11. Doctors, guidelines, and patient preference

These commentaries are based on Dr Gillman’s peer reviewed scientific papers, see Publications

Doctors who find themselves in conflict about practice, as that relates to guidelines, may remind everyone concerned of the statement of the medical board of Australia (which is reflected in statements by most ‘medical boards’):

The practice of medicine is challenging and rewarding. No code or guidelines can ever encompass every situation or replace the insight and professional judgment of good doctors.  Good medical practice means using this judgement to try to practice in a way that would meet the standards expected of you by your peers and the community.

No guideline can ever replace the insight and professional judgment of good doctors

They may also remind everyone concerned that, as several commentators have noted, the initial EBM tenets required:

integrating … the best available external clinical evidence from systematic research…[with] the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice… [without which] even excellent external evidence may be inapplicable to or inappropriate for an individual patient.”  [1].  Patient experience and preferences are commonly under-emphasized in the synthesizing of evidence for inclusion in clinical practice guidelines [2].

Practice guidelines have become overly reliant on RCTs.  Developers should give greater consideration and emphasis to clinical expertise, patient choices, and perspectives [3] — those who use guidelines should take more notice of the statements which invariably introduce the content, as exemplified below from several recent documents.

These recommendations are presented as guidance for clinicians who should consider them in context of individual patients and not as standards of care [4]

Guideline recommendations are based on evidence. Nevertheless, the principal recommendations usually derive from average effects in patient populations. Such recommendations may be expected to apply about 70% of the time, so we have used expressions like “Clinicians should consider…..” in the text. However, there will be occasions when adhering to such a recom- mendation unthinkingly could do more harm than good.

We will also describe treatment options in a way that is not prescriptive. They recognize that implementation will depend on individual and local circumstances. [5]


It thus follows, with elegant simplicity, that a Doctor who declines to use a treatment because it is ‘not in the guidelines’ is not only declaring that he is deficient in his knowledge and experience, but also that he does not consider patient preference and medical ethics.


  1. Sackett, D.L., W.M. Rosenberg, J.A. Gray, R.B. Haynes, and W.S. Richardson, Evidence based medicine: what it is and what it isn’t. BMJ, 1996. 312(7023): p. 71-2.


  1. Greenhalgh, T., R. Snow, S. Ryan, S. Rees, and H. Salisbury, Six ‘biases’ against patients and carers in evidence-based medicine. BMC medicine, 2015. 13: p. 200.
  1. Van den Eynde, V. and P.K. Gillman, MAOI or ECT? Patient Preference and Joint Decision-Making in Treatment-Resistant Depression. Current Treatment Options in Psychiatry, 2022. 9: p. 419-422.


  1. Lam, R.W., S.H. Kennedy, S.V. Parikh, G.M. MacQueen, R.V. Milev, A.V. Ravindran, and C.D.W. Group, Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Introduction and Methods. Can J Psychiatry, 2016. 61(9): p. 506-9.


  1. Goodwin, G.M., P.M. Haddad, I.N. Ferrier, J.K. Aronson, T. Barnes, A. Cipriani, D.R. Coghill, S. Fazel, J.R. Geddes, H. Grunze, E.A. Holmes, O. Howes, S. Hudson, N. Hunt, I. Jones, I.C. Macmillan, H. McAllister-Williams, D.R. Miklowitz, R. Morriss, M. Munafo, C. Paton, B.J. Saharkian, K. Saunders, J. Sinclair, D. Taylor, E. Vieta, and A.H. Young, Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology. J Psychopharmacol, 2016. 30(6): p. 495-553.


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– Dr Ken Gillman

Dr Ken Gillman