The art of medicine

Health professionals are living in an age of guidelines, protocols and evidence-based medicine. Should we consider these major advances in medical management? It's hard to say — physicians' adherence to guidelines is poor, which makes it difficult to determine the true impact of these measures. For example, in the US, the American College of Gastroenterology's recommendations for monitoring Barrett's esophagus is relatively easy to manage — especially when compared to say colon cancer screening in the average risk patient — and yet a survey of gastroenterologists shows that few specialists actually follow these guidelines.

So, why aren't doctors following clinical guidelines? Are they not user friendly or are physicians not well informed about them? The problem is we're inundated by guidelines and this applies to almost all branches of medicine. In fact, there are guidelines to sort out guidelines! A busy clinician may find it difficult to keep up.

Protocols are meant to be practical and relevant to our day-to-day practice. But it's striking how impractical they can sometimes be. Although they do give us a sense of what's probably good practice in theory, we should realize that evidence-based medicine is not an exact science. Much of what we do in the clinical world is hardly exact science. It's probably best described as a hybrid of science, art and empathy.

In the final analysis, guidelines are just that — guidelines. They cannot replace clinical judgement, which in good hands is superior to the rigid application of protocols. Indeed guidelines and clinical judgement are not mutually exclusive.

In light of this, what should the modern clinician do? Armed with an ever-increasing knowledge base, the challenge is to use this to create excellence in medical care. May the art of medicine never die.

— Dr Arni Sekar, Ottawa

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