An elderly woman – who was put on warfarin for her heart disease and for stroke prevention – was found unconscious, and presented to the hospital with a massive cerebral bleed from which she would not survive.

Further history revealed that she also had 50 falls within that year, leading up to the fatal one.

“Fifty falls!” exclaimed a resident in the hospital. “Why would you put her on warfarin?”

“What were they thinking?”

Are specialised disciplines limiting patient care?

Such half-baffled, half-exasperated grumblings are common occurrences in the healthcare setting, and reflects the lack of understanding from a healthcare provider of the clinical decision made by another. But why do such disparities between doctors’ clinical decisions exist?

The age of scientific and technological advancements has allowed experts to study the human body in great detail and unravel the pathophysiology of various diseases, but has simultaneously resulted in the advent of super-specialisation, with doctors branching out to become highly trained and experts in specific areas in the field.

Focusing on different disciplines allow specialists to make better diagnoses and provide better treatment – for diseases that fall under their field of practice, but patients are more than just a disease or an organ. If healthcare providers fail to look beyond their areas of specialty and approach the patient holistically, the patients may end up entwined in treatments or tests that are either inappropriate or unnecessary.

Overrun with information – doctors struggle to keep up-to-date

Part of the matter in question also lies in the sheer volume of academic research, and despite convenient access to clinical practice guidelines and scientific journals, healthcare providers – who lack the time to read and interpret academic research due to heavy workload – may find it difficult to keep up-to-date of the latest best practices.

According to a study in the British Journal of General Practice, only 24.1% out of 928 general practitioners from England and Wales were aware of the guidelines by the National Institute for Health and Care Excellence (NICE), which recommend that women with a moderate or high risk of breast cancer be offered tamoxifen to prevent cancer.

“GPs are overrun with information and every day a new report lands on their desk – so it’s challenging to keep pace with every new development,” said lead researcher from Leeds University, Dr Samuel Smith.

More discussion needed amongst healthcare providers

Time and pace are not the only factors barring doctors from keeping up with latest practice guidelines. Many doctors may face difficulties or lack the confidence in interpreting the bulk of information from publications, and instead of bringing up the topic for discussion with peers, some take cues from paid expert opinions, or continue with experience-based practices.

In the JAMA Internal Medicine, a systematic review of 48 studies involving over 13,000 clinicians revealed that doctors, more often than not, underestimated harm and overestimated benefit of certain practices.

As a result, many women with postmenopausal symptoms were not provided with necessary hormone replacement therapy, while children with acute ear infections were overprescribed with antibiotics. Many GPs were also found to overestimate the benefits of screening for prostate cancer, but underestimated the benefit of warfarin in patients with atrial fibrillation. Such inaccurate perceptions of harm and benefits may cause patients to receive suboptimal care.

“It is extremely concerning that many women at an increased risk of breast cancer are still not being offered the choice of taking tamoxifen to reduce their risk,” said Baroness Delyth Morgan, the chief executive at Breast Cancer Now.

“But unfortunately this is largely not being adhered to, with many GPs lacking confidence in discussing the option with patients and a worrying number not even being aware of it.”

The art of medicine is as important as its science, and though guidelines are based on evidence, healthcare providers can inadvertently jeopardize patient safety if they apply recommended practices without thorough understanding and consideration of the patient’s needs.

In an era of rapidly evolving information, doctors should be bold to admit if they are unsure of specific practices, but also take the responsibility to find out. Such instances highlight the value of open and adequate interdisciplinary communication in the provision of patient care. By discussing and communicating knowledge, healthcare providers can achieve a shared-decision to ensure that patients receive the best care possible. MIMS

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