Table of Contents

HK J Paediatr (New Series)
Vol 7. No. 2, 2002

HK J Paediatr (New Series) 2002;7:66-67


Clinical Guidelines: Friend or Foe?

TF Fok

In this issue of the Journal, Lam et al presented a set of Clinical Guidelines on the management of viral croup, the result of many months of hard work by the working group headed by Dr Barbara Lam. This is one set of the many clinical guidelines that will appear in future editions of the Journal, following the decision of the Hong Kong College of Paediatricians and the Paediatric Quality Assurance group under the Hospital Authority to formulate clinical guidelines on a number of paediatric conditions. The apparent plethora of such guidelines has aroused some anxiety among paediatricians. In a forum organised by the College some months ago when Professor Virginia Wong presented the clinical guidelines on the management of febrile convulsion, some paediatricians expressed the concern that some of the recommendations were impractical in the primary or secondary care setting. Many feared that non-compliance with the guidelines is tantamount to professional negligence in the eyes of the disciplinary body or the civil court. The situation was made worse when the guest speaker from the legal profession stated that the Medical Council would likely demand an explanation from doctors who fail to follow the relevant guidelines in the management of their patients.

Amidst all the controversy, we need to ask ourselves the purpose of having clinical guidelines: are they there to assist medical practitioners in their clinical practice, or are they to be used to tie the hands of the doctors and to create medico-legal pitfalls for them? By definition, clinical guidelines are "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances". They are therefore drawn up primarily to help clinicians. Guidelines can also serve the purpose of helping to maintain or improve the standard of patient care. To fulfill such a purpose, they are often specifically designed to influence policy and practice, and to change the behaviour of health care professionals. To this end, modern day clinical guidelines should fulfill two major criteria.

Firstly, the recommendations must be evidence-based. Long gone are the days when "guidelines" were no more than the consensus of "experts" and were therefore susceptible to bias and limitations. Present day guidelines should be based on the systematic appraisal of available evidence following a set of well-defined rules. The recommendations together with the supporting evidence should be ranked according to methodological strength, and the ranking should be clearly stated in the guidelines. This would enable the readers to have a clear idea about the strength of the evidence, before deciding on whether or not to follow the recommendations. The more seasoned practitioners should also attempt to critically appraise the guidelines before applying them to patient management. Steps to appraise guidelines are available in EBM literature. Readers need to bear in mind that guidelines are not gospel truth that must be followed unquestioned, since the recommendations are at best as good as the evidence upon which they are based.

The second criterion that working groups on guidelines must consider is the acceptability of the guidelines to the local medical profession, having regard to socio-economic factors, as well as the infrastructures and technologies available. To achieve this, a working group should consist of all the key stakeholders in order that views from all sectors can be taken into consideration to facilitate the formulation of a set of guidelines that could be realistically applied to the management of patients. There is for example little point in recommending ECMO as the preferred treatment for certain respiratory conditions in newborns when the facilities are not available locally, even though the evidence favours its use. Similarly, although there is overwhelming evidence in support of the use of surfactant in the treatment of infants with respiratory distress syndrome, recommending its use in most developing countries that cannot afford the high cost would not have been realistic. It is important for working groups on clinical guidelines to meticulously go through all the recommendations to ensure their practicability and acceptability in the local context. They should avoid directly transplanting clinical guidelines from overseas countries or undue influence by overseas experts. Both may lead to the formulation of unrealistic recommendations, often resulting in breakdown of trust between the working groups and the practitioners.

Properly designed clinical guidelines are very useful tools for the clinicians. The article by Lam et al in this issue of the Journal presents one set of such guidelines. It is our sincere hope that all the guidelines yet to be promulgated by either the College or the Hospital Authority will be of a similarly high standard.

TF Fok

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