An Introduction to Clinical Practice Guidelines for Medical Students – Whether you are an aspiring physician, nurse, pharmacist, or other allied healthcare professional, at some point you will need to familiarize yourself with clinical practice guidelines. This article will take a look at exactly what clinical guidelines are, why they are created, and most importantly, why you should care about them.
Clinical guidelines have been around for thousands of years. That’s right…thousands. They have been around so long that some even consider Hippocrates of ancient Greece as one of the first authors of clinical practice guidelines. Still, others believe guidelines go back even further, taking the form of verbal recommendations and traditions that were passed down from generation to generation.
While the history of guidelines is rich, the modern age of guidelines really began with a 1992 Institute of Medicine (IOM) report, which defined guidelines as “systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances”. In the 25 years since the first modern guideline, over 15,000 guidelines have been published around the world, and the output increases steadily each year. From this trend we can see that the importance of medical guidelines will continue to grow as time goes on, as more evidence is compiled and new discoveries are made.
What is a clinical practice guideline?
So you now know that guidelines are old and there is an ever increasing number being published. But what exactly are they?
You can think of guidelines as a sort of “recipe” to assist clinicians during the decision-making process. In essence they are the “how to guides” for a given disease, condition or topic – supporting the rationale for diagnosis, management and/or treatment. Most guidelines are published by medical specialty societies (such as the American Heart Association or Infectious Diseases Society of America), as well as governmental bodies (such as the USPSTF). There are guidelines for nearly every therapeutic area (neurology, podiatry, ophthalmology, etc.) and topic (diabetes, heart failure, asthma, etc.) in medicine. So no matter which profession or specialty you choose, there will be a myriad of applicable guidelines.
So who decides what the guidelines should say? Well, in most cases the guidelines are authored by an assembled panel of experts in the given topic. The panels may be comprised of physicians, nurses, pharmacists, specialists, generalists and even patients. These experts dive deep into published literature and review a mixture of journal articles, study data and empirical knowledge (personal experience) to arrive at a recommendation for each aspect of the topic. They review enormous amounts of data, and it is not unusual for there to be several hundred references in a guideline. The expert panels are large, the costs are high, the process is long, and the results can easily exceed 100 pages (just imagine a large group of individuals agreeing on anything, let alone something that can make the difference between life and death).
Sounds straightforward, right? Well, not so fast. Increasingly, clinicians and clinical managers must choose from numerous, sometimes differing, and occasionally contradictory, guidelines. It’s important to understand why this is the case. Guideline recommendations are derived from two main methods – evidence (published data) and consensus (personal experience of the author(s)). There are multiple ways to interpret evidence, and consensus is limited to the experience of each expert. This is why the best guidelines offer the added feature of grading the recommendations, so that you know the logic behind each statement (i.e., the mix of evidence vs. consensus/experience). The panel of experts will vote on the quality of the literature supporting the evidence and the faith they have in the risk/benefit ratio to determine the grade and strength of recommendation.
Guidelines are not a magic bullet, though. Every patient and circumstance is unique, so this “recipe” is really closer to what you’d expect for a chef, rather than a baker. Because of the variability, many guidelines are prefaced with something to the effect of “recommendations are not intended to preclude clinical judgment.” Guidelines can also be slow to update, so some may not consider recently approved therapies, devices, tests, etc. until they are months (or even years) old. Additionally, guidelines are often incomplete when there is not enough evidence to support a recommendation. For that reason, guidelines usually focus on the more common areas (e.g., diabetes), while other topics and rare diseases that are less understood may lack guidelines altogether.
Guidelines are usually updated or reaffirmed every few years by similar expert panels. You, as a medical professional, are expected to be familiar with all the guidelines in your chosen specialty, as well as know when updates are published. This can be especially daunting if you are in general practice, and the burden may keep you awake at night.
Why do we have clinical guidelines?
So now that we’ve defined what clinical practice guidelines are, what exactly is their purpose? Well, that could be a post in itself. However, from a high level, some of the common benefits of guidelines include:
- To describe appropriate care based on the best available scientific evidence and broad, expert consensus
- To reduce inappropriate variation in practice
- To provide a more rational basis for referral
- To provide a focus for continuing education
- To promote efficient use of resources
- To act as focus for quality control, including audit
- To highlight shortcomings of existing literature and suggest appropriate future research
While all of those benefits are great, guidelines are essentially meant to save you, the healthcare provider, the time of reviewing and critiquing the tens of thousands of peer reviewed articles and studies published each year. The guidelines committee will review the outcomes found in these articles, synthesize the evidence, and ultimately come up with a standardized approach that clinicians can follow in their daily practice. Makes sense, right?
Well, yes it does, but I assume your next question might be: “You’re saying guidelines are meant to save time, but you also said that there are thousands of guidelines with an average length of 100+ pages each, PLUS they change regularly…how is that really saving me time?” Good question. Hold that thought; we’ll get back to it.
Do I need to read and understand guidelines?
Well…the short answer is “yes” (assuming you want to practice medicine in this country). That may sound foreboding, but just remember that there’s plenty of carrot to go along with that stick.
For starters, as a student, guidelines can be a fantastic resource to learn from and can even help you study for exams. They provide you with credible recommendations for various clinical topics and patient scenarios and back up all of those recommendations with graded evidence and links to the sources where the information comes from. Guidelines are essentially the Wikipedia of the medical world (with the editing restricted to those who know what they are talking about, thankfully!).
It’s not just students that need to keep up with guidelines, either. It is said that 10% of medical knowledge becomes obsolete every year. That doesn’t mean that after ten years you will know nothing – anatomy doesn’t change – but medical progress is dramatic. This is one reason why, over the past several decades, the medical profession has greatly expanded its expectations for continuing education. No longer can one expect to be lifetime-certified with just a medical degree. Indeed, specialty board certification – and recertification by formal examination at regular intervals – is now required even for hospital privileges. This is important because continuing medical/pharmacy/nursing education (CME) is largely driven by evidence-based medicine and clinical practice guidelines. This CME (and the guidelines it’s derived from) will focus on that 10% per year that is critical to quality care.
Understanding and following guidelines can also protect you in the case of a malpractice suit. Think about it – “following the evidence-based guidelines” is an incredibly strong defense or justification for or against certain clinical decisions. On the flipside, by not following the guidelines you are opening yourself up for a world of scrutiny. You better be able to back up your decision if you act contrary to the guidelines. Whether you’re for or against that logic, guidelines will become only more important as time goes on. Efforts are even being made to tie reimbursement to performance, which would be based on well-established guidelines and quality measures.
If maintaining your license, protection from litigation and increased reimbursement aren’t good enough reasons to convince you that guidelines are important, remember this – guidelines are also proven to improve patient outcomes – and isn’t that the whole purpose of practicing medicine?
We’ve established that there are literally thousands of clinical practice guidelines, that many guidelines can easily exceed 100 pages, and that you are expected to know what each of these guidelines says and when they update. Seriously…what is a clinician supposed to do? Can’t someone simplify this a bit – maybe with a cliffs notes version or something?
We’re glad you asked. Guideline Central was founded in 2002 and works with nearly 40 different medical societies to create “quick reference” versions of clinical practice guidelines. These summaries extract the key recommendations, algorithms, tables and other critical content into point-of-care references, useful when you need an answer in a hurry and also for those ulcer-perforating exams.
Guideline Central maintains the largest quick-reference guidelines library in the world, including over 1,500 publicly available guideline summaries, as well as 270 “premium” pocket guideline summaries in both hard copy and digital versions. These summaries were developed in cooperation with the societies that authored the full text guidelines, so you don’t have to worry about whether the content is credible or not.
Medical students are eligible for exclusive discounts and additional free content. Contact us today and reference this blog post to learn more.