Physicians don’t follow guidelines: What are we to do?
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* Don Eby

Simos and colleagues reported that Ontario surgeons and oncologists don’t follow guidelines when ordering imaging in women with early-stage breast cancer.1 The paper joins tens, if not hundreds, of similar articles describing the failure of practising physicians to follow guidelines.

Over the last two decades, repeated attempts have been made to “transfer” or “translate” knowledge to practising physicians.2,3 The CMA maintains a database of “approximately 1200” clinical practice guidelines.4 The plethora of published guidelines have had little appreciable effect on physician behaviour. Even the use of moral suasion by labelling guidelines “best practices” has not worked. What is the matter with practising physicians?

We don’t understand what physicians-in-practice consider as evidence or how they incorporate and use it in their practices. There is some ethnographic research that indicates that the process is complex and nonlinear.5 Clinicians are aware of guidelines but do not refer to them directly in their day-to-day practices.6 Evidence used for practice comes from multiple sources, and not all of it comes from approved hierarchies of validity.6

We know physicians do not use guidelines in their practices. Producing more evidence of this fact doesn’t help us understand why they do not. It is clear that new knowledge does not get transmitted through the rational, linear, transfer models we assumed would work. Until we put research efforts into understanding how clinicians actually practise, we will continue to be stuck — wringing our hands and reading more reports that state that physicians don’t follow guidelines.

## References

1.  Simos D, Catley C, van Walraven C, et al. Imaging for distant metastases in women with early-stage breast cancer: a population-based cohort study. CMAJ 2015;187:E387–97.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTg3LzEyL0UzODciO3M6NDoiYXRvbSI7czoyMjoiL2NtYWovMTg4LzMvMjE3LjEuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

2.  Davies H, Nutley S, Walter I. Why ‘knowledge transfer’ is misconceived for applied social research. J Health Serv Res Policy 2008;13:188–90.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1258/jhsrp.2008.008055&link_type=DOI) 
    
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    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000259563200012&link_type=ISI) 

3.  Greenhalgh T, Wieringa S. Is it time to drop the ‘knowledge translation’ metaphor? A critical literature review. J R Soc Med 2011;104:501–9.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1258/jrsm.2011.110285&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=22179293&link_type=MED&atom=%2Fcmaj%2F188%2F3%2F217.1.atom) 

4.  CMA Infobase: Clinical practice guidelines database (CPGs). Ottawa: Canadian Medical Association; 2015. Available: [www.cma.ca/en/Pages/cpg-conditions.aspx#A](http://www.cma.ca/en/Pages/cpg-conditions.aspx#A) (accessed 2015 Sept. 28).
    
    

5.  Gabbay J, le May A. Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care. BMJ 2004;329:1013–7.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiYm1qIjtzOjU6InJlc2lkIjtzOjEzOiIzMjkvNzQ3My8xMDEzIjtzOjQ6ImF0b20iO3M6MjI6Ii9jbWFqLzE4OC8zLzIxNy4xLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

6.  Gabbay J, le May A. Practice-based evidence for health care clinical mindlines. London, New York: Routledge; 2011.