Incorporating Guidelines Into Clinical Practice: An Interview With Gary L. LeRoy, MD

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Many PCPs are overwhelmed by the vast and ever-increasing numbers of guidelines issued by multiple societies.
Many PCPs are overwhelmed by the vast and ever-increasing numbers of guidelines issued by multiple societies.

Clinical practice guidelines (CPGs) have increasingly become institutionalized as ways to provide guidance to clinicians regarding patient care.1 CPGs are "statements that include recommendations intended to optimize patient care."2 They are "informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options."2 According to the Institute of Medicine (IOM), "Trustworthy CPGs have the potential to reduce inappropriate practice variation."2

While a guideline may be regarded as a mere "suggestion for behavior," clinicians have "strong incentives to comply with these guidelines when they are issued, making adherence to them almost compulsory."1 Additionally, adherence to guidelines may be used as evidence of due diligence in the event of a malpractice claim.1

Despite their advantages, many clinicians do not necessarily agree with the centrality or content of CPGs.3 Others — especially primary care physicians (PCPs) — are overwhelmed by the vast and ever-increasing numbers of guidelines issued by multiple societies, which they are expected to master and incorporate into practice, especially because the guidelines issued by specific societies focusing on specific conditions do not address the realities of patients with multiple comorbidities.4,5

To shed light on the role of CPGs in primary care practice, MPR interviewed Gary L. LeRoy, MD, a family physician in Dayton, OH and a member of the board of directors of the American Academy of Family Physicians (AAFP). Dr LeRoy is also the associate dean for student affairs and admissions and associate professor of family medicine at Wright State University, Boonshoft School of Medicine, Dayton. Dr LeRoy serves the Dayton community through Reach Out Montgomery County, Dayton Public Schools, American Red Cross and Saint Vincent's Homeless Shelter. He is the president of Dayton and Montgomery County Public Health.

What are your perspectives on the role of CPGs in primary care?

Dr LeRoy

Today's guidelines are overwhelming in number and almost impossible to master. As a personal family physician, if I were to read every single guideline issued by every society or medical institution, along with my other daily responsibilities, it would be like reading all 8 volumes of Harry Potter every single day. It is virtually impossible for PCPs to read and master all of these recommendations, so as in other areas of medicine, one must triage the guidelines based on what is most immediate and relevant to one's practice.

How do you suggest 'triaging' the guidelines?

One suggestion is to prioritize the guidelines that are most relevant to your practice. For example, if I look at my practice over the last 26 years, I have gone from a population consisting of mostly pediatrics to young adults and now, many of my patients are in the geriatric range. So I spend more time with the geriatric guidelines and less with the pediatric guidelines.

I also urge physicians to keep up with their CME requirements. CME activities will often discuss guidelines that are recent and relevant to your practice.

Does the AAFP issue or recommend specific CPGs?

Yes, the AAFP develops CPGs that are informed by a systematic review of evidence and assessment of the benefits and harms of various care options. The guidelines are developed in adherence with the standards of the Institute of Medicine (IOM)2 as well as the Council on Medical Specialty Societies.6 The guidelines are designed to be specifically relevant to family physicians. (Further information about the development of the AAFP guidelines can be found here.)

In addition, AAFP evaluates and often endorses CPGs issued by other societies. Sometimes, the AAFP's guidelines differ from those of other societies—for example, the AAFP does not endorse the recommendations of the American College of Cardiology, the American Heart Association, and several other societies on the management of hypertension in adults.(The AAFP Guidelines can be found here.)

Were you yourself involved with authoring the AAFP guidelines?

I have been involved with many AAFP commissions, but not this one. On the other hand, I am the president of the Board of Healthcare in Dayton, Montgomery County, and am very familiar with clinical guidelines and guidelines in other areas of public health. We have a task force on the Board of Health that is in charge with looking at guidelines and disseminating them through social media and printed or electronic media so that people are aware of what is and isn't valid. The Public Health commission is doing something similar to what the commission at AAFP is doing—weeding out information and seeing what is practical for our communities and citizens.

Do you think that adherence to guidelines is protective against malpractice litigation?

I think that physicians should adhere to community standard of care, and that there is no absolute way to shield against all potential litigation. I recommend trying to follow, to your best extent, the clinical guidelines as they become the community standard.

What is the relationship between CPGs and the physicians' individual clinical judgment?

I think it is very important to remember that we are not treating guidelines. We are treating patients. For example, treating an 85-year-old who has not previously been classified as having hypertension with an antihypertensive drug is probably not a wise clinical decision. The person might become symptomatically hypotensive, for example. We need to treat the reality that our patients live in.

It is also important to remember that guidelines are not rules or laws. Physicians should treat patients by using their best medical judgment. In fact, most clinical guidelines contain similar verbiage acknowledging the importance of a clinician's medical knowledge and clinical experience. When we talk about the practice and art of medicine, that's what it's about—using the facts and knowledge you have acquired over the years, together with common sense, to pick and choose which guidelines apply best to a given patient. Each patient is unique and different. Guidelines are not a one-size-fits-all.

Communities are also unique. We may want overweight people to eat more fresh fruits and vegetables, but some people may have circumstances that make it difficult for them to get to a grocery store that carries these healthier options. They may not have a car, and the nearest store is ten miles away. They may have to catch two buses to get there and return with children in tow. It is important to craft treatment plans and apply guidelines that are realistic for the communities in which you practice and see if they are valid and reasonable for the patients you serve.

Do you have any further suggestions for clinicians?

I encourage clinicians to keep abreast of the news to whatever extent possible. Often, guidelines are embargoed before publication but released to journalists prior to being released to physicians or the public. I go into my office and my patient says, "I was watching Good Morning America and I found out there's a new guideline on such-and-such that was published in today's issue of New England Journal." While it isn't always possible, following the health news and reading the journals in which new guidelines appear is an important way to have meaningful conversations with patients about the newest recommendations.

It is also important to use common sense. You do not necessarily have to be the very first person to adopt every new guideline. You can adopt a guideline when you see that there are no unintentional negative consequences and explain your rational for hesitating to the patient. Patients should be part of your choices of which guidelines to follow. Have conversations and communicate, and then document the discussion and why you came to a particular conclusion. 

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References

  1. Manski C. Improving patient care using clinical guidelines and judgement. VOX Centre for Economic Policy Research (VOX CEPR Policy Portal), 2017. Available at: https://voxeu.org/article/improving-patient-care-using-clinical-guidelines-and-judgement. Accessed: July 29, 2018.
  2. National Academies of Science, Engineering and Medicine. Clinical Practice Guidelines We Can Trust. Available at: http://www.nationalacademies.org/hmd/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust.aspx. Accessed: July 30, 2018.
  3. Lugtenberg M, Zegers-van Schaick JM, Westert GP, Burgers JS. Why don't physicians adhere to guideline recommendations in practice? An analysis of barriers among Dutch general practitioners. Implement Sci. 2009 Aug 12;4:54.
  4. Buffel du Vaure C, Ravaud P, Baron G, Barnes C, Gilberg S, Boutron I. Potential workload in applying clinical practice guidelines for patients with chronic conditions and multimorbidity: a systematic analysis. BMJ Open. 2016;6(3):e010119.
  5. Upshur RE. Do clinical guidelines still make sense? No. Ann Fam Med. 2014 May-Jun;12(3):202-3.
  6. Council of Medical Specialty Societies. (CMSS). Principles for the Development of Specialty Society Clinical Guidelines. Available at: https://cmss.org/wp-content/uploads/2016/02/CMSS-Principles-for-the-Development-of-Specialty-Society-Guidelines-September-20122.pdf.  Accessed: August 21, 2018.
  7. Carey RM, Whelton PK; 2017 ACC/AHA Hypertension Guideline Writing Committee. Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Synopsis of the 2017 American College of Cardiology/American Heart Association Hypertension Guideline. Ann Intern Med. 2018 Mar 6;168(5):351-358.
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