Are guidelines making us stupid?

One emergency physician thinks there is mounting evidence a cultural shift risks turning doctors into "process workers".

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Clinical guidelines make doctors stupid.

It’s a rather blunt thesis. But one experienced Australian emergency physician says there is mounting evidence a cultural shift risks turning doctors into “process workers”.

Dr Steve Walker has spent two decades rescuing people in helicopters with NSW Careflight, and also works in Penrith’s Nepean Hospital.

Now, he has warned that doctors’ critical faculties are withering as they blindly follow guidelines written by others to more quickly push patients through the system.

Dr Walker concedes much of his evidence is anecdotal, but he says it’s something that needs to be talked about. His view is based on his own experience and conversations with colleagues who fear that now, under more pressure than ever, they are being deskilled.

“It’s become a very automatic, and at times almost a subconscious, process,” Dr Walker told The Medical Republic. “Hand in hand with that, you lose some of the critical thinking that’s always underlined the medical process.”

Dr Walker addressed a conference of the Australian College of Emergency Medicine this month warning that Australia’s healthcare system was on the same track as the global aviation industry.

Three years ago, the world’s peak aviation body released a damning report that named “automation dependency” as a growing threat to air safety.

“They really said pilots no longer fly planes enough and it’s becoming dangerous, because there’s too much use of and reliance and dependence on automated, computerised flight,” Dr Walker said.

Pilots were being urged to return to the “old fashioned flying of planes” so they remained proficient, he said.

“When you try to squash risk too much in one direction it’s got a nasty habit of blowing out in another direction.”

While clinical guidelines and automation were generally good things, the same problems were emerging in healthcare.

Dr Walker, who graduated from medical school in 1988, worried that the next generation of doctors were not being encouraged to rely on their own clinical judgment.

“[Clinical guidelines] do offer protection from major departures in the standard of care. But every doctor in emergency can tell you the stories of patients who don’t fit a guideline or who have been put on the wrong pathway and have done poorly as a result.”

In the chaotic ED environment where doctors face increased time pressures imposed by bureaucrats, patients can be easily “pigeonholed”, he said.

“Afterwards people scratch their heads and think ‘how the hell did that happen?’ Often it’s just because somebody hasn’t stopped and asked what’s really going on.”

Dr Walker argued there were additional problems with some guidelines, saying underlying evidence was sometimes of low quality, and that they regularly clashed between groups of physicians, institutions, and jurisdictions.

He said they were of more benefit to non-clinicians and administrators than doctors and patients, and had in a number of high profile cases been influenced by commercial vested interests.

A 2001 JAMA study reviewed 17 “current” clinical guidelines advocated by the Agency for Healthcare Research and Quality, finding only three were up to date, and seven needed a “major update”.