Clinical Judgment and Clinical Practice Guidelines

Abstract

Clinicians make judgments under conditions of uncertainty. Decision research has shown that in uncertain situations individuals do not always act rationally, coherently, or to maximize their expected utility. Advocates of clinical guidelines believe that these guidelines will eliminate some of the cognitive biases that the practitioner may introduce into the medical decision-making process in an attempt to reduce its uncertainty. Other physicians have grave doubts about guidelines' application in practice. Guideline implementation lags well behind their development. Studies of practicing physicians and a survey of clinicians in one specialty and setting indicate that experienced clinicians may be implementing guidelines selectively. Many clinicians are concerned that guidelines are based on randomized trials and do not reflect the complexity of the real world, in which a decision's context and framework are important. Their reluctance also may be due to the difficulty of applying general guidelines to specific clinical situations. The problem will only increase in the future. The patients of the 21st century will be older and have more complex disease states. Physicians will have more patient-specific therapies and need to exercise more sophisticated clinical judgment. They may be more willing to use guidelines in making those judgments if research can demonstrate guidelines' effectiveness in improving decision making for individual patients.

Invasive aspergillosis: an important risk factor on the short- and long-term survival of acute myeloid leukemia (AML) patients

“…Many other clinicians are concerned that randomized clinical trials and related guidelines do not reflect the complexity of the real world [25][26][27]. In the recent years, two large studies have shown the efficacy of posaconazole to significantly reduce the incidence and IFIrelated mortality in patients with AML, MDS, or undergoing HSCT [10,11].…”

Statin utilization according to indication and age: A Danish cohort study on changing prescribing and purchasing behaviour

“…The present study provides a picture of a guideline production based on an international scientific collaboration. Although, guidelines tend to shape the allocation of scarce health care resources [86][87][88], guideline recommendations are often partly based on extrapolations from RCT's and consensus assessments because published clinical evidence -described in relative terms in selected populations -rarely contains information readily applicable for clinical practice [89][90][91]. In fact, the threshold for statin therapy in asymptomatic individuals in the risk-scoring charts is entirely arbitrary [92][93][94].…”

Optimizing the language and format of guidelines to improve guideline uptake

“…This recommendation includes multiple steps 37,57 in a complex decision tree 13,36,60 as well as different conditional factors that should influence the clinician's approach. 13,61 This type of complexity hinders understanding and persuasiveness and may render recommendations more difficult to accept 22,62 and thus less likely to be implemented. 37,63 Managing this complexity to produce uncomplicated recommendations requires "atomization" -the process of extracting and presenting individual concepts from the complex recommendation.…”