“What day is it, there’s a different guideline”: how physicians manage conflicting clinical practice guidelines in outpatient care settings

Clinical practice guidelines offer evidence-based recommendations for the prevention and management of medical conditions to improve healthcare quality and outcomes. Yet, as these guidelines proliferate across sources and evolve over time, conflicting guidelines have become increasingly prevalent, posing a significant challenge for both clinical decision-making and adherence to practice recommendations. However, there is limited knowledge on how physicians manage conflicting guidance. The purpose of this study was to identify physicians’ strategies for managing conflicting clinical practice guidelines in outpatient care settings. Semi-structured interviews were conducted with physicians practicing in outpatient care, followed by inductive qualitative content analysis. Participants ( N = 20) were attending physicians ( n = 11), residents ( n = 8), and fellows ( n = 1), practicing in family medicine ( n = 10), general internal medicine ( n = 7), or an internal medicine subspecialty ( n = 3). Participants widely acknowledged the prevalence of conflicting clinical guidelines. Physicians engaged in five strategies to manage conflicting guidelines in practice: (1) employ clinical judgment to personalize guidelines, (2) seek additional information, (3) rely on the most familiar or preferred source, (4) engage in shared decision-making, and (5) proceed with the more aggressive clinical recommendation. Overall, physicians’ strategies for managing conflicting guidelines varied, combining established standard-of-care practices with heuristic-based techniques. Some of these strategies promoted more personalized application of guidelines. More research is needed to determine the effects of the identified physician strategies on clinical and patient-centered outcomes, and to examine how the presence of conflicting guidelines affects dissemination and implementation outcomes.