Dealing with Physicians Who Won’t Get with the Guidelines

Case Study: Dr. Jones is an orthopedic surgeon who is a dedicated and long-standing member of Mercy Hospital’s medical staff. He trained in the 1990s and has enjoyed a successful and respected orthopedic practice at the hospital for many years.

The hospital’s Utilization Review Committee recently started a routine process to compare specialty-specific blood utilization in each department. The intent was to ensure that transfusion guidelines were followed in each specialty by looking for outliers in blood utilization.

Over the past decade, the threshold to transfuse many blood products has been lowered, especially for red blood cell products. There is a clear cost-of-care advantage to the hospital to forgo unnecessary blood utilization; in addition, there is now convincing evidence that the more conservative use of red cell transfusions prevents transfusion reactions, instances of volume overload with subsequent pulmonary congestion, and unnecessary delays in hospital discharge — all without sacrificing overall clinical outcomes.

Dr. Jones’ use of red cell transfusions in hip fracture patients and total joint replacement patients was found to be more than twice the utilization of his peers (even when adjusted for admission volume). A careful look at his ordering pattern suggested that he ordered blood for his patients at hemoglobin levels well above the current Associations for the Advancement of Blood and Biotherapies (AABB, previously the American Association of Blood Banks) guidelines.

In addition, the hospital’s Peer Review Committee recently had been referred a case of Dr. Jones that was concerning for postoperative heart failure requiring a transfer to the ICU, in which transfusion volume was thought to play a factor in the patient’s deterioration. The Peer Review and UR Committee jointly asked Dr. Cunningham, the new orthopedic department chairman (and 20 years junior to Dr. Jones), to meet with Dr. Jones to review his practice patterns and ensure he was aware of current transfusion guidelines and would follow them in the future.

Dr. Cunningham caught Dr. Jones in the surgeon’s lounge later that afternoon and asked to set up some time to review his transfusion utilization data and the newest transfusion guidelines. Dr. Jones was dismissive of any idea that his practice was outside the standard of care. He not only refused to meet with Dr. Cunningham but loudly argued in front of the operating room staff that Dr. Cunningham was an inexperienced surgeon who had no business judging his clinical decision-making, and that this whole thing was “fake news” designed by Dr. Cunningham’s competing orthopedic group to hurt his practice.

The next morning, Dr. Cunningham stopped by the CMO’s office to get advice about what to do next.

When Medical Staff Won’t Get with the Guidelines

Most aspiring and established chief medical officers are familiar with the Get With The Guidelines (GWTG) program developed by the American Heart Association and the American Stroke Association to enhance the implementation of guideline-based care in hospitals.(1)

GWTG and other programs like it were developed by professional healthcare organizations to accelerate the adoption of evidence-based care shown in clinical trials to improve outcomes and quality performance in hospitals. These programs and other practice guidelines have become a key strategy to reduce the practice of outdated and no longer acceptable types of medical and surgical care.

The list of guideline-based care available to physician leaders attempting to keep their hospitals at the cutting edge of appropriate care is exhaustive.

• The American Heart Association has programs to improve care for patients with heart failure, acute myocardial infarction, and in-hospital cardiac arrest.

• The American Society of Colorectal Surgeons has practice guidelines for treating rectal cancer.(2)

• The Infectious Disease Society of America has guidelines for the optimal treatment of community-acquired pneumonia.(3)

• The American Diabetes Association has guidelines for diagnosing and treating diabetes.(4)

• The Associations for the Advancement of Blood and Biotherapies (AABB) has guidelines for transfusion care.(5)

The list goes on and on.

The average time from discovery to routine implementation of new medical treatments is estimated to be close to 17 years.(6) This delay and gap in optimal treatment are ethically unacceptable to most healthcare administrators and hospital boards. It also represents an ongoing liability risk to physicians and the hospitals where they deliver services.

Providing Recommended or Guideline-Directed Care Delivery

A hospital’s brand reputation is closely tied to its ability to offer cutting-edge technology and current healthcare practices. Many subspecialty certification and recognition programs for hospitals hinge on adopting recommended or guideline-directed care delivery.

For all these reasons, chief medical officers are often called upon to ensure the hospital’s medical staff incorporates the most up-to-date recommendations and uses the preferred therapeutic options.

This work to keep the care model current has many functional components: ensuring a rigorous peer review committee is in place, managing and reviewing ongoing professional practice evaluation (OPPE) data collection, conducting morbidity and mortality conferences, sponsoring continuing medical education courses, etc. One additional and commonly used approach is to identify a specialty or a professional society’s clinical guidelines and make them the common standard in the hospital.

Implementing guideline-based care while not infringing on the professional autonomy of the medical staff and leaving flexibility for unique features of individual cases can be challenging. One of the most common avenues to implement guideline-directed care today is building electronic health records order sets with the recommended care embedded within them.

Using disease- or condition-specific order sets often creates a situation where doing the “right” thing is also the easiest way to complete the ordering process, so it becomes the norm for most of the physicians on staff. Education and awareness campaigns are often used to inform physicians about new or changing practice recommendations, but this approach is typically not as impactful as an embedded order set. Transparently reporting on the overall compliance of the hospital with guideline-recommended care can be useful after either approach.

Finally, auditing actual patient care to quantitate providers’ use of guideline-directed care under the oversight of the Peer Review, Utilization Management, or Quality Committee becomes the final arbiter of how well physicians have adopted the recommended care.

Most physicians are eager to build guideline- and peer-recommended care into their clinical practices. And the competitive nature of many physicians makes the transparent sharing of guideline compliance a potent avenue to accelerate the adoption of guideline-directed care. Involving physicians, nurses, and other ancillary health professionals in adapting clinical guidelines to the unique operational features of the hospital will promote a higher level of adoption.(7)

Convincing Reluctant Physicians

Even though the majority of physicians on the medical staff may endorse the hospital’s efforts to modernize care patterns and adopt current clinical recommendations, anticipate that there will be some physicians who are reluctant to embrace any change in their usual and long-standing clinical care choices.

The CMO must be prepared for this resistance and have a strategic plan to address outliers on the medical staff. Research in implementation science has looked specifically at the varied reasons physicians may be reluctant to adopt guideline-directed care. Several thoughtful descriptions of a differential diagnosis of varied reasons for non-adoption are available.(8)

In my experience, a successful strategy to address non-adopters of new care guidelines starts with assuming “good intent” on the part of the reluctant physician. An accusatory or condescending attitude is never helpful in these situations. Remember, physicians went into this work to help their patients, cure disease, and reduce patients’ suffering, so no matter how far removed from current best practice the physician seems to be, always assume good intent in their clinical reasoning when approaching the outlier physician.

Always check your data and information before you ask to meet with physicians who seem to be outside of the guideline-recommended care. Do you have enough data to make conclusions about their practice pattern? Given that much of the data may be acquired by an electronic query, are you confident in the accuracy and correct attribution of the data?

Are there unique features of the physicians’ practice or the characteristics of their patient demographics that might be an explanation for practice outside of the guidelines? For example, an internist may have low compliance with the AHA’s acute myocardial infarction guidelines. Still, on closer review, it’s clear the majority of his patients come from a dementia care facility where he is the medical director. They have advanced directives that preclude aggressive treatment.

Or consider the orthopedist who seems to be using antibiotic-impregnated cement at an unnecessarily high rate and much more often than the other orthopedists on staff. On closer inspection, he has developed a reputation and practice focus in revision total hip arthroplasties where the use of antibiotic-impregnated cement is justified, and he does very few primary total joint arthroplasties.

After you have assured yourself that the data are accurate, the case attribution is correct, and you can find no practice or patient characteristics that might explain a departure from recommended care, it’s time to meet with the provider.

When meeting with the physician, you will be well served to employ a “humble inquiry” mindset.(9) “Tell me about your approach to the treatment of … .” Or, “I’d like to understand why your treatment plans differ from many of your peers. … ” Physicians often are unaware that their practice is outside of the norm or does not follow current professional society recommendations.

Here, the conversation and intervention may flow easily and will likely be a rewarding experience for the physician leader. When the meeting evolves into a collegial conversation where you can transparently share data on their care choices alongside their peers, show any clinical outcome gap, and provide a copy of the guidelines, the physician may greatly appreciate it, and you can be proud that you have positively influenced patient care.

However, these conversations are often met with resistance. Be prepared for “my patients are different” and “I’ve been practicing this way for years without a problem.” Be ready to receive copies of medical literature that argue against the guideline in question.

Again, don’t let your hackles get up. Remember “humble inquiry.” Keep the door open for ongoing dialogue. It is always fine to say, “Thank you for the information,” and promise to review a study or alternate recommendations. Set up a time to meet with the physician after you’ve had a chance to review whatever additional information they may provide. A successful approach to the resistant physician may take several meetings.

Second meetings are often better when they include an additional colleague, especially a more senior colleague, such as a chief medical officer or division chief. A physician’s continued reluctance to adopt the guideline can often be addressed effectively in a well-attended department meeting, where the weight of having all his or her colleagues as part of the discussion makes it hard to continue to argue against the recommended care.

If patient safety or clinical outcomes are adversely impacted by the lack of compliance with a guideline, the issue can be referred to the hospital’s medical executive committee (MEC). The MEC has the prerogative to mandate education, proctoring, or additional clinical training. And as a last resort, the MEC can restrict privileges if the care the provider is delivering is clearly substandard.

The approach described above has intentionally graduated steps that start from a position that assumes good intent and a willingness to learn and improve their clinical practice. If necessary, they can move to meetings with the clinical leaders, the department, and the MEC intervention.

Caveats to Consider

Several caveats should be considered when approaching a physician who is practicing outside of the accepted guidelines.

First, all these conversations should be kept confidential and under the umbrella of the peer review and quality improvement processes outlined in the medical staff’s bylaws or rules and regulations. Ignoring confidentiality can do irreparable harm to a physician’s practice and open the hospital up to liability.

Second, don’t try to address the issue by influencing referral patterns or call schedules that will just steer business away from the provider in question. This is an inadequate approach that can be challenged as unfair competition or an illegal restraint of trade.

Lastly, don’t just give up and ignore the issue because it is hard work and causes conflict in your life. Your patients deserve the best care possible, and sticking with a graduated approach to getting physicians on board is an important obligation for you as a physician leader.

Resolution of the Case Study

After reviewing the situation with the chief medical officer, Dr. Cunningham and the CMO meet with Dr. Jones together. To address the concern that the issue is related to competition between the two orthopedic practices, Dr. Cunningham also asks another orthopedist from Dr. Jones’ practice, an avid supporter of following the AABB transfusion guidelines, to join them.

At the meeting, Dr. Jones asserts that his patients are more elderly and have more underlying cardiac disease than do the patients of the other orthopedists on staff and that the guidelines allow for transfusion at higher hemoglobin levels for these patients. He is insistent that this is why his blood use is higher than that of the other orthopedists on staff.

Dr. Cunningham was ready for this assertion and came prepared with age and cardiac history data for himself and peer orthopedists to review. He also went to the meeting with reprints of current transfusion guidelines and a pocket-sized reference card with the guidelines to give to Dr. Jones.

After some reluctance, Dr. Jones agrees to review the information and follow the recommended transfusion thresholds more diligently. He also agrees to meet again in several months to review data.

Over the next year, Dr. Jones’s compliance with the current transfusion guidelines improves and begins to match that of his peers. The following year, Mercy’s hospitalist program begins a new co-management program designed to improve the medical management of elderly orthopedic patients and orthopedic patients with co-existent medical conditions. Dr. Jones is a big supporter of the co-management program and finds the help in the postoperative care of his patients a time-saver in his postoperative rounding.

The co-management approach seems to further align Dr. Jones’ practice patterns with the other orthopedists. The transfusion care for all of the orthopedists at Mercy Hospital now closely matches the AABB guidelines.

While the above case study is based on an actual occurrence, all physician and hospital names are fictionalized to protect confidentiality.

Excerpted from Difficult Dilemmas for Chief Medical Officers: 30 Case Studies (American Association for Physician Leadership, 2026)

References

1. AHA Get With The Guidelines. American Heart Association. https://www.heart.org/en/professional/quality-improvement/get-with-the-guidelines .

2. Langenfeld SJ, Davis BR, Vogel JD, Davids JS, Temple LKF, Cologne KG, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of rectal cancer 2023 supplement. Dis Colon Rectum. 2024;67(1): 18–31. https://doi.org/10.1097/dcr.0000000000003057 .

3. Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crother K, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7): e45–e67. https://doi.org/10.1164/rccm.201908-1581st .

4. American Diabetes Association. Standards of care in diabetes 2025. Diabetes Care. 2025;48(Suppl1).

5. Carson JL, Stanworth SJ, Guyatt G, Valentine S. Dennis J, Bakhtary S, et al. Red Blood Cell Transfusion 2023 AABB International Guidelines. JAMA. 2023;330(19):1892-1902. https://doi.org/10.1001/jama.2023.12914

6. Rubin R. It takes an average of 17 years for evidence to change practice — the burgeoning field of implementation science seeks to speed things up. JAMA. 2023;329(16):1333–1336. https://doi.org/10.1001/jama.2023.4387

7. Beauchemin M, Cohn E, Shelton RC. Implementation of clinical practice guidelines in the health care settings: A concept analysis. ANS Adv Nurs Sci. 2019;42(4):307–324. https://doi.org/10.1097/ans.0000000000000263 .

8. Cabana MD, Rand CS, Powe NR, Wu AS, Wilson MH, Abboud PA, Rubin HR. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999; 282(15):1458-1465. https://doi.org/10.1001/jama.282.15.1458 .

9. Schein EH. Humble Inquiry: The Gentle Art of Asking Instead of Telling. Berrett-Koehler; 2013.