Guidelines are in the air and it seems that doctors are unable to make a decision/recommendation about any clinical problem, without consulting guidelines.
A WHO guideline is defined broadly as any information product developed by WHO that contains recommendations for clinical practice or public health policy. Recommendations are statements designed to help end-users make informed decisions on whether, when and how to undertake specific actions such as clinical interventions, diagnostic tests or public health measures, with the aim of achieving the best possible individual or collective health outcomes.
Needless to say, there are a number of problems with this rather unwieldy definition of a guideline. Anybody who is or has been a clinician knows that guidelines cannot possibly cover all clinical situations and that the reliance on experience and knowledge of the patient are of paramount importance. Obviously, the success of vaccination programmes is widely recognised, although even though this is disputed by some groups. Somehow, I don’t think the reliance on guidelines will convince these groups otherwise.
It seems to me that the term evidence-based is inherent in any published guideline. Whereas this may be true in certain circumstances, for example vaccination against certain infectious diseases, there is an underlying belief that evidence is objective whereas we all know that evidence is subjective and depends on the way it is collected and by whom. If evidence is truly objective, then there would be no need for lawyers! We know that lawyers can ‘prove beyond a reasonable doubt’ that innocent people are guilty as we see in the recent Royal Mail scandal when hundreds of innocent people were found guilty of theft leading to severe stress, marriage dissolution and, in some cases, suicide. That particular scandal brings to mind the description of lawyers by Jonathan Swift in his book Gulliver’s Travels: there was a society of men among us, bred up from their youth in the art of proving by words multiplied for the purpose, that white is black, and black is white, according as they are paid. To this society all the rest of the people are as slaves.
It is remarkable how some diseases become ‘fashionable’ and some don’t. A good example of the former is sickle cell disease (SCD). I attended the annual meeting of the American Society of Haematology (ASH) every year from 1974 until the outbreak of Covid-19 and was always struck by two things; the paucity of delegates of colour and of papers addressing the needs of patients with SCD. Although SCD was described in the American literature since the 19th century it was not until the late 1940s that the molecular basis was unravelled. During the last 10 years the interest in the treatment of SCD has exploded and the number of delegates of colour attending the annual meeting of the ASH has increased dramatically. Like wise the number of guidelines has increased.
Lest I be mistaken for a Luddite (a much-misunderstood term. Luddites were primarily concerned with the effect of industrial mechanisation on employment and not opposed to mechanisation per se) let me be clear, guidelines are important in terms of strategy but cannot possibly cover all clinical circumstances. A good example of strategy is: should our haematology colleagues engage in the treatment of a rare disease such as severe aplastic anaemia. A perusal of the guidelines will help to make an informed decision whether the unit should carry out treatment for this rare disease or refer to a specialist unit. Guidelines are helpful in deciding whether to give HLA matched platelets or not as a matter of policy but cannot and should not determine when platelet transfusions should be given to a specific patient in a unique set of clinical circumstances.
A number of advances in medicine have occurred because of serendipity and not rigid obeyance of guidelines. The discovery of penicillin and of H.Pylori as an aetiological agent in peptic ulcer disease are good examples of a serendipitous advance. I am sure there are many more examples of serendipitous discoveries in medicine. Blood transfusion was originally believed to be a treatment for insanity in the 16-17th centuries and it was not until the 18th and 19th centuries, through careful clinical observation and experimentation that transfusion to reverse the effects of hypovolemia became a recognised treatment. It was not really until WWII that blood transfusion, as we know it today, albeit with some improvements, became widely accepted as a life-saving therapeutic intervention.
Another expression, allied to guidelines, is ‘thinking outside the box’. Many people who use this expression have no idea of its origin. It probably originated in the mid-1950s and is really a commentary of perception, although it has now come to refer to anybody or any idea which is not hide-bound by strict adherence to guidelines. The concept is widely used in the corporate world but is probably relevant to many walks of life, including medicine.
About the Author
Shaun Richard McCann received his M.B. from University College Dublin. He became a Member of The Royal College of Physicians in Ireland (MRCPI), by examination, in 1973. He was a specialist medical fellow at the University of Minnesota from 1974-76. The main focus of his research then was red cell structure and function, especially in hereditary spherocytosis. Click here to learn more.