Cookbook clinical practice

For many years I have been dismissive of the trend towards what I call “cookbook practice”.  This is clinical practice in which all the decisions are pre-set, and the clinician just fills in the blanks and follows the resulting algorithm for treatment or referral.  My objection was based on the idea that clinical judgement is an expected skill/attribute exhibited by practitioners, and they should not have to be spoon-fed.

Recently, I have begun to have my thinking modified by some new data (well, ‘new’ to me anyway!).  Safety and quality in healthcare has been expensively studied over the years, and it has been found that having clinical guidelines in place significantly reduces the incidence of adverse events.  This may suggest that even good practitioners can benefit from having robust well-founded clinical guidelines to help with decision-making.  I’m still not completely comfortable with the idea, as I worry that guideline-based practice actually reduces the need for clinical judgement.  Maybe clinical guidelines work because practitioners need help making good decisions?  What if we looked at improving their decision-making, and their critical thinking?  Would that not achieve the same or better results?

In some ways, it seems analogous to the issue of young drivers on the roads.  This group are horribly over-represented in road crash statistics, so it seems logical that something needs to be done.  Is it more training and guidance for a longer period of time that is required, or is it more effort into creating drivers who think actively about what they are doing and learn good attitudes and habits?  If having L-plates for 2 years proves to be safer, what about 3 years?  If the restrictions of provisional drivers licences make young drivers safer, what’s wrong with applying those restrictions to all drivers.  After all, if we did not allow anyone to drive until they were 21, the road crash data for 16-20 year olds would improve dramatically!

I think the answer is the have reasonable guidelines, then teach people how to think properly.  Some sort of attitude test if you like.  If you don’t pass, you don’t get a licence until you grow up a bit more.  I know some 16 year olds who are more mature than some 46 year olds, and much safer drivers as a result.  Likewise with clinical practice, I think it should be mandatory to pass some sort of critical thinking test before you are allowed near patients.  How that would look in practice, I’m still thinking about.  Watch this space …

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