Monday, 6 August 2018

Clinical practice guidelines versus shared decisions

In the April post I was talking about the call for the end of clinical practice guidelines. This is an issue that is generating controversy and I think it’s worth revisiting, especially following the publication of “Making evidence based medicine work for individual patients” by Margaret McCartney and collaborators, where they say that there is concern because the guidelines, instead of reducing variations and improving the quality of assistance have managed to bureaucratize medicine, while at the same time reinforcing historical authoritarianism. This happens because, according to the authors, based on the evidence, the guides encourage doctors to ignore the real needs of the people they serve. In addition and to top it all, a review concluded that 62% of the guidelines were based on irrelevant evidence for health problems affecting people visiting the family doctor.

Shared clinical decisions

Evidence-based medicine should end the era of clinical practice guidelines and find other more useful instruments for office work. The guidelines, as we see, are not only inoperative, but reinforce autocratic attitudes and what currently is convenient, instead more professional training is required so that doctors know how to properly understand what patients really care about and subsequently determine how diagnostic and therapeutic options can be proposed in a comprehensible way. Everything points to the combination of more medical training in motivational interviewing and shared clinical decision dialogues, and together with the development of decision support materials (decision aids), will become the strategy that will allow real value to be placed in medicine based on evidence.

Changing clinical practice guidelines for shared decisions is not an easy journey. Evolving from an attitude based on "here we do things the way we do it" towards knowing how to listen to patients in a structured way, which implies acquiring certain skills in the emotional handling of interviews, because the social reality is so varied that there are people who want to be very active in the decisions that must be taken within their clinical process, or even want to direct (see ePatientDave), while others prefer to be completely led. In an environment of shared decisions, everything is more open than in one of clinical practice guidelines, and it must be foreseen that, in this new framework, patients can make decisions that are not recommendable from the doctor's point of view, and that is not easy to manage.

Massachusetts General Hospital as an example

Karen Sepucha and collaborators have published within Health Affairs the Mass General program to promote shared clinical decisions at all levels of care, from primary care centres to the most technological units. From reading the article you realize the importance of having a planned strategy to move from clinical practice guidelines to shared clinical decisions. According to the published data, the Mass General, during the last ten years, has trained more than 900 clinical professionals (doctors, nurses and others) who, on a voluntary basis, have accessed training programs in methodology for shared clinical decisions and they have elaborated 40 decision aids (support materials to help in the decision-making process), which have been used on more than 28,000 occasions.

We must speak less about empowering, which is still a delegation from the one with the power to those who don’t have it and, as they do in the Mass General, better train clinicians to learn to listen and make decisions collaboratively. We must admit, however, that the new world of clinical management opens doors and creates uncertainties. It’s not perfect, but it strives to base welfare work more on the needs of people.

Jordi Varela

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