When Guidelines Don’t Guide

Abstract

Participants were sensitive to both the best clinical evidence of benefit, as recommended by CPGs, and patient context when determining how care should be managed.

Variation in the diagnosis and control of hypertension is not explained by conventional variables: Cross-sectional database study in English general practice

“…Unwarranted variation can contribute to inefficiency through over- and under-utilisation of healthcare, however distinguishing warranted from unwarranted variation is challenging [17] [30]. Factors can lead to variation including individual factors such as clinician decision making [31] [32] [33], local cultural beliefs of clinicians and patients [33], and system factors such as incentives and system delivery factors [33] [34]. In a systematic review of variation research in OECD countries only 10% of studies focused on the underlying cause of variation [34].…”

Effects of live and video simulation on clinical reasoning performance and reflection

“…They argue that the skillful deployment and completion of clinical reasoning tasks shift according to the case and context, painting a complex and situation-specific (situated) picture of clinical reasoning [ 15 ]. Beyond the complexity of the clinical reasoning tasks themselves, there is a developing literature on contextual factors —common features of clinical practice (e.g., patient frustration, interruptions, and language barriers) that typically are not used to establish the correct diagnosis [ 16 – 18 ]. Based on recent research [ 19 , 20 ] and the theoretical proposition that knowing is bound to activity, social norms, environment, and cultural factors [ 21 ], the presence of contextual factors can lead physicians to think about and react to different aspects of a case.…”

“…Based on recent research [ 19 , 20 ] and the theoretical proposition that knowing is bound to activity, social norms, environment, and cultural factors [ 21 ], the presence of contextual factors can lead physicians to think about and react to different aspects of a case. Differences in situation-specific perceptions and the metacognitive reactions to contextual factors can greatly alter the quality or accuracy of physicians’ diagnostic and management reasoning [ 18 , 22 ].…”

Examining the Influence of Context and Professional Culture on Clinical Reasoning Through Rhetorical-Narrative Analysis

“…Researchers observe physicians’ continued regard for practice as something more than merely following guidelines. Furthermore, evidence can be challenging to use or to assume is legitimate, when it is produced with methods and samples that are decontextualized (Grypdonck, 2006; Lingard et al, 2003; Little, 2003; Mercuri et al, 2015; Pope, 2003). One study revealed that when social information is included in a sample case, physicians disregard CPGs in their diagnostic assessment more often (Mercuri et al, 2015), and another revealed that when faced with contradictory evidence, physicians tend to fall “back on what they ‘really knew’—their own experience” (Pope, 2003, pp.…”

“…Its original formulation urged clinicians to use scientifically acquired epidemiological evidence to direct clinical decisions, and cautioned against the use of “unsystematic observations from clinical experience” and “intuition” (Guyatt et al, 1992, p. 2421). Despite this formulation, researchers have shown that physicians do not always follow the approach, such as in cases where contextual factors do not allow for the easy application of evidence obtained in randomized controlled trials (RCTs; Mercuri et al, 2015). In such cases, physicians make decisions that they are then required to explain and justify through a conscious application and demonstration of rational information.…”