Urologists say clinical guidelines, experience play complementary role

When guidelines were first introduced, some urologists told Urology Times they considered the use of guidelines "cookbook medicine" and a threat to their ability to practice medicine as they knew it. Urologists today don't share that concern.

Urology Times talked to urologists around the country about the extent they turn to clinical guidelines or to their own experience when deciding their approach to patient care. We also asked where they see a need for additional guidelines or improvements on existing ones. Urologists unanimously agreed that guidelines and clinical experience are both essential for making good patient care decisions.

"That's because we don't have guidelines for everything," Dr. Kitchens said. "There are guidelines for hematuria and how to manage kidney stones, erectile dysfunction, and areas like that, but there are a lot of areas where the AUA does not have guidelines that we go by our own training and tried-and true-stuff that we know works-and people seem to get better.

"As individuals, we try things that may not necessarily be what everybody else is doing. But if something works in your own practice with your own patients, you tend to use it."

Dr. Kitchens, medical director of a group of 24 urologists, says practicing medicine really is a function of using both guidelines and experience.

"We always try to follow the guidelines if guidelines are established," she said. "That's just good care. In our practice, we actually have a medical quality committee where, if there is a question about how to do something or how to follow a protocol, we want everyone to be on the same page. We will set forth our own little guidelines after reviewing AUA guidelines and say, 'Hey, guys, this is what we need to start doing.'

"To look at it from a legal standpoint, if something does happen, we can say we followed the standard of care and we followed the guidelines."

"As much as possible, I rely on the practice guidelines," Dr. Cabelin said. "Not all guidelines are available from all the institutions, however. Usually, the AUA has more urology guidelines so I use more of theirs. But, if for instance, bladder cancer has guidelines from the Bladder Cancer Network, I will use those guidelines. I use National Comprehensive Cancer Network (NCCN) guidelines as well."

In practice 12 years, Dr. Cabelin says the guidelines don't preclude physicians using their experience as doctors in making treatment decisions.

"It has to be a combination of both guidelines and personal clinical practice," he said. "For example, PSA guidelines change. There are many guidelines for PSA and it really comes down to the fact I don't consult the guidelines for that. I know what the guidelines are, and I use what I think is best.

"What's not in the guidelines are things like the patients you are talking to [and] their emotional status." Dr. Cabelin pointed out. "The anxiety, the morbidity, for instance, is sometimes not factored into guidelines. That's where being a physician comes into play. You can't over-rely on the guidelines."