A surfeit of guidelines?

I am writing a syllabus for doctors training in Rehabilitation Medicine. The syllabus will cover, among other things, the knowledge people need. The working party developing the syllabus suggested that, for each competency or topic, we should recommend a guideline the trainee should be familiar with. Sounds sensible?

It must be sensible. The General Medical Council, in its guidance for doctors entitled Good Medical Practice (here), in Domain one (Knowledge, Skills and Performance), in paragraph 11 it says to the doctor: “You must be familiar with guidelines and developments that affect your work.” Let us investigate.

Cerebral palsy guidelines

A systematic review of clinical guidelines on cerebral palsy, just published (here), identified 13 guidelines. Of these, two were then excluded after applying the AGREE quality standard criteria, two were excluded because conflicts of interest were not disclosed, and one was a previous version of a selected guideline. The World Health Organisation, who were sponsoring the review, then removed two on a topic covered by a third guideline more recently, and one that did not link evidence to recommendations.

This selection process, removing low quality or redundant guideline, left five guidelines of presumed high quality. Three of the five were from NICE (National Institute for Health and Care Excellence) in the UK.

These five guidelines made 493 separate recommendations! Some of these concerned service provision, others were a single recommendation atomised into small pieces, yet others were very similar one to another. Therefore the 493 recommendations were reduced to 339 unique recommendations; among these, 184 were treatment recommendations.

But, before you conclude that there must be large amounts of evidence and many effective treatments, you should read on. Most recommendations focused on mobility, and most recommendations concerned action to alter impairment.

There were few recommendations concerning the child’s activities or social participation. Few recommendations related to what rehabilitation teams or therapists should do.

One explanation is that the NICE guidelines accounted for the majority of the recommendations. NICE uses procedures to select evidence that disadvantage any rehabilitation research. This, in turn, it probably because biomedical interventions are the primary concern of NICE.

Osteoarthritis guidelines

A systematic review of ‘physical treatments’ for patients with osteoarthritis, published in 2014, identified 17 high quality guidelines (here). The abstract recorded: “There were variations in the interventions, levels of evidence, and strength of recommendations across the guidelines. Forty different interventions were identified. Recommendations were graded from “strongly recommended” to “unsupported.””

Backpain guidelines

For low back pain, 12 guidelines were identified in a 2021 systematic review of guidelines (here). There were many recommendations (it is difficult to count, but over 30). While there some consistent themes, the authors noted: “Recommendations were inconsistent or inconclusive with respect to medication (NSAIDs, opioids; topical); epidural steroid and other injections; acupuncture and manual, postural and thermotherapies.”

Amputee guidelines

Another systematic review of guidelines published recently (here) concerned people who had had an amputation. Like the review on cerebral palsy guidelines, this was sponsored by the World Health Organisation. It was restricted to guidelines published since 2008.

The search identified 13 guidelines. Nine were removed for a variety of reasons detailed in the paper, leaving four. One of these concerned amputations affecting the arm.

These four guidelines made 217 recommendations: 20 concerned assessment, 66 concerned service design or delivery, and 131 concerned interventions.

The intervention recommendations did concern some important topics such as: management of pain; education; management before and after operation; and care of the remaining limb. It can be seen that these are very focused on the times before and soon after the surgery, and other surgical matters.

However there were few truly rehabilitation recommendations, for example about management of pain in the phantom limb, ‘lifelong care’, and vocational or educational activities. This lack of advice on rehabilitation to work, or leisure and sport, or further education is particularly surprising as two of the four guidelines came from the Veteran’s Association in the US, who would have been interested in fit, younger people, usually men.

In summary, and generalising a bit from these examples:

There are many published guidelines on many clinical rehabilitation problems.
On an average day a clinician might see 5-10 patients for whom there would be at least one guideline available.
Each guideline has many recommendations, some with over 100 separate recommendations, and for some conditions there may be over 300 separate recommendations in total.
Guidelines differ greatly in quality, and determining quality (if it is possible) takes much effort, more than any clinician could ever give.
Guidelines of apparent similar quality nonetheless make different and at times contradictory recommendations.
Guidelines may not give recommendation on many if not most important topics of concern to patients needing rehabilitation.
Thank goodness that we can say, echoing the Pirates in the Caribbean:
It is only a guideline”

Returning to training and to the General Medical Council, I draw two conclusions.

It would be unfair (to the trainee) to recommend that trainees should become familiar with a guideline on each topic. There are so many on each topic that a trainee cannot check each one for quality. Additionally, there is too much inconsistency between guidelines, and guidelines do not necessarily give guidance on important, relevant questions.

The UK General Medical Council should review the wisdom of paragraph 11 of its central guidance document for doctors, Good Medical Practice. It would not be difficult to find a guideline supporting almost any practice. One might be familiar with the guidance, but should one follow it?

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