Argue the Toss: Guidelines or Expertise
This piece is closely connected to the one at:
There is a series of posts at:
http://www.bmj.com/content/350/bmj.h841/rapid-responses
The first four posts (or 'articles' as the BMJ describes them) comprised two by Dr Philip S Rathbone and two by me. I have exchanged some e-mails with Philip, and he has an interest in 'whether guidelines must be followed' which he further explained in an e-mail to me. He explained in his e-mail that he is concerned about an 'unthinking application' of guidelines (I am going to assume for this piece that guidelines and guidance are equivalent terms, and are essentially interchangeable), without properly considering the overall situation: this is something I also write about, explaining that for guidelines to be short enough, and clear enough, to be useful, they must necessarily 'ignore some unusual situations, and that if you apply the guidelines to those unusual situations, the result is often a disaster'.
I also have a second issue, which can briefly be described as 'different professionals following profession-specific guidance which does not properly join-up if you are a service user [who becomes entangled with several different professions]'.
EXPERTISE
Philip and I, were actually discussing not a medical issue, but a legal issue on the BMJ website via our rapid responses. Cynically, my general position is that medics seem much better at anatomy and physiology, than they are at law. But whatever the subject - be it clinical treatment or law - 'experts' understand a lot, about their area of expertise. Put very simply, 'an expert has done the studying, understood the thing, and 'has grasped it''.
Think of a really keen car restorer, who can take apart old cars, and put them back together, without needing to keep looking at manuals for guidance - 30 years of tinkering with cars, means this person 'understands how they work, how they are put together, and what-goes-where'.
So experts, tend to see guidelines as restricting them: they just want to look at the situation, and then apply their expertise to the problem.
GUIDELINES
Guidelines, might in part be to introduce joined-up behaviour (for example, they might specify which person must record a change in a situation, on a database). But usually, guidelines are an attempt to 'push staff who are not-really-experts, into making good decisions'. In fact, it is clear that many junior clinicians, or clinicians who are working in an area of practice they are unfamiliar with, tend to 'regard the guidelines as being rules'. And, many staff 'fall on [compliance with] guidance, for 'back covering in awkward situations''.
There is, however, a built-in problem: any guidance which is clear enough to understand, and concise enough to be read, cannot correctly cover 'very unusual situations'. To make it worse, the behaviour described by the guidance, which will work fairly well for perhaps 95 - 99 per cent of all situations, tends to 'fail catastrophically for those very unusual situations'. The proof of 'they fail catastrophically in unusual situations' is lengthy, so I will not go through it here.
As Dr Rathbone wrote on the BMJ:
If a doctor considers that a guideline does not apply to a particular patient at a particular time then there is no obligation to follow it. Indeed, if this were the case, unthinking application of a guideline could itself be viewed as negligent.
IN CONCLUSION
The situation is this:
If all staff were experts, guidelines would be largely unnecessary, and the approach would be 'Just use your expertise - get on with it, and take responsibility for your decisions'.
But, if staff are inexpert, they will on the whole make better decisions if they follow guidelines - not always such good decisions as would be made by experts, and with some really bad decisions where the guidelines 'don't fit the situation properly [but the inexpert staff either do not realise that, or lack the confidence to depart from the guidance]', but better than what would happen if you simply left inexpert staff to 'make your own decisions'.
So, IF the staff 'are very well-trained and expert', it works best if they are left to use their expertise without being 'hampered' by guidance - but IF staff are 'under-trained and inexpert', it works best if they are constrained by guidance.
Training costs money, and to compound this until something really bad prompts 'an enquiry' (Mid Staffs, the Neuberger LCP review, etc) and the enquiry finds that 'there were issues around staff training', almost no organisation will admit that its staff are indequately trained - the resolution of this conundrum, is very tricky !