Rammya Mathew: Three questions I ask before using a guideline

4 February, 2019

I found this Comment (from a London GP) in the current print BMJ interesting. Citation, extracts and a comment from me below.

CITATION: Rammya Mathew: Three questions I ask before using a guideline

BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l358 (Published 28 January 2019)

Cite this as: BMJ 2019;364:l358


Scenes of vehement nodding are all too familiar when someone proclaims that “clinical guidelines are just guiding principles, not a set of rules to be slavishly followed.” But equally familiar is the sense of unease that sits high in one’s stomach when choosing to actively ignore them. The worry that ensues, about our decision making being called into question, has probably plagued most of us at some point...

Never mind the fact that the patient doesn’t want more tests. Never mind that the decision makes little sense in the context of the patient’s overall health. Never mind that the guideline is derived from a population based study and may not apply to the patient sat at the other side of the desk. We could just dismiss this as bad medicine, but I suspect that the subconscious pull of guidelines is much stronger than we realise.

To counter this we need a better understanding of how to use guidelines—when they’re appropriate and when they’re not. I don’t recall ever being asked to unpick a guideline in my medical training despite using them almost daily. In a bid to resist the slow creep of guideline centred decision making, I’ve started to ask myself three questions:

Does the guideline apply to my patient?

Is the advice pragmatic?

Is it what my patient wants?

If the answer to any of those is no, I give myself the freedom to walk away from the guideline and to do what I think is right for the patient.


Comment (NPW): Does anyone know of any guidance to help health professionals when to follow, or not follow, clinical guidelines? Perhaps every guideline should include a brief comment on the risks of not following the recommendation?

Best wishes, Neil

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HIFA profile: Neil Pakenham-Walsh is coordinator of the HIFA global health campaign (Healthcare Information For All - www.hifa.org ), a global community with more than 19,000 members in 177 countries, interacting on six global forums in four languages. Twitter: @hifa_org FB: facebook.com/HIFAdotORG neil@hifa.org