This is an intriguing issue that highlights the basic conflict between the public health and individual practitioner perspectives. Public health aims to to take care of an entire population, and creates guidelines that will help produce better health in the majority of patients. Individual practitioners want to do what is best for their patients. What the guideline says may or may not apply to particular patients. In this article, the subject is cancer screening of patients who already have cancer and are not expected to live for very long. A guideline might suggest that the doctor should do a prostate exam on a patient because he is over a certain age, but if he is dying of brain cancer, it will probably be a useless endeavor. Even if the patient does have prostate cancer, it probably is not relevant to the palliative care they will be receiving over the last few weeks or days of their life. This example makes it clear that doctors need to be free to provide appropriate care, even if that means disregarding guidelines. Guidelines should help guide behavior to ensure that doctors provide adequate care to all patients, but they should not serve as a set of rules that doctors must always follow. This would limit the efficacy and cost-effectiveness of the care doctors provide. What would be ideal is a balance between national standards and physician autonomy. Figuring out just where that balance should fall is a key question.
Nik brings up a good point. Guidelines and protocols that are implemented blindly have limited value and even the potential to harm patients. That being said, I think the example in this article is of limited value when trying to draw larger conclusions about the role of guidelines. When a patient has terminal brain cancer, there is likely to be little disagreement as to whether or not this person also needs to be screened for prostate cancer because they are over the age of 50. When the appropriate course of action is less obvious, however, I think treatment and screening protocols have the potential to be much more beneficial. So many of my academic experiences with clinical decision making were dealing with fairly black and white scenarios, case studies that were strategically designed to have a “right” answer. During my first year as a practicing clinician, however, I quickly discovered that almost all decisions are made in a grey area where there isn’t a definitive solution to every problem. It is in these instances that guidelines that are based on the best available evidence could serve as a crucial component to selecting the right course of action.
Certainly any clinician has a wealth of knowledge and scientific reasoning to draw upon to make a clinical decision, and as such it is important that they be able to practice with autonomy. However, I believe that every clinician is operating in an area of clinical uncertainty where a “good decision” is open to interpretation. Whether conscious or subconscious, there are a myriad of factors that can influence how a clinician reaches a conclusion, including financial incentives, patient preferences, mentor preferences, traditions, and geographic practice norms, as well as scientific deductions. Since there are so many factors that can play a role in what a doctor or a nurse or a physical therapist decides to do with a patient, why not provide some basic guidance, which we can be assured is rooted in research and empirical evidence? I agree with Nik that these recommendations need to be implemented wisely with common sense considerations, but I believe that should be implemented nonetheless.
This is an intriguing issue that highlights the basic conflict between the public health and individual practitioner perspectives. Public health aims to to take care of an entire population, and creates guidelines that will help produce better health in the majority of patients. Individual practitioners want to do what is best for their patients. What the guideline says may or may not apply to particular patients. In this article, the subject is cancer screening of patients who already have cancer and are not expected to live for very long. A guideline might suggest that the doctor should do a prostate exam on a patient because he is over a certain age, but if he is dying of brain cancer, it will probably be a useless endeavor. Even if the patient does have prostate cancer, it probably is not relevant to the palliative care they will be receiving over the last few weeks or days of their life. This example makes it clear that doctors need to be free to provide appropriate care, even if that means disregarding guidelines. Guidelines should help guide behavior to ensure that doctors provide adequate care to all patients, but they should not serve as a set of rules that doctors must always follow. This would limit the efficacy and cost-effectiveness of the care doctors provide. What would be ideal is a balance between national standards and physician autonomy. Figuring out just where that balance should fall is a key question.
ReplyDeleteNik brings up a good point. Guidelines and protocols that are implemented blindly have limited value and even the potential to harm patients. That being said, I think the example in this article is of limited value when trying to draw larger conclusions about the role of guidelines. When a patient has terminal brain cancer, there is likely to be little disagreement as to whether or not this person also needs to be screened for prostate cancer because they are over the age of 50. When the appropriate course of action is less obvious, however, I think treatment and screening protocols have the potential to be much more beneficial. So many of my academic experiences with clinical decision making were dealing with fairly black and white scenarios, case studies that were strategically designed to have a “right” answer. During my first year as a practicing clinician, however, I quickly discovered that almost all decisions are made in a grey area where there isn’t a definitive solution to every problem. It is in these instances that guidelines that are based on the best available evidence could serve as a crucial component to selecting the right course of action.
ReplyDeleteCertainly any clinician has a wealth of knowledge and scientific reasoning to draw upon to make a clinical decision, and as such it is important that they be able to practice with autonomy. However, I believe that every clinician is operating in an area of clinical uncertainty where a “good decision” is open to interpretation. Whether conscious or subconscious, there are a myriad of factors that can influence how a clinician reaches a conclusion, including financial incentives, patient preferences, mentor preferences, traditions, and geographic practice norms, as well as scientific deductions. Since there are so many factors that can play a role in what a doctor or a nurse or a physical therapist decides to do with a patient, why not provide some basic guidance, which we can be assured is rooted in research and empirical evidence? I agree with Nik that these recommendations need to be implemented wisely with common sense considerations, but I believe that should be implemented nonetheless.