Medical Decision Making: When Evidence and Medical Culture Clash

Abstract

A clinical practice guideline (CPG) is a recommendation for standardized workflow and decision -making for a specific clinical situation. Thousands of clinical practice guidelines exist, and the quality of guidelines varies. In Chap. 7, we examine why physicians do not follow agreed-upon evidence-based clinical practice guidelines. We discuss the problems and benefits of using clinical practice guidelines and how they are adopted into practice, providing examples of clinical practice guidelines for hand hygiene and perioperative beta blockers. We discuss the measurement of adherence to clinical practice guidelines and the effect of multiple medical conditions and multiple clinical guidelines on adherence. We discuss the disadvantages of applying individual behavior models to understand clinical practice guideline adoption and present several systems frameworks to aid in implementing clinical practice guidelines. Clinical practice guidelines will remain ubiquitous in modern medicine, and the quality of CPGs will improve over time. However, current information available online is not sufficient to support busy practitioners in decision making. A systems framework should be used to understand CPG adoption, and care should be taken in using CPG adherence as a performance metric.

There is a need for “decision-support systems that integrate clinical data with current, evidence-based, best-practice information and that provide information on when and why it may be appropriate to deviate from best practices” (Haynes (2005) Evidence-based medicine. In: Building a better delivery system: a new engineering/health care partnership. The National Academies Press, Washington, DC, pp 117–118). Such a system would provide a relevant synthesis of EBM recommendations, potentially dangerous drug-drug interactions, and contradictory recommendations. This custom “patient- centered” clinical practice guideline could be incorporated into the electronic health record, and this would become the quality measurement standard by which the clinical care would be measured. This would avoid the dangerous paradox created by following clinical guidelines where good clinicians are punished for applying physiology, pathophysiology, pharmacology, and EBM to individual patients.