Physician Judgment and Clinical Practice Guidelines

Abstract

Decision Making and the Practice of Health Care” by Paul R. Falzer in this special issue. Falzer (2018) and Klein, Woods, Klein, and Perry (2016) have called attention to the fact that external payers (insurance companies, government programs) may reward or penalize individual physicians or clinical groups depending on whether their behavior accords with the recommendation of an evidence-based clinical practice guideline (EB-CPG). (Klein et al. [2016] call this the “best practices regimen,” but to avoid confusion with a methodology focused on design of exemplary and successful approaches for accomplishing clinic tasks [Mold & Gregory, 2003], we will refer to “enforced conformance” to EB-CPG). Clinic administration may then institute a system to measure and reward individual physician performance to assure the group practice overall meets the stated standard. Falzer identifies flaws in the logic behind making reward contingent on meeting guideline-related standards and reviews the varied responses physicians have to enforced conformance. Although we concur with many aspects of the critique, we value the science and wisdom embodied in the guidelines and recognize that at times physicians may need external motivation to heed them. The focus is CPGs that in good faith address the health needs of patients and society. There are three frameworks for these. Guidelines can be based on the judgments of expert clinicians and other stakeholders (Crownover & Unwin, 2005), on studies providing justified evidence that clinical practices are likely to have beneficial effects (Alonso-Coello et al., 2016), or on broader analyses that consider the money needed to produce those beneficial effects so that society’s resources may be allocated to the most cost-effective practices (Mandelblatt, Fryback, Weinstein, Russell, & Gold, 1997; Pandya, 2018). Interestingly, the expert judgment recommendations are correlated with the cost-effectiveness analysis recommendations (Kuntz, Tsevat, Weinstein, & Goldman, 1999). CPGs from any of these frameworks can experience the problems Falzer (2018) identifies when recommendations become requirements and nonconformance with them is penalized. However, physicians cannot simply be ordered to behave in a way that maximizes rewards or optimizes outcomes. The way they manage patients is based on long-established habit (Hamm, 2009a). Hearing about, reading, or studying an EB-CPG endorsed by a respected authority does not make physicians immediately change behavior, even if they intend to. They have to learn the recommended alternative behavior, recognize when the guideline describes something different from what they usually do, and make the conscious choice to change behavior. This must be done consciously until it can become a new habit (Abernathy & Hamm, 1995). This situation is more complex when the current habitual practice involves multiple actors (Ackerman, Gonzales, Stahl, & Metlay, 2013; Gonzales, Steiner, Lum, & Barrett, 1999), not just the individual doctor, and when the current practice pays better (Hamm, 2009b). Hence an individual physician may need to be strongly motivated to conform to a guideline even when he or she intellectually accepts it as correct. 782850 EDMXXX10.1177/1555343418782850Journal of Cognitive Engineering and Decision MakingJudgment and Guidelines 2018