“Did you follow the guideline?”

It is usually the first question, and it often arrives before any serious attempt to understand the clinical context in which the decision was made.

At the bedside, the task is unchanged: assess the patient and formulate a management plan. The patient does not present as a flowchart, nor does she progress in accordance with one. She presents with her own physiology, her own tolerance for risk, and her own expectations, all of which may sit comfortably within a framework or diverge from it in ways that only become clear once care is underway.

Within RANZCOG, a substantial portion of our collective effort is devoted to producing and refining clinical guidance. There is a considerable body of material, ranging from concise practice statements to detailed documents that run to many pages. As Fellows and members, there is an expectation that we are familiar with them and that they inform our practice. That expectation is reasonable. The translation of evidence into usable form is essential in a specialty defined by acuity, variation, and consequence.

The difficulty arises in what happens after the fact.

When an outcome is less than ideal, the discussion rarely begins with competing risks, patient preference, or the reasoning that shaped the plan. It tends instead toward alignment. Was the pathway followed? In that shift, what was intended as guidance begins to take on the character of instruction. Decisions made under pressure are recast as departures from an established route, and the requirement becomes explanation rather than understanding.

The uncomfortable reality is that alignment offers no guarantee of protection. A clinician may depart from a guideline and face criticism for doing so. A clinician may adhere to it and still face criticism if, in retrospect, the circumstances are judged to have required something different. The standard that emerges is not one of compliance but of judgement, assessed after the event with the clarity that hindsight provides.

The legal framework is more nuanced than this experience suggests. In Rogers v Whitaker, the High Court established that the duty of care is not defined solely by professional practice, particularly in relation to disclosure and patient autonomy.¹ The principle articulated in Bolam v Friern Hospital Management Committee permits reliance on a responsible body of professional opinion,² yet Bolitho v City and Hackney Health Authority makes clear that such opinion must be capable of logical analysis.³ More recently, Montgomery v Lanarkshire Health Board has reinforced the centrality of the patient’s perspective in determining the scope of information required for decision-making.⁴

These principles are reflected in Australian statutory frameworks. Provisions such as section 5O of the Civil Liability Act 2002 (NSW) and section 59 of the Wrongs Act 1958 (Vic) recognise peer professional opinion while preserving the court’s capacity to reject that opinion if it is not reasonable.^5,6 The existence of a guideline may inform the analysis, but it does not resolve it.

A local illustration reinforces the point. In South Western Sydney Local Health District v Gould, adherence to a recognised guideline was initially characterised as irrational in the clinical circumstances.⁷ Although that finding did not stand on appeal, the case demonstrates how adherence can be reframed as error once the outcome is known, leaving its protective value uncertain.

None of this diminishes the importance of guidelines. In a system of considerable scale, they provide a necessary foundation. They support consistency, assist clinicians working under pressure, and offer a shared language across disciplines and institutions. For many, they are relied upon repeatedly during a demanding shift when time and cognitive bandwidth are limited.

The problem emerges when that foundation is mistaken for the entirety of good care. Patients do not resemble the populations from which guidance is derived.

The longer one practises, the more apparent it becomes that the “typical” patient is a statistical construct, whereas the individual before you reflects a convergence of variables that resist standardisation.

Comorbidity, circumstance, preference, and the unpredictable course of disease intersect in ways that no document can fully anticipate. It is within that space that clinical judgement operates.

Judgement is acquired rather than assumed. It is shaped over time, often under the supervision of clinicians whose expectations were demanding and whose feedback was direct. Many remain grateful for that experience years later, not despite its intensity but because of it. Without that formation, the capacity to move beyond the written word would be diminished.

It is also rarely exercised in isolation. Decisions are discussed, tested, and refined in conversation with colleagues. Input from midwifery, nursing, and allied health frequently alters the trajectory of care in ways that are not always captured in formal documentation. The final decision may carry a single name, though the thinking behind it is often collective.

Continuity adds another layer. It allows for pattern recognition, for early identification of deviation from the expected course, and for decisions to be made with a depth of context that episodic care cannot provide. In its absence, reliance on written guidance increases, not because it is superior, but because it is available.

There is also the lived reality of practice. Clinicians operate in environments that are busy, scrutinised, and frequently stretched. Decisions are made with incomplete information and under time pressure, with the knowledge that they may later be reviewed in more favourable conditions. Within that setting, guidance can come to feel less like support and more like a benchmark against which actions are measured, sometimes without adequate regard for the circumstances in which those actions occurred.

Another risk sits just beneath the surface. The presence of a defined pathway can create a sense that the problem has already been solved. In moments of uncertainty, this can reduce the instinct to seek a second opinion. In truth, those are precisely the moments in which discussion is most valuable. Written guidance cannot replace clinical conversation.

It is also worth recognising that not all guidelines arise from identical processes. Some are grounded in strong evidence and broad consensus. Others emerge following adverse events, as part of an institutional response. In such instances, the production of a document may offer reassurance that a process has been undertaken, without necessarily addressing the deeper contributors to the event.

With experience, the conclusion becomes difficult to avoid. High quality care is neither purely protocol-driven nor purely experiential. It is a synthesis of both, delivered through continuity, collaboration, and attention to the individual patient.