Volume 196 - Issue 9
Clinical pathways and guidelines: a plea for professional independence
Author: Paul M McGurgan
Med J Aust 2012; 196 (9): 567. || doi: 10.5694/mja12.10352
Published online: 21 May 2012
Published online: 21 May 2012
To the Editor: Clinical pathways and guidelines are the inevitable consequence of evidence-based medicine and, in general, have been a force for good in terms of patient care. However, the experiences of Nanan
et al1 and Dietz and Stokes,2 and
my own experience of working with countless exasperated colleagues
in clinical practice, suggest that the ...
To the Editor: Clinical pathways and guidelines are the inevitable consequence of evidence-based medicine and, in general, have been a force for good in terms of patient care. However, the experiences of Nanan et al1 and Dietz and Stokes,2 and my own experience of working with countless exasperated colleagues in clinical practice, suggest that the pendulum may have swung too far towards uniformity of care.
The uniformity promoted by clinical pathways and guidelines is an attempt to counter the truism that variation is the enemy of quality. However, all health care professionals need to appreciate the importance of two key concepts in medicine — one old and one modern. The first is the value of gnosis, the Greek philosophical term for knowledge gained through experience, such as in clinical practice. The second is the modern definition of evidence-based medicine, which is the integration of the best research evidence with clinical expertise and patient values.3
The problem with evidence-based medicine is that too often the emphasis is on the evidence rather than the clinical expertise or the patient’s unique perspective. As an antidote, I propose paraphrasing the words of Sir Douglas Bader4 as a foreword for every guideline or clinical pathway document: “Guidelines are for the guidance of the wise and the blind obedience of fools”.
Competing interests
I am head of a clinical obstetrics and gynaecology service (Osborne Park Hospital, Perth) and a Fellow of the Australasian Association for Quality in Health Care. I have written guidelines and I run a medical student workshop on evidence-based medicine theory and practice.
References
- Nanan RK, Poulton AS, Champion BL. Clinical pathways: a departure from the art of medicine. Med J Aust 2012; 196: 96. 0_CBBJGCHE
- Dietz HP, Stokes BJ. A plea for professional independence. Med J Aust 2012; 196: 104-105. 0_i1142858
- Sackett DL, Straus SE, Richardson WS, et al. Evidence-based medicine: how to practice and teach EBM. 2nd ed. Edinburgh: Churchill Livingstone, 2000. 0_i1142860
- Douglas Bader Foundation. Some quotes from Sir Douglas Bader. http://douglasbaderfoundation. com/2010/10/15/some-quotes-from-sir-douglas-bader/ (accessed Mar 2012).