Why Do Doctors and Patients Not Follow Guidelines?

Ilaria Baiardini; Fulvio Braido; Matteo Bonini; Enrico Compalati; Giorgio Walter Canonica


Curr Opin Allergy Clin Immunol. 2009;9(3):228-233. 

In This Article

Why Do Doctors Not Follow Guidelines?

Two reviews of medical literature have identified the most important factors that could limit the doctor's nonadherence to guidelines.[6•,22] Analysing 76 different studies, 293 possible 'obstacles' have been identified and grouped in seven 'barriers', according to a common theme: the educational programmes and the incentives for compliance practitioners tend to perceive as barriers to guidelines implementation, and therefore they do not follow them in daily practice.[23]

In order to ensure that guidelines recommendations have a real influence on the outcomes linked to patients, they must have an impact on the doctor's knowledge, on his attitude and behaviour. Although behaviour can change even in the absence of significant changes in knowledge and attitude, behavioural changes influenced by new knowledge and attitudes are more permanent compared with an indirect manipulation of the behaviour alone.

Knowledge modification can be impeded by the following factors:

  1. Lack of consciousness about guidelines availabilities: it is difficult for the doctor to be aware of available guidelines and to be able to apply them properly and critically in clinical practice; over 10% of doctors ignore the existence of 78% of available guidelines.

  2. Lack of familiarity towards guidelines: although the doctor knows that some recommendations for a particular disease are available, this does not guarantee his total familiarity with these documents.

Attitude modification can be influenced by the following factors:

  1. Lack of agreement towards guidelines: doctors cannot accept a particular document, or the concept itself of the guidelines. In particular, about 10% of doctors consider guidelines inapplicable in clinical practice because they represent an excessive simplification, are not too useful and advantageous and are drawn up by specialists whose credibility is considered insufficient. Moreover, many doctors consider guidelines as something that could inhibit their autonomy and flexibility and make the doctor-patient relationship impersonal.

  2. Lack of auto-effectiveness: the doctor may not trust his abilities in putting the recommendations provided by guidelines into practice, because of burnout syndrome, stress, difficulties in updating and so on.

  3. Lack of success expectations: if the doctor is quite sure that following the guidelines recommendations does not improve clinical outcomes, he will hardly be inclined to follow them. This can also depend on the fact that the doctor often thinks of the single patient, and this could prevent him from gathering a positive result considering all the population.

  4. Lack of motivation and consolidation of habits in clinical practice can prevent the doctor from accepting changes.

Behavioural modification can be determined by the following factors:

  1. External barriers: knowledge pertinence, together with a positive attitude towards changing, is a necessary but not sufficient factor that can guarantee guidelines adherence. As a matter of fact, the doctor can meet with external obstacles connected to the guidelines themselves (see below), to the environment (organizational factors, lack of resources, economic aspects) or to the patient. Payment and cost issues are the most cited obstacles to guidelines implementation.[24]

Also, the inertia of previous practice caused by customs or habits may represent a barrier to guidelines adherence. Physicians may have difficulty changing deep-seated routines, despite the awareness and familiarity with the guideline itself. For this reason, it could be difficult for clinicians to develop new routines for chronic disease management.[25]

Age, sex and country of the potential users may influence the predisposition.[18] However, other studies[26] show that there is no significant association between the general practitioner's (GP's) sex or professional experience and barriers.

Also, doctors' cognitive styles, such as evidence versus experience on the basis of knowledge, the conformity to local common practices and the sensitivity to concrete concerns, physicians' habits and customs, can constitute barriers to guidelines adherence.[27]

GPs may not follow guidelines if they think that they are based on opinion, poor evidence or do not consider patients' values and preferences. Moreover, the recommendations and guidelines volume means that most GPs do not have time to read and memorize the full details of all guidance.[28] Time factors (for example the time spent performing services) and lack of local resources and legal issues (all the concerns related to liability) are also identified barriers to guidelines implementation.[24,29•]

The attitude to guidelines varies according to the individual position on the professional hierarchy and on the function of the quantity of research activities. Organizational factors such as professional and patient turnover or lack of coordination among the different wards in the hospital also represent barriers to guidelines adherence.[30•]


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