The guideline multiple: beyond the dilemma of either relationships or standards

Abstract

Teaching the guideline multiple! This commentary offers a means of teaching clinical reasoning that takes account of tensions between written guidelines & the messy world of clinical practice

Context presents a ‘thorny’ problem for clinical reasoning despite the reality that every act of clinical practice takes place within a context.¹ As Krimmel-Morrison et al's² paper suggests, naturalistic clinical reasoning appears very differently from ‘the psychological models of knowledge representation’ of three decades ago.³ This grounded theory study, drawn from the accounts of 15 primary care physicians from the United States, beautifully sketches out the way that clinicians' thoughts and actions are shaped by their interactions with patients and caregivers. They describe internal conflict for the physicians: ‘These relationally-situated constructions of clinical reasoning created tensions in participants' minds between approaches that were aligned with their personal or professional standards, and more tailored approaches to patients' unique illness experiences’.² This is a challenge that health care practitioners face daily—negotiating practice both to satisfy guidelines drawn from generalisable research studies and to genuinely partner with patients and their lifeworlds. Krimmel-Morrison et al² ask the question: ‘how can training programs meaningfully incorporate these situated, relationship-based constructions of clinical reasoning into their models of training and assessment?’ In this commentary, we reflect on the underlying challenges within this question and reflect on one possible means of doing so.

This is a challenge that health care practitioners face daily—negotiating practice both to satisfy guidelines drawn from generalisable research studies and to genuinely partner with patients and their lifeworlds.

The challenges presented by conflicting patient preferences and evidence-based practice were understood by the participants in Krimmel-Morrison et al's² study as ‘an either-or dilemma’. We posit that this understanding is not just a product of the sample or of the situation but reflects how evidence and guidelines are taught and assessed. Knowledge is conceptualised early in medical training as one kind of thing: something that a person knows or knows how. And we have little argument with this representational view of knowledge, what Sfard might call the ‘acquisition’ model of education.⁴ After all, no one wants to think that a physician operates outside of this knowledge; health care is a scientific discipline that is based on measurement, data and managing bias. But at the same time, such knowledge cannot be formed outside of relationships with people and material surroundings, therefore it cannot be neutral truth or the product of a purely rational process. Thus, as Koufidis et al¹ point out, we must ‘conceive the world we are living in (Umwelt) in multiple and sometimes competing ways’. And we must introduce this multiplicity when we teach.

Koufidis et al point out, we must ‘conceive the world we are living in (Umwelt) in multiple and sometimes competing ways’. And we must introduce this multiplicity when we teach.

Context is often described as something separate to a guideline. A guideline, in this way of thinking, is something known and accepted and singular, which is applied within a particular context. However, as Mol writes,⁵ ‘no object, no body, no disease, is singular. If it is not removed from the practices that sustain it, reality is multiple. … But attending to the multiplicity of reality is also an act. It is something that may be done—or left undone. It is an intervention’. We propose therefore that medical schools can (and should) teach our students to attend to this multiplicity by rethinking how medical education teaches guidelines or standards or evidence. They are both a contextual knowledge captured on a page and also an activity that can only be achieved through relationships that are always situated in time and space.

Medical schools can (and should) teach our students to attend to this multiplicity by rethinking how medical education teaches guidelines or standards or evidence.

So how can a guideline or professional standard be multiple? Surely there is just one standard—is not that after all the point? Drawing from post-humanist literature on educational standards,^6-8 we offer two ways of thinking about evidence-based guidelines. Firstly, and most commonly, guidelines are conceptualised as representations of scientific knowledge. From this perspective, a guideline is a concrete piece of text, which represents either a natural truth or a social agreement as to a significant truth.⁷ Secondly, and more controversially, guidelines can be understood as an activity in which people participate. From this perspective, a guideline only exists within use; only through its enactment does it actually guide practice. And these contexts include all the uniqueness of this patient, talking with that health professional in a specific time and place. These enactments are always relational—in the sense that they happen with and between people and objects. Thus, a guideline is not the same everywhere; it is similar but necessarily different. Guidelines coordinate rather than standardise and a physician is constantly moving between the guideline as enacted and the guideline as represented. This movement can be understood as exploring ‘the broad corridors of acceptability’ (to appropriate Ellaway's phrase).⁹ There is often a great deal of stretch within a guideline before it reaches its limits. At this point, such enactments ‘rupture’,⁷ as they are no longer recognisable as the guideline at all.

Thus, a guideline is not the same everywhere; it is similar but necessarily different. Guidelines coordinate rather than standardise.

Despite all our enthusiasm, teaching ontology is not likely to be attractive to health care professional students. Therefore, we suggest teaching the guideline multiple should be done through practising, which is, after all, the only place they can be understood and embodied. In this way, students can move between seeing guidelines as concrete texts or diagrams representing knowledge and also as activities, in which a person participates. Through ‘juggling’ the representation and enactment,⁶ the learner begins to understand how much stretch and flex there is within the broad corridors of acceptability. And this should be done with the deliberate aim of promoting understanding of the guideline multiple – the multiplicity that is always part of clinical practice (and Umwelten).

Simulation offers the most obvious means to teach this view of guidelines. Students can be given the opportunity to bodily experience variation in how guidelines can be enacted and the associated contradictions that exist in enacting such guidelines in clinical practice. Ideally, these are drawn from real cases and experiences, where patient wishes or family interference or material challenges such as lack of resources can be simulated. Ontological fidelity can then serve as a principle for the design of these simulations in order to centre stories and experiential elements of being human in medicine: ‘Reimagining case content to attend to ontological fidelity might mean attending not only to the relevant clinical information, but also to the other human dimensions of a clinical encounter’.¹⁰ Such simulations should also pay attention to the variation in the students themselves and their realities. As Mulcahy notes,⁶ ‘the (skilled human) body is a site of contradictions and ambiguities’; and this is reflected by the tensions and experiences of physicians described in Krimmel-Morrison et al's article.² Students can learn about their own multiplicities and have an opportunity to grapple with contradictions they must manage into the future.

In sum, this commentary responds to the provocation of how to teach ‘situated, relationship-based constructions of clinical reasoning’.² We argue for learning about the variable and contradictory nature of clinical reasoning by introducing guidelines as multiple—where students move between representations and enactments. Such an introduction could occur in simulated or real environments but must allow the student to experience the ‘juggle’ of situated, relational, clinical practice.

We argue for learning about the variable and contradictory nature of clinical reasoning by introducing guidelines as multiple.

Open Research

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no new data were created or analyzed in this study.