The “Ultimate Jazz”: Finding the Silver Lining Among Clinical Experience, Guidelines, and Legislation
We read with great interest the “dialogue” between Dr Martellucci1 and Coccolini et al2 regarding the metaphor among jazz music and surgery, in the era of evidence-based medicine, in regular and emergency setting. It was firstly supported that, even in the era of evidence-based medicine, a current surgeon still has the potential for improvisation1. Moreover, the value of improvisation of a surgeon in an emergency or trauma setting was also underlined.2
We would like to push the rationale of this dialogue a step forward. It is well-established that medical guidelines have gained widespread recognition because they offer the potential of improving medical education that leads to higher standards of care.3 However, this outcome will only be achieved if they are, indeed, implemented.
In addition, even though that surgery is an art,4 it is different than music in terms of that mistakes have real consequences other than producing a cacophony. The underlying fear of mistake is enhanced in the current era of legalistic culture in which we practice.5 Doctors are sometimes publically crucified for mistakes that can scar an entire career with potential financial and professional consequences. Finally, it will be inevitable to confront with conflicts when clinicians compare their own clinical experience with Guidelines. Many physicians feel that Guidelines interfere with their clinical freedom and are concerned about the potential legal implications from following or not such recommendations. When the so-called “personal medical truth,” established throughout one's career, falls into question or shown to be incorrect, will likely cause a crisis in even the most seasoned clinicians.
This is where a question is born. Which is the cost of improvising beyond the frontiers of Guidelines? Unfortunately, there has been little focus on the precise definition or meaning of the term ‘Guidelines’; what is more, there are a number of related words or concepts that overlap with Guidelines and blur the edges of precision.6 One of the current definitions is that of a related set of generalizations derived from past experience arranged in a coherent structure to facilitate appropriate responses to specific situations.6 This definition can lead to many misinterpretations because even if Guidelines were developed to aid the surgeon in pursuing the most appropriate treatment for the clinical circumstances of a specific patient, they should be based on a constantly progressing knowledge and may have potential legal significance to the extent that they represent the state-of-the-art.5 Of interest, the mere fact that Guidelines exist, do not of itself establish that compliance with it, would be reasonable in the circumstances, or that noncompliance would be negligent.5
In this uncharted frame, Guidelines can serve legislators in the regulation of difficult clinical or medico-ethical activities or form the basis of expert evidence adduced either for the plaintiff or the defendant in civil cases involving claims of medical negligence.5 Guidelines should not be understood as restrictions of therapeutic freedom but they should be considered as a compass for orientation in treatment reality characterized by rationalization and rationing. As Guideline-informed treatment increasingly becomes customary, acting outside the Guidelines could expose surgeons to the possibility of being found negligent, unless they can prove a special justification in the circumstances.5 But, Guidelines cannot be appropriate for all clinical situations. This is the legislative and clinical “window” for improvisation. The decision to follow or not follow a recommendation from Guidelines must be made by the physician on an individual basis, taking into account the specific conditions of the patient.3 Guidelines may be considered as a corridor which helps physicians to separate necessary from unnecessary items.3 Deviations from Guidelines for specific reasons are possible.