What’s Behind a Guideline?

Abstract

Taking the French oncology sector as a case study, this paper shows that guidelines are used strategically by individual physicians and groups of physicians. While some studies have made convincing arguments about the rise of guidelines as a manifestation of a new type of objectivity, this case study provides evidence that the proliferation of medical guidelines is also the result of an attempt by some physicians to improve their positions relative to competing groups. Guidelines could indeed be strategic resources used by professional actors at the expense of other professionals in order to (1) maintain a sufficient amount of activity and (2) increase control over therapeutic decisions. The study also points to other kinds of changes that guidelines may influence, beyond medical practices and coordination: the evolution of the structure of power relationships inside the medical profession. A perspective on the sociology of organizations, which places concrete exchange and bargaining relations at the core of its analysis and treats social control as being continually challenged and (re)produced, helps to identify other reasons why standardization does not prevent local specificities and may even enhance them.

Reflexive standardization and the resolution of uncertainty in the genomics clinic

“…As already noted, work on the sociology of standards (Timmermans & Epstein, 2010), including considerable contributions from within STS (e.g. Abraham, 1993; Castel, 2009; Halverson, 2019) has emphasized how flexible standards come to be when interpreted on the ground, serving as a powerful resource for different interest groups.…”

Struggles Over Antibiotics: Physicians’ Stance-Taking Toward a Nonconforming Policy in an Intensive Care Unit

“…The emotional and moral load of working in an organizational “site of moral load, of human suffering and fear” (Good, 1994, p. 85), may contribute to explaining the reasons of the physicians’ intense—yet oscillating—commitment toward the “watch and wait” approach. This policy basically does not take at face value the evidence-based international guidelines, does not pursue a defensive medicine approach, and therefore pushes physicians’ work far from the comfort zone patrolled by following protocols (Berg et al, 2000; Castel, 2009; Timmermans & Angell, 2001; Timmermans & Kolker, 2004). Last but not least, the clinical premises of this policy—that is, prioritizing long-term optimization of antibiotics over the short-term infective risk reduction—conceal a moral dilemma: they give a relative primacy to the ward ecology over the single patient’s immediate benefit.…”

“…This article draws on an ethnographic fieldwork in an Italian traumatic and neurosurgical ICU (fictionally called “Central Italy Intensive Care Unit” [CEICU]) adopting a guidelines nonconforming policy (Castel, 2009) concerning infection management and antimicrobial stewardship. Friendly labeled by its members “the watch and wait” approach (see the “watchful-waiting” attitude of doctors; Robinson & Heritage, 2014, p. 214), this policy challenges the international evidence-based guidelines and sustains an innovative and “off-label” approach to cope with one of the most pressing contemporary health care issue worldwide: antibiotic resistance (Center for Disease Dynamics, Economics & Policy [CDDEP], 2015).…”

Creating an (ethical) epistemic space for the normalization of clinical and “real food” oral immunotherapy for food allergy

“…CPGs can take on different forms similar to “essays” outlining the philosophies of groups (Timmermans and Berg, 2003: 123). Moreover, CPGs can be developed to impact professional boundaries and organizational patterns (Castel, 2009). For instance, Timmermans and Berg (2003) showed how the Nursing Interventions Classification (NIC) guidelines were developed to unite nurses around a common “task package” and to stake out claims to specific areas of technical expertise.…”