Translating Medical Guidelines Into Practice.

“Dr. Willson! I tried what you told me to do, but my 7-year-old son is still constipated and messing his pants at school. I want to see a specialist.” This is certainly a reasonable request that I am willing to facilitate; however, the question is how soon the pediatric gastroenterologist will be able to see her son. My nurse confirms my fear, saying, “Dr. Willson, the next available appointment with the pediatric gastroenterologist will be in 10 weeks.” My nurse then hands me a copy of the consensus guidelines on diagnosing and managing constipation developed by Community Care of North Carolina (CCNC). I base my management on these recommendations and hand the parent education notes to the mother. I tell her that the pediatric gastroenterologist wants me to start her son on this treatment while he is awaiting his appointment. The consensus guidelines on constipation created by CCNC provide an immediate “consultation” with the gastroenterologist. Often, by following the guidelines, the constipation resolves and the specialist referral may be cancelled, allowing the specialist to see other referrals sooner. If the child does not improve, then I can call the specialist and request a more urgent visit. Unnecessary laboratory and imaging studies are avoided, leading to decreased costs. Also, by knowing the guideline was followed, the specialist may be ready to look for more unusual diagnoses that require more expensive tests. The American Academy of Pediatrics has documented what most of us in general pediatrics have known for years: there is a shortage of pediatric subspecialists in the United States [1]. To address this problem, CCNC, a statewide, physician-led network of primary care practices, brought together pediatric subspecialists from across the state to draft consensus guidelines for primary care physicians to use when treating conditions commonly referred to specialists. The goal was 2-fold. First, guidelines can educate the doctors “in the trenches” about the latest work-up and management of commonly referred conditions and, second, they can decrease unnecessary referrals to subspecialists. Besides guidelines on constipation, there are also guidelines on gastroesophageal reflux, chronic abdominal pain, sickle cell disease, and headaches. Is this cookbook medicine? I do not think so. These guidelines are merely starting places for managing some of the most perplexing conditions of childhood. Over time, the management may be modified by the primary care physician to meet the specific needs of the patient. A referral to the specialist may still be needed, but the specialist will know better where to start in her evaluation. At the Brody School of Medicine, we have introduced these CCNC guidelines at our annual CME day and have used the guidelines as teaching tools for our residents in our continuity clinics. We encourage our physicians to access them through the CCNC website. Over time, we hope that our subspecialists will be able to document fewer unnecessary referrals and shorter waiting times for referrals, and we hope our primary care physicians will document improved parent satisfaction and outcomes. Clinical guidelines, created by credible experts, are a powerful tool to help reach our nation’s goal of improved access to care, higher quality care, and decreased cost.