Doctors’ clinical judgment risks being sacrificed on the altar of protocol driven care

In healthcare today, much of our work is driven by the need to fit neatly into a clinical pathway. This leaves many doctors feeling frustrated and mourning the loss of autonomy.

Everything we do—from what we prescribe, the investigations that we order, to the referrals we make—seem governed by predefined pathways. It can feel like there is always someone ready to point out that what you thought was clinically necessary falls outside the pathway parameters and therefore shouldn’t have (or can’t be) done. When something goes wrong and our practice falls under the scrutiny of the medicolegal microscope, expert witnesses refer to best practice guidelines to assess our actions, and woe betide doctors who’ve veered off a clinical pathway without clear justification.

Medical record entries have also become longer and more detailed, indicative of the perceived need to meticulously document every action, and every positive or negative finding. In recent years I have seen general practice notes so lengthy that it’s hard for the next clinician to follow the narrative. This trend is driven by fear—fear of being criticised by a colleague, an expert, or the courts. The idea that “if it’s not in the notes then it hasn’t happened” perpetuates defensive note keeping. This fear creates a cycle: more defensive documentation becomes accepted practice, increasing the burden of administration on the profession as a whole. The heavier workload leads to doctors being increasingly busy, overwhelmed, and who then worry that they’ll miss something and subsequently practise more defensively.

An example of this is the expectation to record safety netting advice in every clinical encounter. Did you ensure the patient knew how to access help if they became suicidal? Did you make sure the patient knew when they should seek help should their back pain get worse? Did you make a note of the advice and was it sufficiently detailed? The worry about needing to repeatedly record such information may actually detract from the quality of the conversation that precedes it.

At Practitioner Health, a growing number of our patients are stressed and overwhelmed by the complexity of managing both clinical and administrative workloads. It’s no wonder that this is the case when so many doctors feel constrained and sometimes paralysed by the black and white nature of clinical pathways. The focus on guidelines and protocols can also have a chilling effect on the morale of staff who feel as if the very system that trains them no longer trusts their decision making.

Guidelines and evidence based medicine are clearly hugely important, but regulators, policy makers, experts, lawyers, coroners, and judges need to acknowledge that much of medicine operates in shades of grey. With the exponential growth of our service over the past few years, one of our biggest challenges has been to redevelop our processes and pathways, while keeping in mind that our clinicians are highly skilled individuals who should be allowed to exercise their judgment and feel trusted in their decision making.

What if we didn’t have to write such defensive notes? What if we didn’t have to worry that our referral would be rejected because that blood test wasn’t requested beforehand? I wager that as clinicians, we’d have more time to truly listen to our patients without worrying about the ensuing paperwork. And as patients, we’d feel as if we were genuinely being heard.