The amount and quality of research that informs excellent family practice has increased dramatically in the past 3 decades. This has strengthened the confidence of family physicians recommending interventions in the prevention, diagnosis, and management of disease and illness. It has also heightened our patients’ expectation that we bring up-to-date medical science to their encounters and apply it consistently, avoiding inappropriate variation.
Evidence-based revolution
In the early stages of the evidence-based revolution, each physician had the task of reviewing the literature, selecting the most appropriate research, and coming to individual conclusions. This individual approach lacked the perspectives of colleagues, consultants, researchers, and the public. The development of clinical practice guidelines (CPGs) led by professional groups and associations, government and other public agencies, non-government disease-based charities, and others used a transparent, collegial process to apply a critical analysis to scientific literature. Where the literature did not address the clinical concern, they debated and came to a consensus on their best professional opinions. Their analysis and discussion was translated into clinical recommendations coded by levels of evidence reflecting the rigour or credibility of the research or their opinions. Thanks to the Internet, these clinical guidelines are widely and easily available to practitioners on a variety of websites.
An example of such websites is CMA Infobase,1 which includes evidence-based CPGs developed or endorsed by authoritative medical or health organizations in Canada. Other groups, such as the Guidelines Advisory Committee working within the Center for Effective Practice,2 critically review the guidelines themselves and provide summary recommendations categorized by level of evidence. Toward Optimized Practice3 is a joint venture of the Alberta Medical Association and the Government of Alberta that develops their own guidelines or adapts those from other sources to the Toward Optimized Practice program.
A report by the Institute of Medicine to the American Public Health Service in 1990 described the role of CPGs as follows:
[Clinical practice guidelines] translate knowledge into patient and practitioner decisions that improve the value the nation receives for its healthcare spending .... [They are] part of a significant cultural shift, a move away from unexamined reliance on professional judgment toward more structured support and accountability.4
Finding balance
Family physicians must remember that all this evidence, whether as original research or translated into guidelines, describes what occurred with groups of patients who were selected according to study criteria. While this evidence provides increased certainty and precision in predicting effects of prevention, diagnosis, and management for groups of patients, the probability of such effects for individual patients meeting with their family physicians remains uncertain. We can characterize this uncertainty precisely with P values, z scores, and confidence intervals, but it remains uncertain for each particular patient.
So how are CPGs essential to excellent family practice and the patient-physician encounter that is at the heart of clinical medicine? The Royal College of General Practitioners describes this “consultation” of a patient with a physician as central to the practice of medicine:
The essential unit of medical practice is the occasion when, in the intimacy of the consulting room or sick room, a person who is ill or believes him/herself to be ill, seeks the advice of a doctor whom she/he trusts. This is a consultation and all else in the practice of medicine derives from it.5
In these consultations, patients will trust that their physicians are knowledgeable about and up-to-date with the latest scientific evidence. Physicians must also work with patients, involving them in the management of their illnesses. Physicians must nurture the trust developed in those relationships over time, as this is the source of many positive effects.6 Together, the patient and physician must decide what is best given similarities and differences between the particular patient and the patients in the research populations, the narratives and meaning of the illness to the patient, the patient’s fears and expectations, and other relevant sociocultural factors.
As Sir Donald Irvine states:
Clinicians must retain freedom to decide with their individual patients what is best in the circumstances.... Either arbitrariness at one end of the scale of decision-making or rigidity and unyielding diktat at the other, are incompatible with what is best for patients.7
Further, family physicians have the opportunity to revisit clinical issues within a continuing relationship over time. When circumstances change and fears, wishes, and aspirations are revealed in confidence as the relationship builds, patients and physicians can revisit the recommendations of guidelines and reconsider choices in light of ongoing life. Here, and elsewhere, the scientific evidence reflected in CPGs is essential to excellent clinical care. The incorporation of guidelines into the decisions made jointly with patients and often their families—not in a prescriptive or inflexible way, but reflectively, adaptively, and wisely in light of ongoing circumstances—is excellent family practice.
The Physician of the Future document, developed to guide medical education in Mexico, asserts:
[T]he best professionals are not necessarily those who follow protocols and guidelines most strictly but rather those that know when and how they should deviate in their application for the benefit of a given patient.
It goes on to note:
[We want] physicians who, beyond establishing relationships with patients, win their confidence; physicians capable to reconcile what belongs to the rational world with what is relational, but also having very clear in their minds that if their professional approach is only rational their practice will not be good medicine while if their practice approach is only relational it will not be medicine at all.6
Practising good medicine requires finding a balance between science and circumstance, but CPGs are essential to this process.
Notes
CLOSING ARGUMENTS
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Clinical practice guidelines are expert syntheses of research relevant to clinical problems.
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Patients expect that family physicians will bring up-to-date knowledge to the discussion of their problems.
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Knowledge based on clinical research is precise for groups of patients but uncertain in the individual case.
Footnotes
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Cet article se trouve aussi en français à la page 523.
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The parties in this debate refute each other’s arguments in rebuttals available at www.cfp.ca. Join the discussion by clicking on Rapid Responses.
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Competing interests
None declared
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