Guidance is Not Just Guidance

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Not too many years ago, all medical practitioners used to practice the shady art of anecdotal medicine. Very much like the crafts and skills passed from tradesmen to their apprentices they would learn their art from their seniors, based on a foundation of scientific principles and years of experience. If taught that a few micrograms of arsenic in a glass of tonic will drive away a fever, then this jewel of wisdom would become part of their own knowledgebase to be practiced and eventually passed onto their own juniors.

In the 1960s flaws in this model began to be noticed. Wide variation in the practices of different physicians became apparent, which brought into question which, if any, were the most beneficial. A body of studies to determine which were the most effective started to be catalogued, with the intention of guiding clinicians in what became known as evidence based practice. This expanding body of work began to yield some unexpected and unwelcome results. As well as determining the most effective practices, it also discovered that many had no benefit at all, and indeed some actually did harm.

A foundation principal of medical ethics is Primum non nocere (first do no harm), and the realisation that many treatments contravened this principle triggered an obstinate denial in otherwise proud and often arrogant clinicians. The first rebuttal came from mistrust of the clinical evidence that was being gathered, and indeed superficially this seems reasonable as many trials can lead to contradictory conclusions, and bias can often affect the outcomes. In addition to the studies, there needed to be a system of critically appraising the evidence, and a hierarchy of the value of evidence was developed to assist this process. Anecdotal (experiential) evidence being at the bottom of this list. The concept of critical appraisal is taught in modern day clinical schools, however, mastery of this skill takes considerable experience that many of us don’t have the time to develop.

It’s lucky then, that there are those who are motivated to become experts, and indeed make a career from doing the hard work for us by reviewing the evidence, critically appraising its validity, and performing meta analysis based on sound mathematical principles developed outside of medicine. In a nutshell giving us a mathematically robust result as to the most clinically effective (or ineffective) practice. This information is readily available for any clinician motivated to do some reading and research. However, this is still more work than many have the time to do, so with this in mind, this body of evidence is further catalogued into easy to understand literature known as guidance.

It seems that for some, even this resource of easy to follow pathways of best practice is still too much to follow. If you don’t follow the current guidance then you’re either likely to be guessing, or you’re basing your treatment choices on outdated practice, something you’ve heard, something you think you’ve seen, or something you’ve read in an unappraised article. Either way, unless you learned it recently from someone who follows current guidance, you are likely practicing less effective medicine, and/or maybe doing harm.

Sadly, there appears to be a strong resistance from practitioners to acknowledge this and to change their practice. Often attempts to remind peers as to the current guidance on best practice are met with strong rebuttal. Among the numerous retorts heard, the most common, is that “guidance is just guidance”. This is a semantic argument that means absolutely nothing. Guidance is indeed guidance, and it’s meant to be that way. It’s meant to guide the treatments you use, but the authors are aware that there may be reasons to deviate from it that cannot be encompassed within the scope of evidence. That’s entirely reasonable, but if you are going to deviate from a pathway of treatment that has been studied and reviewed by numerous senior practitioners who are experts in the critical appraisal of evidence provided by numerous studies, then you need a good reason to do so. Simply doing what you think is best because it’s only guidance is an excuse to do whatever you want. If you’re climbing Mt. Everest, and the Sherpa tells you the best route is up the North face, you need a good reason to ignore him and take the Southern route, especially if someone else’s wellbeing is at stake.

Why, over 4o years on from the publication of Archie Cochrane’s Effectiveness and Efficiency, many of us still continue to practice anecdotal medicine is a puzzle. There appears to be an unhealthy obstinance in medicine that pins us firmly to the trailing edge of best practice, and routine practices such as splinting sprains, giving antipyretics to children, giving PPIs in upper GI bleeds, prescribing Z drugs and Benzodiazepines for more than 2-4 weeks, giving antibiotics for viral chest infections, sore throats, sinusitis, and otitis media, nebulising children, giving antidepressants in mild depression, and using injectable medicines instead of oral, are all too common.

I wonder how long a lawyer would be able to continue to practice if he/she applied the same approach to his/her legal practice. Guidance is not just guidance, it is an evidence based handbook on the most likely way to benefit your patient, and do the least harm.

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Teddy Marsh

Teddy is a medical author, and is interested in aspects of medical law and legislation. He likes to challenge conventions, and write about the topics that most avoid or simply refuse to acknowledge. In his own words he states he "prefers the simplicity of unpolished honesty no matter how much it irritates"

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