Guidelines and protocols: What should I really be doing?

August 1, 2009

Medical school, postgraduate training, continuing medical education . . . in common with most other doctors, I have been learning throughout my career. I sometimes, perhaps rather pompously, consider myself to be an expert, or at least a specialist.

Medical school, postgraduate training, continuing medical education . . . in common with most other doctors, I have been learning throughout my career. I sometimes, perhaps rather pompously, consider myself to be an expert, or at least a specialist. Yet now it appears that I need guidance on almost every aspect of my professional life as a radiologist.

We are inundated with advice on how to perform our role. Guidance and protocols emanate from a variety of sources and cover an ever-increasing variety of topics. What to image and what not to image; which imaging modality for what indication; what sequences to employ for which anatomical sites and clinical conditions. We even receive advice on what data to record.

I am beginning to sound like a reactionary old fart. Surely, I cannot be against the development of best practices and the dissemination of information that will ensure such practices benefit patients worldwide?

Well, no, not exactly. But consider the environment in which these guidelines are developed. A group of eminent specialists is drawn together to consider a selected topic. It is likely to be six weeks before the group even has its initial meeting.

The aims of guideline development are discussed and agreed, and a literature search strategy is approved. Delay before agreement? Possibly another six weeks.

The literature is collected, collated, and circulated to the relevant specialists for their opinion. A Delphi process may even be employed to ensure scientific rigor. Delay: 12 weeks?

The detailed guidance is drafted and circulated to all group members. Comments are sent, received, and incorporated into the final draft, which is again circulated. Careful indexing, referencing, and copyediting are undertaken. Twelve weeks to complete these steps?

Electronic publishing means that the document should now be available. In practice, most doctors will become aware of the publication only when the hard copy arrives, perhaps six weeks later.

At best, the process has taken nearly a year, and it can often take longer. The result? An abstracted literature review, delivered in glossy format and accompanied by expert opinion, appears at least a year after the most recent article referenced in it was published.

The effect that such documents have on practitioners is complex. Do I stop thinking about the care of my patients if I have a guideline to follow? Do I stop reading the literature if a comprehensive overview will be published in a few months' time? Do I need to remember what I learned at medical school in the 1960s? Do I need to be a medical practitioner if all the difficult decisions are made by the clever people who produce these guidance documents?

Don't get me wrong, I do believe that guidelines can help improve healthcare services. But they can also promote laziness, suppress intellectual challenge, and lead us to ignore the individuality of different patients and their expectations and needs.

We have, for example, introduced a protocol for the investigation of suspected deep vein thrombosis. This condition is no longer managed by a doctor because the pathway is clearly defined. Try explaining to the nurse managing the process that the patient does not need a follow-up venous ultrasound to detect the
pro-pagating clot because I have already diagnosed a ruptured Baker's cyst. This tries my limited patience sorely.

All guidelines are eventually ignored. The updating process is resource-intensive, and many guidelines, sadly, rapidly become outdated. Is this the best we can hope for, that guidelines have a limited shelf life and that you will still have to read original articles?

There are exceptions, of course. Do you remember receiving guidance regarding the investigation of low back pain? When I began in radiology, we received clear advice that a lumbar spine x-ray was of no value for acute or chronic low back pain in the absence of suspicious clinical findings. Yet how many lumbar spine x-rays have I seen over the last 30 years?

Now we have another report that says imaging in cases of acute and chronic low back pain is of no value in the absence of red flags. The only difference is the modality, this time MRI.

Someone needs to tell primary care physicians that they are supposed to read guidelines, not use them to wallpaper the toilet. Or maybe they are thinking for themselves and recognize that a little bit of imaging can do you good.