunately, clinical appropriateness isn’t the only criterion that is used. Ambulance services these days are big, complex organisations. There are many factors that feed into decisions about clinical guidelines, not only clinical ones. These may include

  • Monetary cost
  • Government regulatory rules
  • Skills maintenance considerations
  • Frequency of use vs risk of use
  • Equipment availability
  • Manual handling and safety concerns
  • Impact on other guidelines
  • Buy-in from other stakeholders
  • and about a million other things

These factors sometimes change, so options that were formerly impossible suddenly become possible. Medication X coming off-patent or being formulated differently might turn the equation around. A spike in patient presentations requiring Equipment Z might overcome problems with maintaining skills.

 

4. No-one likes a sooky lah-lah

Ultimately a lot of concerns around clinical guidelines come around to attitude. Paramedics love a good whinge, as do most people. But moaning and complaining about things is a great way to make yourself, and those around you, unhappy. It’s best avoided where possible.

When I hear people kvetching about how clinical guidelines are written, it really bothers me. It displays a lack of appreciation of the thought and consideration that is involved in generating a guideline. They aren’t randomly spewed out on a whim – if anything, they’re over-thought.

Most modern ambulance services have a mechanism whereby frontline practitioners (paramedics) are able to recommend changes to clinical guidelines. Use it. Moaning about constantly changing clinical practice improves nothing. Let’s change our culture of complaint.

If nothing else, it’ll improve the level of conversation in the write-up room.

 

 

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6 Responses to A note on Clinical Practice Guidelines

  1. cannulator says:

    Drug X might’ve come off patent but no one gives that dose. But we will. Because. Just because.

    Maybe there is an image problem just as much as there is an appreciation shortfall in the old guideline game.

    • cannulator says:

      I think the biggest roadbloack is an ignorance about or lack of education in evidence based practice. You can’t have a conversation without footnotes nowdays, as if opinion, especially experiental matters little unless you hold God status. Acceptance of change might follow increased education in research methodlogy and appreciation rather than just results presentation. Especially in environments where a large portion of practitoners didn’t get that sort of education. That would be the perfect platform to achieve in the #FOAM universe

    • James says:

      In my experience, there are very few cases of “just because” in guidelines development. There’s usually another factor at play that isn’t always obvious.

  2. Dinosaur says:

    I don’t have so much of an issue with guidelines changing, rather in my service a lack of discussions or education about the rationale for the changes.
    Discussions seem to be based around compliance rather than clinical reasoning these days, so you get a talking to about non compliance with a guideline, and all too often if you ask for the clinical reasoning you are greeted with anger because the auditor is so KPI driven they don’t know the answer.

    • James says:

      It’s a pity you haven’t been getting the clinical reasoning, Dinosaur. I think it’s generally a bigger part of the training days than it used to be.

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