Why Physicians Don’t Always Follow Best Practices

Experts involved in creating guidelines, who stress that they are only broad evidence-based recommendations that cannot take into account every situation and nuance that physicians and patients may face, point to a wide variety of reasons why guidelines are sometimes not followed:

• Lack of information. Sometimes, the information either doesn’t get to physicians or isn’t absorbed. This is especially true outside the otolaryngology specialty.
• The “recency” effect. If a physician has had a recent bad experience with a patient despite following practice recommended in a guideline, he or she may be less inclined to follow the guideline later, especially in the immediate future.
• Patient resistance. Even when presented with the reasons why a certain treatment strategy is not appropriate, a patient might insist on that strategy anyway.
• Insurance barriers. Sometimes insurance might resist paying for or decline to pay for care recommended in a guideline, say, imaging in a timely manner.
• Access to drugs. A shortage in a medication could make it difficult for physicians to get access to the medications recommended by a guideline.
• Willingness or ability to pay. Sometimes, a patient might not want to make the out-of-pocket expense that’s required to move forward with care recommended by a guideline.
• Slow adopters. With any innovation, there will some people who will be slow to change, even if they are aware of the evidence and the recommendation.

Making Guidelines More Widely Available

Dr. Tunkel said that the AAO-HNS makes an effort to give lectures on guidelines at meetings, makes slide shows available on its website, and involves other disciplines in the development of guidelines so that they are as comprehensive and as widely relevant as possible. But there is still work to do to disseminate the information.

“I think guidelines in and of themselves published in a medical journal is probably not a very good way of encouraging adherence or acceptance of a guideline. We need to incorporate [them] into clever ways of implementing things,” Dr. Tunkel said. “There’s still a group of physicians who don’t know about guidelines when they get published. And so the Academy tries to do that with the website. They also try to involve as many people as they can into the development of guidelines. Each of the guidelines that is developed is open to peer review and for a public comment period because we want to involve as many people as we can in reviewing the draft of a guideline.”