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Decision Time

By Jock Hoffman, CRICO

Related to: Clinical Guidelines, Communication, Cures Act: Opening Notes, Primary Care, Obstetrics

Do clinical guidelines protect or jeopardize a physician's exposure to allegations of malpractice? Are they good or bad for patients?

Recently, the merits of clinical guidelines have been debated in response to a suggestion that physicians practicing evidence-based medical care should be shielded from malpractice liability. Proponents believe guideline adherence will ensure appropriate care while enabling physicians to forego tests and treatments not supported by the evidence—in effect reducing “defensive” medicine and its associated costsOpponents fear that reliance on (potentially faulty) guidelines will curtail physician autonomy, endorse health care rationing, and permit aberrant practice with impunity.

For non-political reasons, CRICO produces and promotes clinical decision support tools in high-risk areas including obstetrics and the diagnosis of breast, colorectal, and prostate cancer. The dual intent is to support physicians during complex decision making processes and protect patients from preventable adverse outcomes. Practice recommendations are derived from medical literature, peer societies, and loss prevention expertise and periodically vetted through clinical leaders and experts.

Rather than proposing iron-clad standards to dictate practice, CRICO sees such guidelines as a backstop for time-stressed physicians overwhelmed by a tsunami of clinical information to absorb. This is especially valuable in relation to cancer diagnosis where physicians and patients cross numerous decision points on the diagnostic path: a pathway strewn with risks to patients and providers.

Analysis Outpatient Cases Asserted

In a review of 2,951 (2005–2009) outpatient cases in CRICO’s comparative benchmarking system, 16 percent (N=486) alleged a failure to diagnose cancer: primarily breast, lung, colorectal, and prostate cancer.

This analysis highlights the fact that even evidence-based recommendations rely on safe execution. In CRICO’s cancer-related guidelines, physicians received guidance at the key decision points where missteps might leave the patient—and provider—vulnerable to an unresolved symptom or an unclosed communication loop:

Assessment: periodically update a patient's personal and family history to ensure timely age- and risk-stratified cancer screening, including appropriate referrals to high risk counseling.

Test results: assume responsibility for confirming receipt of, reviewing, and transmitting to the patient, all diagnostic tests they order.

Follow up: document follow-up testing recommendations and communicate the follow-up plan to the patient and all responsible providers.

Referrals: after referring a patient to a specialist, make sure to coordinate the care among providers and clarify for the patient the specific roles and responsibilities.

The best malpractice defense is good practice, and careful adherence to well-crafted guidelines can play an important role in good practice (including the documentation of one's rationale for deviating from recommendations). Systems that falter in the execution of a guideline's recommendations, however, leave patients exposed to preventable errors and undermine the defensibility of physicians guided by credible evidence.

Additional Material

November 1, 2010
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