Best practice makes perfect

Following international best practice is a phrase more associated with corporate boardrooms than hospital operating rooms. But keeping up to date with the latest medical knowledge and surgical techniques has become a prerequisite for today's surgeons and clinicians. Two years ago, the RCSI set up a clinical guidelines committee to draw up a series of pointers for surgeons and doctors dealing with common ailments. The first set of guidelines - for the clinical management of breast cancer - was published in November.

This suggested a multidisciplinary approach to care involving surgeons, medical oncologists, radiologists and nurse specialists, all of whom would specialise in breast disease. Specific recommendations focussed on selection for mammography, avoidance of open surgery for diagnostic purposes and surveillance of women at high risk.

Other guidelines under development deal with prostate cancer, colorectal cancer, acute pancreatitis, diagnostic laparoscopies which is the use of keyhole surgery to diagnose abdominal problems, and the initial management of severely injured patients.

Written by experts in each field, the guidelines must be scrutinised and approved by the college before they can be distributed to surgeons and hospitals around the country, says Professor Niall O'Higgins, chairman of the RCSI's clinical guidelines committee. "The idea behind the guidelines," he says, "is to provide reassurance to patients that we are doing things in accordance with international best practice, and provide support, guidance and reassurance to surgeons and other medical people.

"People expect high quality care and they understand the association between high quality and outcome. They're much more informed so they're demanding more and more, and we have to be sure that their management matches best international practice." Broadly speaking, guidelines cover best practice in diagnosis and treatment of a condition, says Prof O'Higgins. What, for instance, is the best method of imaging in each case? Which is the preferred way to do a biopsy or to find out the stage of the disease? How, when and in what order should surgery, radiotherapy and chemotherapy be used in the treatment of cancer? What standards should be required? "Standards are very important because they have training implications," he says. "Patients must know that the doctor doing the operation is properly trained and is doing it to the best standards because there are very strict criteria for doing certain procedures."

Yet the guidelines are only that - pointers to guide doctors in diagnosis and treatment, not rules that they must obey: "If you write a recipe book for doctors to follow, you imply that if they go outside of that, they've done something wrong. That is not always the case. Doctors treat people, not diseases. If the guidelines are too strict, you risk removing clinical judgement. If they're too lax, they're of no value. So you have to find a middle road. It's not easy."

EVEN the language used in the guidelines must be chosen with care, Prof O'Higgins says. "In the future, it's likely that if there is a problem, doctors could be asked why they didn't follow the guidelines. So, when writing, we have to be very careful not to use words such as `should', `ought' or `must' because nothing in medicine is (definitive). There is always a human element in any decision." So far, the response from the profession has been that clinical guidelines are "helpful, important and necessary", says Prof O'Higgins. But there is a concern that if they are made too rigid, by requiring, for instance, highly sophisticated equipment, they might restrict care to a couple of major specialist hospitals.

Such concerns became apparent when the breast cancer guidelines were published. A controversy immediately sprang up with rural patients and politicians fearing their local breast cancer unit might be shut down, even though the guidelines made no such recommendation. It's an indication of how something as innocuous as heath guidelines can have wider ramifications.

Yet, outside of the media glare, the work of the committee goes on. The next areas to be addressed, says Prof O'Higgins, are likely to be hernia repair, melanoma or skin cancer, gastro-intestinal bleeding, gall bladder disease and the surgical management of thyroid disorders.

"It's the nature of the profession to be self-improving. There is a thirst for improvement and excellence and that is born out of better teaching, better research and better practice. There is abundant evidence that good teaching drives better practice and better practice enhances the quality of research, which in turn drives the quality of teaching and education. It's a continual loop.

"We really hope over the next few years there'll be many sets of guidelines. But we'll have to revisit the guidelines every few years in light of new developments."