In general there is strong opposition in the medical fields to anything that is new. Medical facilities are usually structured with a pyramidal hierarchy, similar to the army. This makes it difficult as a young health care worker (or an older one with a tendency towards new things) to include or follow anything that is new because you usually have strong opposition from the upper levels who oppose this because "we have been doing it this way for X years and everything a was fine!". 

This had been researched and written about, but I think that anyone working in the field has had similar experiences. 

on the one hand a Guideline has to be broad enough to "allow" R&D (and not to create obstacles), on the other hand regulatory, quality, preclinical and clinical experts from industry as well as from national authorities need a guidance to set up agreed common Standards. Any deviations from a guideline have to be adequately adressed and justified.

One also needs to keep in mind that guidelines are rarely universal as they try to be. They very seldom take into account the broader political, social and cultural implications, and that presents an obstacle in their implementation. So sometimes it is very hard to explain if such a deviation occurs. So there is a fine line when making and following guidelines. 

Many, if not most, physicians still regard following guidelines as "cookbook medicine".  They rail against them claiming that "every patient is different", but ignore the fact that there is a vast and growing literature that can and has been used to develop (at least some) guidelines that truly are evidence based.  

The question is how to determine which guidelines are, and which are not grounded in solid evidence.   Some of the latest analytics technologies powered by sufficient electronic data inputs from large populations of patients (including genomic information), best global evidence based practices for highly specific (and ever changing) patient conditions, machine learning,  predictive modeling, and ample computing power can produce clinical decision support systems that provide highly individualized real time evidence of exactly what course of clinical action has the best statistical chance of working to produce optimal clinical results at the lower possible cost for individual patients.  

But, very few physicians are familiar with these capabilities, let along use them.  With the rapid movement from a volume to a value based purchasing and reimbursement system now in the U.S., that will change dramatically by the end of this decade.

There are many different types of barriers - the area of changing physician behaviour and guideline compliance has received a lot of research attention. Some of the factors not mentioned above include strength and transparency of level of evidence, credibility of agency/ individuals who issued the guideline, the engagement or lack of of practitioners/clinician's in the guideline, engagement of patients in guideline development, engagement of policy-makers or decision-makers within an organization.  Whether the guideline can be systematized or supported by administrative support/ billing/ performance accountability.  The level of uptake by peers - social norms within a profession, the amount of press, the level of harm of non-compliance and consequences (legal, liability, standards within a profession or organization),  the buy-in of "safety culture", the attention/ systems in place for quality assurance within an organization, whether an organization is a teaching centre.  Just consider the challenge of compliance of "hand washing" in an organization

Guidelines are not meant to replace the wisdom of the physician, but rather to complement it. A wise physician is always needed to implement any guidelines.

I agree with Marc. Just to highlight that the term "guidelines" by itself do not carry  or suggest any form of "the need to comply" or "have to comply" attribute. It looks like "it is good for you to follow" and "it is okay if you do not follow". The phrase "It is only a guideline" might ring a bell.

On the other hand, the willingness or the political will of those in authority to exercise R & R (not Rest and Recreation, but Reward or Reprimand) for compliance would be a good way to ensure the intended good behind the formulation and subsequent implementation of those guidelines can be greatly appreciated.  

In addition to what has been already discussed about the tendencies to remain with the prevalent practices and be less prone to changes, there is at least in some cases, another aspect that gets in the way - should something go wrong, the administrators feel that it is easier to justify if all commonly used practices were followed in patient care. Monetary ramifications are not easily ignored...  

Patient care is both complicated and complex.  There is a difference.  Complicated implies "a lot of moving parts" but with a sufficiently reductionist approach, care can be codified as a sequence of steps, each with an optimal solution.  Complexity, though, occurs when each of those steps interacts with the others, creating more than one optimal solution.  Transfusing for an upper GI bleed in an otherwise healthy individual may be complicated (assess actual hemoglobin loss, current fluid balance, potential for rebleeding, cardiac reserve, blood type, etc); but the same decision becomes complex in the ICU patient with ARDS, diastolic dysfunction, hypoalbuminemia, heparin-induced thrombocytopenia and difficulty cross-matching.  Guidelines may cover 80 to 95% of circumstances, but never all.  A good computer algorithm can work most of the time, but it's only judgement developed after 4 years of medical school, residency, fellowship and clinical experience that dictates when the guidelines are not applicable.  That being said, physicians should document and justify when they are deviating from recommended practice.  Monitoring systems (local QI, CMS, etc.) cannot yet distinguish appropriate variance from carelessness, and being tagged as "noncompliant" with guidelines is the perfect way to stifle innovation.

 "Complexity, though, occurs when each of those steps interacts with the others,"

They often do...

"...creating more than one optimal solution."  

I would phrase the above as more than one reasonable solutions from different perspectives; optimum, by the definition can only be one - the best, solution.

Good point.  Your wording better captures what I was trying to express!

One of the most important barreer against guideline implementation is the fact that many guidelines are difficult to read. Too long and wordy documents in which the important messages are diluted within the extensive review of the topic. If people do not read the documents, then they do not implement them. Shorter documents, with clearly identifiable important messages and more effective figures and tables will increase guideline efficacy

Luigi, complex topics can ce simplified only so much.

Of course, I agree that some guidelines being the product of many minds tend to become confounding rather than illuminating because of attempts to satisfy many dominating egos.

Guidelines depends on experts consensus. Such consensus must be very clear and  show synthetic writing. I agree withTausit's reference to different egos intervention.

Guidlines should only be used as guidelines, not as protocols to be rigidly applied.  Every individual patient is an individual and must have their clinical management tailored to suit their individual situation.

Simplicity and brevity are the key components for guidelines. The evidence can be provided in a linked document for those who wish to follow it up.

However I totally agree with Mark Noble, guidelines are not rigid protocols and we should apply guidelines with thought to each individual patient

Short and well illustrated guidelines are recommended to apply in the daily practice.

Please also remember that following guidelines often depends on the financial resources to implement them. There are many areas in the world where financial restraints play a major  role. Creators of guidelines will help poorly resourced countries if the they include more affordable but  still clinically appropriate guidelines

I figure that guidelines are evidence based and directed to benefit the major stakeholders (patients). The guidelines could be based on consensus by a focus / expert group. I think the difficulty to follow the guidelines is also dependent upon the "acceptability" of the guidelines to certain groups of practitioners or an individual practitioner. When individuals are already in a "comfort zone" on how they do things, to change the mindsets of these individuals towards accepting the new practice may require influencing, coaxing or even "dangling the carrot". Hence, from the administrative point of view the difficulty to follow guidelines not only depends on the understanding the purpose and content of the guidelines but the mechanisms to adopt and adapt those guidelines to benefit the masses.

I think that guidelines are very difficult to follow,  because they do not keep in mind, the different formation of physicians. In my opinion, are better the methodologies of work. They are ways of working. 

1º Making QUESTIONS about problem for being treated.

2º Follow steps to obtain ANSWERS.

3º According to thes ANSWERS, prescribe best option of treament.

If I may add a suggestion, people who make guidelines should get regular feedback from the people who follow guidelines. The information should include to what extent the guidelines are followed and the reasons behind that. 

From the experiences penned down above, it is obvious that reluctance to follow guidelines is multifactorial.  However, one also needs to realize that while holding on to old assumptions is easier, it can more often than not also be counterproductive.

Can anyone give examples of the most accepted / adopted / implemented guidelines world over? there might me innumerable guidelines which are hardly followed, but which are the ones that are followed at least satisfactorily ...then we ask the Q y some are followed and some not

There are so many reasons.  First, it's hard to break old habits.  "I've been doing it this way for 20 years and it's how I was trained and it works fine" is hard to get over for some people.  Also, for those who want to keep up, there is so much new information coming out in any field of practice that it can be hard to keep current as however much you read, there's still more out there. Then, if you want to implement a new practice, you need to get a whole team on-board and perhaps new equipment, infrastructure, or policies, with all those bureaucratic and people-related barriers in place. In health care there are so many things that we don't know yet, that haven't been explored in the literature, that many recommendations from guidelines have a strength of evidence rating of expert opinion, which makes it hard for some to adopt.  Lastly, there is a disconnect between the highest level of practice consistent with current guidelines and reimbursement policies.  It takes time for payment to catch up with research findings and guidelines, especially when the "new way" is more expensive than the old one. So, even if a provider wants to do something new, there is no way to get paid for it.

Renee:

"So, even if a provider wants to do something new, there is no way to get paid for it."

Generally speaking, health care system is more concerned in two things: 1) keeping the cost down, and 2) ensuring that they are not considered negligent should something go wrong. In the latter case, "new" can be risky but old, even if not the best, is the well-know standard procedure and it is often automatically deemed adequate. 

I do agree with you that the system is rather complex to implement changes, even when there is a clear indication of advantages. 

Surely, there must  be something that works even in a "health care" system.

It may be money, it may be fear, it may be the "good Samaritan" mindset or something else! As medical professionals, we must identify the areas / domains where we want /wish / deny / negate guidelines or protocols!!!

"Surely, there must be something that works even in a "health care" system."

Of course, the system works reasonably well overall... just not optimally in terms of best possible health care or the most efficiently for given resources.

There are two main factors that get in the way: inertia of a large and complex system, and "free market" which is motivated exclusively by the desire of profit maximization. 

Though guidelines are valuable for management , there is no compulsion to immediately  follow them . Doctors gain experience with a protocol & follow them , until there are  problems in management . In addition , unless they get to know about new guidelines through journals or CME updates , they may not be aware of it . Every country should evolve its own guidelines , as guidelines of developed countries may not apply to developing countries . The main reason is non availability of diagnostic facilities & newer therapeutic procedures .

In general when the guidelines are not realistic and reasonable towards achieving the stated goals and objectives.

We have had dismal experiences with asthma guidelines over the decades.  Patients come in various forms and seek help for AEs; we most often START with step FOUR and de-escalate over time.  Enthusiasm about guidelines appears to be inversely proportional to the age (and wisdom?) of the chest physician !

Although guidelines are only to guide but still they are pivotal step atleast at the start of management . I'll agree with singh sahab that in our set-ups we have barriers like availability of  facilities, finances and expertise to strictly comply to the guidelines.

Guidelines for management for common diseases are provided by expert groups based on current evidences and the best way to use them for optimal patient care.  While these are created with the best of intentions, whether they work in 'real life 

situations' i e in general and family practice areas,  depends to a large extent on the 

important variable ---compliance.  In other words, the primary care-givers have to be 

convinced that these guides are the best at a given point in time. Speaking with over three decades of interest in asthma and COPD, I believe that these principles have 

to distill to the grass root levels.  Otherwise they are likely to remain in the ivory towers where they are created.

actually guide line is a basic element for every  step in life either illness or wellness. these take shape based on experiences as well as current evidences means  guide lines are well thought principles. obviously principles are always to be followed to  obtain desired results. it does not mean that  these are to be followed blindly but can be  adjusted as per present situation, requirement  but  not convinience.

i do agree with clara's point of view. actually, it is duty of the expert who issues any guide line, to see that  precautions in adopting or following guide lines should be adequately  defined so that there must be no if n but in  following them.

I speak only is his long years of experience, guidance is certainly good and next to it a professional reference doctors or even the best guide can not offer all the facts about a disease and to predict all possible opportunities and trouble, when it should be used!

  Therefore, it should be quite a bit little relativize and say basically is good that we have and use, but it must rely on personal experience myself or other colleagues who were confirmed as knowledgeable in certain areas in medicine!

I fully agree with short, clear and documented response dr.Om Prakas!

I briefly to conclude that short guides are good but very useful without personal experience  medicus think their importance diminish relativize because each case is individually!

No guidelines can not predict in advance possible problems and complications that arise unexpectedly in the treatment of patients, can help serve as a basis with their own experience and knowledge -medicus- doctor, who leads the patient!

A significant challenge to guidelines are the sheer number of guidelines and the lack of integration of guidelines in appropriate clusters of disease. With the rise of multi-morbidity of chronic disease in both youth and aging populations there is a need for integrative guidelines, rather than single disease guidelines.

The "buy-in" of any guidelines requires benchmarking of the draft before it enters into effect. Compliance is improved when stakeholders give their in-puts before the final version of the guidelines is printed and distributed.  The managerial commitment constitutes another important issue. Managers must make guidelines available to practitioners who are expected to use them and provide the resources needed for the implementation of the guidelines. Lastly, guidelines should be rooted in or adapted to the local culture and  practices.