|EDITORIAL - ON THE CROSSROADS OF TIME
|Year : 2016 | Volume
| Issue : 2 | Page : 61-65
Whence clinical guidelines must govern medical practice
Yatish Agarwal1, Bipin Batra2
1 Editor-in-Chief, Astrocyte; and Professor of Radiology at New Delhi's Safdarjung Hospital and Vardhman Mahavir Medical College, India
2 Executive Director, National Board of Examinations; and Executive Editor, Astrocyte
|Date of Web Publication||30-Dec-2016|
Editor-in-Chief, Astrocyte; and Professor of Radiology at New Delhi's Safdarjung Hospital and Vardhman Mahavir Medical College
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Agarwal Y, Batra B. Whence clinical guidelines must govern medical practice. Astrocyte 2016;3:61-5
With the art of medicine a casualty to the number game of contemporary science, and evidence-based medicine the driving ethos, modern medicine is no longer a celebrated and pious creature of sublimity, divinity and goodness that it perhaps was in the eras of yester. With old-fangled pharmacy potions giving way to hi-tech structured molecules which cost and must bring in billions of dollars to the fat balance sheets of pharmaceuticals, laboratories spinning their wheels to the tune of Lady Wealth, and expensive technologies contributing to rising healthcare costs, the practice of clinical medicine is no longer an exercise in acquiring skills, knowledge, commitment, devotion and wisdom. Rather, it must stand tall, bearing the scrutiny of a social order, where people, governments, legal frameworks dictate that medicine be run by promulgated best care practices, or shall we say, clinical guidelines. Rigorously developed, these evidence based statements guide a healthcare practitioner in taking clinical decisions about appropriate health care for specific proven circumstances. 
Since the mid-1980s, these clinical guidelines have increasingly become a part of grammar of medicine. Based out of contemporary scientific research, fuelled by a critical appraisal of hardcore scientific evidence these "systematically developed" guidelines have become a familiar part of clinical practice in developed economies of Europe, North America, Australia, New Zealand and parts of Africa and Asia. On a daily basis, clinical decision at the bedside, rules of clinical conduct at hospitals and clinics, choice of screening or diagnostic tests, line of treatment, dose, duration and frequency of a medical treatment, or a surgery, period of a patient's stay in a hospital, frequency of a patient follow-up, and a host of other finer details of clinical practice are being guided and influenced by these guidelines. Carefully gauzing the quality of accumulated supporting clinical data, these guidelines shed light on the interventions of proven benefit, and those still in the experimental phase.
The big picture
The major thought-engine behind developing clinical guidelines is to evolve a tool for making healthcare consistent and efficient and for closing the gap between what clinicians do and what scientific evidence supports. The ultimate goal is to do away with variations in service delivery among healthcare providers, hospitals, and geographical regions and the presumption that at least some of this variation stems from inappropriate care, either overuse or underuse of services, and, at the same time, the intrinsic desire of all healthcare providers to offer, and of patients to receive, the best care possible. 
The principal benefit of guidelines is to improve the quality of care received by patients and to improve health outcomes. Guidelines that promote interventions of proven benefit and censure ineffective ones have the potential to reduce morbidity and mortality and improve quality of life.
Buoyed by unambiguous and concise protocols, these guidelines encapsulate the benefits and harms of all on hand options, along with estimates of the probability of potential outcomes, thus empowering patients to make more informed healthcare choices and to consider their personal needs and preferences in selecting the best option.
The potential benefits for the healthcare providers are also no less. With explicit, definite and authoritative recommendations to put up with, physicians can easily improve the quality of their clinical decisions. They can be more sure-footed, consistent, and assured about the interventions they seek to make, and need not fear being outdated or outrun by the modern advances in medicine. Supported by stout evidence of good science, it allows them to eliminate ineffective, dangerous, and wasteful practices, while following well-designed critical care pathways, algorithms, and self-audits. When called to do so by a suspecting social order, they can argue their case well and defend themselves stalwartly against any charges of greed, unethical behavior, and malpractice.
While thus offering a win-win landscape both for the patients and physicians, clinical guidelines also tend to support quality improvement initiatives. Each quality assessment tool in clinical practice must first be tagged with an agreement on how a specific set of patients must be treated. These guidelines are a common point of reference for prospective and retrospective audits of clinicians' or hospitals' practices - the tests, treatments, and treatment goals prescribed in the guidelines provide a ready review criteria for rating compliance with best care practices.
Clinical guidelines also act to bolster medical research. While formulating evidence based guidelines, researchers can easily identify specific gaps in the accumulated evidence, and thus, design such key research questions that must be answered to establish the true effectiveness of an intervention.
The guidelines, protocols, and care pathways developed by government panels and professional medical societies in the developed world focus upon bringing homogeneity in clinical practice. These guidelines are often unmindful of the expertise and resources at hand. Such a model becomes extremely difficult to follow in countries, where the quality of care must be dictated by a host of factors, among others - the geographic region; the healthcare facility at hand, including its infrastructure and the standards of training and expertise of its healthcare providers; and the paying capacity of an individual patient.
In a country so large and widely disparate as India, where the standards of healthcare between countryside, towns and metropolitan cities are as dissimilar as chalk and cheese, no "single" guidelines, protocols, and care pathways can be held "sacrosanct". They must be developed each to suit a particular condition, taking into account the infrastructure of a healthcare facility, the expertise of a healthcare provider, and the financial health of individual service-receiver. This is no easy task and imposes considerable responsibility upon government panels and professional medical societies in the country, which must structure the guidelines, protocols, and care pathways to suit the ground realities.
If responsible guidelines are to be developed, it requires a careful thought, a through consideration of ground truths, and a robust understanding of scientific evidence. This must be welded to purity of thought, and no concessions be permitted for a bias, a hidden agenda, or any self-serving motives.
Often enough, however, guideline development groups lack the time, resources, and skills to formulate the requisite guidelines and try to fabricate "one-size fit-all" protocols. Such exercises are largely a copy-and-paste job, with guidelines being "picked" from resources which may or may not befit a community, and are often essays in vanity, puerility and whimsicality. Equally, most of the times, not one member in the committee possesses the requisite ground experience, nor the committee is confident of its goal or objectives. If such ill-designed ill-gotten guidelines are formulated, inevitably they are doomed to disaster.
Simplistic straitjacketed algorithms that reduce patient care into a sequence of binary (yes/no) decisions mostly do grave injustice to the complexity of medicine and the parallel and iterative thought processes inherent in clinical judgment. Words, numbers, and inflexible algorithms can be used by those who judge clinicians unfairly. Guidelines are also potentially harmful to doctors as citable evidence for malpractice litigation and because of their humungous economic implications.
With the golden edict of primum non nocere no longer the guiding spirit, and a new corporate culture having come to the fore, the entire landscape of healthcare practices stands radically transformed. A breeding ground for a myriad of questionable if not unsavory practices, the emphasis of these healthcare institutions has majorly shifted to financial numbers. Keeping a job may well be a fruit of the moolah one rakes in, rather than a reward of good-old practices which worked around humanness, social cause and people's well-being.
In times such as these, where a patient must be thought of as a client, and the needle of suspicion rides high in a client's mind, where each test, treatment, and treatment goal must wear the test of scrutiny, and the social club forgetful of the old holy order which once governed this hallowed saintly profession dissects each prescription, each doing of a physician, and is ready to crucify him, it is perhaps time that the artful craft of medicine be allowed a quiet burial, and instead, guidelines for best care practices capture the hearts of the physicians. This must make for a decree of the times, a diktat, notwithstanding the vagaries of unpredictability that cloak the human biological system.
In times such as these, where a patient must be thought of as a client, and the needle of suspicion rides high in a client's mind, where each test, treatment, and treatment goal must wear the test of scrutiny, it is perhaps time that the artful craft of medicine be allowed a quiet burial, and instead, guidelines for best care practices capture the hearts of physicians.
The authors are grateful to Prof DK Gupta and Prof RS Sethi, both faculty members with New Delhi's Safdarjung Hospital, for providing useful inputs towards this editorial.
Dr Dinesh Kumar Singal, Senior Gastroenterologist, Pushpawati Singhania Research Institute, New Delhi, deserves our deepest gratitude for sharing with us his creative pictures shot at Chidiya Tapu, Andaman and Nicobar Islands.