Guideline-based medicine: A take-away from the AUA oral board exam

Dr. Rosevear is a urologist in community practice in Colorado Springs, CO. Urology Times blogs present opinions, advice, and news from urologists and other urology professionals. Opinions expressed by bloggers are their own, and do not necessarily reflect the views of Urology Times or its parent company, UBM Medica. Please let your voice be heard by joining the conversation in the comments section of each post.

Every year the AUA holds a 2-day course in Dallas designed to prepare the next generation of urologists for the oral board exam. It’s a great course, and I have been lucky enough to be a faculty member there for the last 3 years.

I left this year’s course with the same opinion of our future colleagues I’ve always had; they are an incredibly intelligent group of men and women. Urology residencies are able to pick some of our country’s very best medical students and turn them into incredible young surgeons.

Even with their intelligence, the AUA’s course is useful for two reasons. First, for a generation of doctors raised to excel at multiple-choice tests, an oral exam, even one that is exceptionally standardized, is important. Oral exams can be intimidating, but the real world is not multiple choice and the ability to intelligently discuss a topic these residents have spent the last 5 years mastering certainly has its role.

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Second and perhaps more important, the oral board exam tests residents on standardized medicine-something practicing urologists face every day. Let me give you an example. In my residency, we had an attending surgeon who was truly a world expert on a specific type of cancer. If one of my children needed a urologic intervention, would I let this attending within 10 feet of her? No way, as his knowledge of pediatric urology was minimal. But when it came to his specific field, he truly knew it all. We as residents learned how to treat that type of cancer by listening to how he talked to patients and doing what he did. Why? Because in his hands, his algorithms worked.

The problem with that style of learning though, was that he was not practicing guideline-based medicine. I’m not saying he was practicing bad medicine, but nowhere in the NCCN guidelines would you find what he did. The reason: He was one of the experts who wrote the guidelines and his practice existed to push the boundaries of medicine. He was doing what the rest of us didn’t do to help figure out tomorrow’s guidelines.

The problem for the residents who attend the oral board review course is that they are being tested on standard, boring, evidence-based, guideline-driven medicine. For some of them, when the pressure is on and they are unsure what to do, they revert back to doing what their attendings did. And that can be a problem.

Let’s be honest, this is a problem for those of us in practice, too. As you may know, my group recently merged with the other urology group in town. One of the many advantages of this merger is the ability to standardize medical treatment. I know what everyone is thinking: Why is standardization a good thing? Sounds like big-box medicine and, in some ways, it is. But that is a good thing. Every study I have read conclusively shows that when doctors follow guidelines, the care they provide is better-far better than if a doctor does whatever he or she thinks is best. As I have said before, the days of physicians simply doing what they think are best without following guidelines are over.

Next:"So how are we addressing this problem?"

While that statement is not that controversial, the logistics of ensuring a group follows guidelines are actually exceptionally challenging. Take microscopic hematuria, which is one of my favorite diagnoses because there is great data on the best way to treat it, there are exceptionally written and researched guidelines on its workup, it is very common, and when properly evaluated it yields numerous significant urologic pathologies that can be treated surgically with great outcomes. That said, there exists a significant variation in hematuria evaluation patterns among physicians in my own practice. So how are we addressing this problem?

We started by creating a committee to review the guidelines and the data as it applies to our patients and make recommendations on best practices. We then take those recommendations, use our electronic medical record to identify patients who present with microscopic hematuria, and allow the best practice recommendations to be presented to our physicians in real time to help guide evaluation. Lastly, we intend to monitor our doctors’ compliance to recommendations and provide a financial incentive to those who follow guidelines. We believe that this strategy aligns the interests of our physicians with the best available treatment algorithms for our patients.

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The biggest complaint we encountered during this process came from doctors who felt that the guidelines did not apply to every situation and physicians needed to be able to react to those unusual situations appropriately. We absolutely agreed! The modern physician can best be described as a risk manager. His or her job is to evaluate a situation, understand what guidelines exist, and realize when the guidelines don’t apply to a specific situation. Our hope is that by standardizing the treatment of our patients, we can ensure that, on average, our patients receive the very best treatment that modern medicine can offer.

This is not to say that what my know-it-all attending is doing is wrong. Quite the contrary. We need urologists like him to push the boundaries of medicine to create tomorrow’s guidelines. But for those of us in the trenches of urology and for those young urologists studying for the oral boards, guidelines exist for a reason, and our job is to understand them and apply them where appropriate.

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