Background
Methods
Research design, recruitment and sampling
Interview settings
Analysis and interpretation
Results
Group 1 (n = 7) | Group 2 (n = 8) | Group 3 (n = 3) | Group 4 (n = 7) | Total (n = 25) | |
---|---|---|---|---|---|
Female (n) | 3 | 2 | 0 | 5 | 10 |
Age in years min – max (mean) | 31 – 39 (34.3) | 45 – 62 (55.9) | 40 – 47 (44.3) | 31 – 45 (37.0) | 31 – 62 (43.4) |
Years as GPa min – max (mean) | 1 – 4 (2.9)a
| 8 – 35 (22.6) | 12 – 13 (12.3) | 0 – 4 (2.4)a
| 0 – 35 (9.6) |
Specialist in general practice (n) | 0 | 8 | 3 | 0 | 11 |
Specialist in another medical discipline (n) | 1 | 1 | 0 | 1 | 3 |
Complications for the GPs of applying multiple guidelines
A highly problematic situation
When you have so many chronic diseases and are expected to follow all the guidelines – the result is chaos. (Group 1, M4)
There are no guidelines yet which can encompass ‘complexity-based medicine’. To grasp how to work with the complexity we confront as GPs requires a massive, theoretical quantum leap. Perhaps in 10–15 years we will realize that all of today’s reductionist guidelines within the natural sciences were wrong and had led us astray. (Group 2, M7)
Increased insecurity
The insecurity that a ‘guideline hell’ brings is negative, but that is not talked about very often. (Group 2, M7)
More ‘defensive medicine’
I often chose to ‘protect my back’ by doing too much, by following up too thoroughly, for instance, ordering additional x-rays or other extra examinations. (Group 4, K10)
We never get criticized for doing too much. You don’t get in trouble for having initiated unnecessary examinations even if they lead to complications. But you can be sure you’ll get in trouble if you haven’t done enough! We’re much more vulnerable to the entire health care system’s expectation that things must be done. There’s an intense ‘action imperative’ to do more. (Group 2, M7)
When I deviate from the guidelines, I am careful to write my reasons down in the patient record. For instance, if I take a patient off acetylic acid because he developed a stomach ulcer, I write that I am aware of the increased risk of a blood clot. Good record-keeping helps protect me. (Group 3, M11)
Complications for their patients when GPs apply multiple guidelines
Excessive pharmacological and non-pharmacological treatment
It’s great that there are guidelines, and I try to follow them. But when the patients have several diseases, there are too many guideline recommendations. Especially when patients are getting older, how much medicine should you give them? (Group 3, M12)
I see how patients go into the hospital and have new medications added because the hospital has followed the guidelines. We often have to take responsibility later for having the patients discontinue some meds and we thereby ‘break the rules’. That’s no easy job! But we have to try to see the whole patient. (Group 4, K9)
The treatment must be planned, individually, based on the patient's functional ability, interests, what he actually manages to follow up on in everyday life, how many activities he can tolerate during a week. The non-pharmacological regimen should not place an additional burden on people already struggling with chronic diseases. (Group 4, K6)
Increased medicalization
It seems to me as if some of the guidelines’ recommendations are implying: Everybody needs treatment, but so many people just don’t know it yet. We GPs have to counteract this and let our patients know that we don’t think they’ll live any longer or have a better life if we just put them on one additional drug. (Group 2, M6)
Reduced quality of life
A patient of mine with atrial fibrillation, COPD and heart failure is often hospitalized because of dizziness. The cardiologists treat him every time with a beta blocker, in accordance with the guidelines, but he gets bradycard, so I deprescribe it after every hospital stay. Seen in isolation, he could conceivably benefit from being on that medication, but he does not tolerate it. I regulate treatment according to the patient’s symptoms and overall situation. (Group 4, M14)
What matters most is the patients’ quality of life. We as GPs have to listen to what the patients say, and do the best we can to relieve their suffering. (Group 3, M13)