Guidelines. Guidelines. Guidelines. We are inundated with guidelines, telling us how to do this, how to do that, how to manage this condition and that condition. Many clinical groups look like they are re-inventing the wheel. Do we need another set of guidelines on how to assess and manage acute low back pain? The review and publication of these documents is becoming an industry all of its own. In the UK we have the National Institute for Clinical Excellence (NICE), which reviews medical evidence and makes recommendations. No doubt NICE will be renamed before long in the never ending change in acronyms which seems so much a part of the health care industry.
With the plethora of guidelines coming out from organisations all over the world and more local ones such as the Chartered Society of Physiotherapy, anyone who has a clinical role in assessing and treating patients has a lot of information to digest. Missing out on this information would be a mistake. The Health Care Commission, soon to be the Care Quality Commission, has recently prosecuted successfully a rehabilitation and spinal clinic in the UK for not providing physiotherapy to its spinal patients, contrary to guidelines. Contravening the CSP recommendations in this case has led to the clinic being found guilty of not following the agreed approach.
This means we really do need to have a care, not just a duty of care, to be aware of the up-to-date recommendations for the management of a whole host of conditions in our work. If there was a complaint or problem of some kind, we could find ourselves being asked very searching questions about why we had not followed the pathway for the management of the condition recommended by this or that clinically venerable body. And if we really believe that the eminent bodies of people who have looked at the evidence and made their conclusions are worth paying attention to, why would we not follow their recommendations?
Clinical judgment is very important to professionals like physiotherapists and we are right to put store in it. However, we often perceive a conflict between this and the idea of guidelines which instruct us to do things in particular ways. We want to make our own decisions based on our experience and do not appreciate the idea that some of that independence might be removed. Our professions sometimes appear like exclusive clubs where the mysterious techniques and powers are passed down to the willing who then become club members. It can all look a bit protectionist as we resist changes which conflict with our club ethos. Criticism may not be welcome in these circumstances as we try to resist attack.
Yet we have a duty to know what we don't know. We learn to think about the way the body works in normal and dysfunctional ways in a particular paradigm. Mine is the physiotherapy paradigm. I will not speak for others in my profession when I say that parts of the paradigm, my way of thinking about the body and how to assess and manage its problems includes:
Normal function in individuals is common and they need no input from professionals like us and this is good.
Self limiting conditions will tend to be that and there is a questionable need for intervention in many cases.
Most conditions are self limiting and much of our effectiveness is due to nature and time.
Validated measures of outcome have not been used across much of our work, making our effectiveness hard to ascertain.
We may be wrong in assuming the credit for improvement in many patients.
We have not given good evidence that our clinical judgments can be objectively trusted.
An intervention which can be technically provided is often preferred over the softer techniques of cognitive behavioural assessment and management.
However our professions have a very positive future amongst all these changes as they have much to contribute to the welfare of the populations served by them. Our clinical judgments continue to be the yardstick by which we measure what we should do but we should be aware of alternate views, new ideas and new approaches continually being developed. - 14130
With the plethora of guidelines coming out from organisations all over the world and more local ones such as the Chartered Society of Physiotherapy, anyone who has a clinical role in assessing and treating patients has a lot of information to digest. Missing out on this information would be a mistake. The Health Care Commission, soon to be the Care Quality Commission, has recently prosecuted successfully a rehabilitation and spinal clinic in the UK for not providing physiotherapy to its spinal patients, contrary to guidelines. Contravening the CSP recommendations in this case has led to the clinic being found guilty of not following the agreed approach.
This means we really do need to have a care, not just a duty of care, to be aware of the up-to-date recommendations for the management of a whole host of conditions in our work. If there was a complaint or problem of some kind, we could find ourselves being asked very searching questions about why we had not followed the pathway for the management of the condition recommended by this or that clinically venerable body. And if we really believe that the eminent bodies of people who have looked at the evidence and made their conclusions are worth paying attention to, why would we not follow their recommendations?
Clinical judgment is very important to professionals like physiotherapists and we are right to put store in it. However, we often perceive a conflict between this and the idea of guidelines which instruct us to do things in particular ways. We want to make our own decisions based on our experience and do not appreciate the idea that some of that independence might be removed. Our professions sometimes appear like exclusive clubs where the mysterious techniques and powers are passed down to the willing who then become club members. It can all look a bit protectionist as we resist changes which conflict with our club ethos. Criticism may not be welcome in these circumstances as we try to resist attack.
Yet we have a duty to know what we don't know. We learn to think about the way the body works in normal and dysfunctional ways in a particular paradigm. Mine is the physiotherapy paradigm. I will not speak for others in my profession when I say that parts of the paradigm, my way of thinking about the body and how to assess and manage its problems includes:
Normal function in individuals is common and they need no input from professionals like us and this is good.
Self limiting conditions will tend to be that and there is a questionable need for intervention in many cases.
Most conditions are self limiting and much of our effectiveness is due to nature and time.
Validated measures of outcome have not been used across much of our work, making our effectiveness hard to ascertain.
We may be wrong in assuming the credit for improvement in many patients.
We have not given good evidence that our clinical judgments can be objectively trusted.
An intervention which can be technically provided is often preferred over the softer techniques of cognitive behavioural assessment and management.
However our professions have a very positive future amongst all these changes as they have much to contribute to the welfare of the populations served by them. Our clinical judgments continue to be the yardstick by which we measure what we should do but we should be aware of alternate views, new ideas and new approaches continually being developed. - 14130
About the Author:
Jonathan Blood Smyth is the Superintendent of Physiotherapy at an NHS hospital in the South-West of the UK. He writes articles about back pain, neck pain, and injury management. If you are looking for Physiotherapists in Coventry visit his website.
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