Dr. Mitch Shulman: What can we learn from the fact that doctors don’t always follow guidelines?

Guidelines represent the best information that’s currently available for managing situations when looked at from the perspective of a large number of people.

The paper, A Taste of Their Own Medicine: Guideline Adherence and Access to Expertise, was published in the journal, American Economic Review: Insights. The researchers looked at Swedish data from 2005 through 2016. The guidelines referred to dealt with antibiotic use in infection; medication use in the elderly; which medications were recommended for specific illnesses; and medication use in pregnancy. They wanted to see if doctors applied the same guidelines to themselves and to their family as they did to their patients. They were surprised to find out that the doctors didn’t always.

First clue to what’s happening: the compliance of the doctors varied with the type of guideline. They were less likely to follow guidelines about medications used in infections; much more likely to follow the guidelines that dealt with safe medication use in pregnancy.

Guidelines represent the best information that’s currently available for managing situations when looked at from the perspective of a large number of people. For example, some guidelines recommend specific, targeted antibiotics for urinary tract infections or lung infections. These infections are so common that if we used more general antibiotics to manage them, we would run the risk of creating increased antibiotic resistance among the bacteria causing these infections.

However, in the situation of an individual patient who the doctor is treating, while the guidelines might recommend one approach, the doctor might take a different one based on their knowledge of the patient. The doctor might apply the same logic to recommending a course of treatment for themselves or a family member. On the other hand, when a medication has been found to be dangerous in pregnancy, the doctors were much more likely to follow the guidelines. That makes sense, where the data shows unequivocal danger irrespective of the patient’s medical history, not taking this into account would be foolhardy.

This study highlights some important points. When a doctor gives you a prescription for a medication you should understand: 1) why it’s been prescribed; 2) how to use it properly; 3) how long to take it; and 4) what you should be watching for while you’re on it. What are the warning signs that it’s not doing the intended job? How long should I wait to make sure it’s doing what it’s supposed to?

With this information you should feel confident to take the medication as prescribed. A major issue is that when doctors prescribe a treatment, as few as 50 per cent of patients take the medication as intended. This creates significant waste and risk. Doctors use their understanding of medicine to tailor treatment to what makes the best possible outcome possible for the people they know best, themselves and their close family members. There are risks that they are willing to take that they would not want their patients to be exposed to. But this study emphasizes that sharing information with patients might give them the incentive to use the medication as intended and thus reduce the number of return visits and other complications from a treatment plan that hasn’t been followed faithfully.

At the end of the day, it isn’t that the guidelines are wrong, or even whether doctors ignore them. The key point is how important clear communication is.

Dr. Mitch Shulman is an Associate Professor in the Department of Emergency Medicine at McGill Medical School as well as an Attending Physician in the Emergency Department of the McGill University Health Centre. He’s also the CJAD AM 800 Medical Consultant.

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