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Guidelines in medical practice

Guidelines, guidelines and more guidelines. I do not know the countries you come from. I like to imagine that my readers are from all over the world and have varied levels of experience. As a Nigerian that worked in the public healthcare sector, there were no written guidelines. There were standards of practice that were well known to your more experienced colleagues which somehow got transferred to you and you imbibed. If you did your housemanship in a public hospital in Nigeria, you might recall how quickly you learnt to write an action plan in the event of a transfusion reaction and how well you could write that plan from memory.
Dear colleague, I want you to know, that your hard earned knowledge is not wasted. However, you will need to reign it in because in the UK, there are guidelines.

In my first week practicing in the UK, a patient had developed pneumonia on admission. I was going to start him on antibiotics. A colleague asked what choice I had made and how I’d arrived at the choice. Needless to say my choice was based on my existing knowledge of treatment for chest infections. He stopped me and proceeded to show me where I could find the hospital guidelines on antibiotic treatment. He bestowed good advice; I was not to prescribe antibiotics based on my knowledge that deviated from the guidelines and if I found I had concerns in terms of the patient’s response to antibiotics being unsatisfactory, then I was to contact the microbiologist.

There are guidelines for most things in most trusts. Where the guidelines fail you, there will be an on call specialist to provide the advice you need.
As with all things, there is also a downside to guidelines and knowing when to insist on relying on your knowledge over a guideline can be key. I share another experience. A Type I Diabetic was going to surgery and became hypoglycaemic whilst awaiting his daycase surgery. I advised that a glucose infusion be put up. This was based on my many years experience caring for surgical patients. A first year doctor on the anaesthetic team asked that the hypoglycaemia guideline be opened up and this guidance advised oral replacement of glucose. This was the option that the nursing team chose. I did not insist. This led of course, to a delay in the patient’s surgery. This experience taught me two things; the first was to use the right guideline. There is a separate guideline for managing hypoglycaemia in perioperative patients. The second was deciding when to insist on relying on my experience.

Having said all of this, there are a few things that still need to be pointed out. Find out how to access the antimicrobial guidelines in your trust. Also ask about other guidelines like thrombprophylaxis, hypoglycaemia, management of Diabetic emergencies, venous thromboembolism, hyponatremia management, refeeding syndrome etc. This list is certainly not exhaustive but gives you a sense of things to be aware of.

The other thing to say is just as you learn from seniors, for example in Nigeria, there are things you learn on the job that are not necessarily found in guidelines. To learn these, you have to be astute. Pay attention to what your colleagues and seniors do and say differently from you when faced with similar challenges. Don’t be afraid or shy to ask questions. An easy example, following medical school and outside of the diagnosis of muscular dystrophy, I had not encountered the use of serum assays of Creatine Kinase. In my first job, creatine kinase was routinely checked for in patients with neck of femur fractures. Because I asked fairly early on, I learnt that it was indicative of muscle damage if patients had for example been lying in wait for a long time before care arrived. This had implications for muscle strength subsequently and for kidney function.

Be bold enough to trust that your experience counts and is part of the reason you got the job. Be wise enough to combine that hard won knowledge with the new knowledge you acquire.

Have you got any experiences you’d like to share that you think others would find helpful

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