A vital tool for ensuring and improving quality in healthcare is clinical guidelines. Guidelines are used to support the clinicians’ memory and evidence-based decision-making, as well as to guide the choice of investigations and treatments toward the most cost-efficient alternatives. Increased control over healthcare costs is also given higher priority as a larger proportion of public health spending is directed toward private actors operating within publicly funded care. To ensure proper outcome monitoring, strong emphasis is placed on measurable indicators, which are defined by clinical guidelines.
Together with medical advances, the ambition to improve quality through prioritizing measurable results has increased both the number and complexity of clinical guidelines guiding the work of healthcare professionals. Guidelines have evolved from being simple decision-support tools for individual patient situations to being designed more often as comprehensive care processes for different medical conditions, encompassing multiple healthcare professionals, various healthcare settings, and extended periods of time. An illustrative example is the standardized care processes being developed within the Swedish system for knowledge-based management, led by the Swedish Association of Local Authorities and Regions.
The development towards increased management control and a stronger focus on measurable outcomes in public organizations has caused considerable debate, where both the advantages and disadvantages of micromanagement have been widely discussed. The focus of the media debate has, among other things, revolved around the organizational and governance model New Public Management (NPM) and its consequences for employees in the public sector.
However, management control through guidelines affects different professions in different ways and also varies across countries. Thus, there is insufficient empirical research examining the concrete consequences that management control through guidelines has for physicians in Swedish primary care and for their work. Therefore, in the article General practitioners and management control through guidelines: a qualitative study of its effects on their practice, which my co-authors and I have recently had published, we examine the consequences for Swedish general practitioners (GPs).
We interviewed 11 GPs across Sweden about how they concretely experience that management control through guidelines affects their work and what consequences they perceive it has for healthcare. We found that management control through guidelines creates complex challenges for GPs, challenges that could be divided into three distinct fields of tension.
In the first field of tension, there is a tension between the high ambitions that underlie management control through guidelines, and the negative side-effects that these ambitions cause. All GPs expressed a deep-rooted sympathy for the ambitions of using guidelines to ensure quality, improve efficiency, and increase equality among patients. Guidelines were seen as an indispensable support in the complex clinical everyday practice for achieving these objectives. At the same time, the guidelines lead to an increased overall workload, as new guidelines more often add tasks than remove existing ones, including more extensive investigations and treatments for various conditions. The increased workload negatively affects physicians’ ability to make well-considered medical decisions and worsens their working environment. The downside of overly extensive investigations is also that healthy patients undergo medical examinations unnecessarily, healthcare costs increase, and patients who are truly ill have to wait longer for investigation and care. Another aspect that emerged was that guidelines in the form of care agreements that define the responsibilities of each healthcare setting were considered to reduce flexibility and impair collaboration between doctors.
The second field of tension is the tension between the measurable knowledge that guidelines most often emphasize and the unmeasurable knowledge that is considerably more difficult to capture in guidelines. Examples of unmeasurable knowledge that GPs use daily in their encounters with patients include clinical intuition and, by using a holistic perspective, taking the patient’s entire life situation into account in the assessment. Other examples include supporting behavioral changes and fostering patient acceptance to improve their quality of life. Unmeasurable practical knowledge is also needed to manage complex situations where knowledge from guidelines is difficult to apply, such as patients with diffuse symptoms or patients with multimorbidity. An excessive focus on measurable knowledge risks displacing unmeasurable knowledge and hindering its development.
The third field of tension is the tension between the high value that GPs place on their own professional autonomy in relation to the guidelines, and factors encouraging them to relinquish this autonomy even if in the specific situation it may not be in the patient’s best interest. Such factors include the perception that following guidelines is a duty, as well as the expectation that adherence will result in less demanding work and a reduced personal responsibility. The interviews provided examples of how uncritical adherence to guidelines can worsen patient care. At the same time, an important purpose of clinical guidelines is to protect patients from incompetent physicians and bad practice, which was also emphasized in the interviews and highlights the complexity of this field of tension.
In summary, management control through guidelines creates various fields of tension that pose challenges in the daily work of GPs. Since the trend toward more numerous and complex guidelines is natural in a healthcare system that focuses strongly on measurable outcomes, it is important for healthcare decision-makers and guideline developers to acknowledge its potential side effects and to address its ethical dimensions. The normative question of the extent to which GPs should be allowed to exercise their professional autonomy in relation to guidelines is also important to consider.
Written by…
Jens Lundegård, PhD student at the Centre for Research Ethics & Bioethics and specialist in family medicine.
Lundegård, J., Grauman, Å., Juth, N. et al. General practitioners and management control through guidelines: a qualitative study of its effects on their practice. BMC Primary Care (2026). https://doi.org/10.1186/s12875-025-03171-8
We have a clinical perspective
Hi,
Thank you for sharing your work. It’s an important question, especially today when we know a lot more about how to treat ailments effectively. It would be great if doctors took an individualized approach with patients who are interested in trying alternative medicine that has been around for centuries, rather than defaulting to medicines that often cause more harm than good (natural thyroid medication, blood thinners, anti-inflammatories, etc.). I am uncertain why GPs do not engage in case studies with patients who are proactive in their care, have done the research, and find that alternative medicines help. I’d send them home with a notebook and have them document what they are taking, the time, vitals, meds taken, and what they ate and drank for the day. It stops being anecdotal evidence if there is a method in place and others using the same method corroborate the findings. Some doctors engage in fishing expeditions, and others are led by existing research, practices abroad, clinical judgment, and rational reasoning.
To what extent should GPs be allowed to exercise their professional autonomy in relation to clinical guidelines?
To the extent that the guidelines prevent them from effectively treating their patients, provided their alternative approach is highly unlikely to cause harm and is supported by sound reasoning, alternative research, clinical judgment, or common sense.
Consider an example where guidelines fail patients. At more than 10 hospitals across multiple states, the standard protocol for repositioning an immobile patient is to place them in the supine position in bed. This appears to be the universal position taught to nurses and aides. This is a problem.
It may sound critical, but it’s true: clinicians and staff at these hospitals seem to lack basic medical common sense. For one, patients with motility issues—including those with PEG tubes, congestive heart failure (CHF), or pulmonary edema—should not be placed in a supine position shortly after eating, or at all in certain cases. This is especially concerning during continuous PEG feeding and in patients with CHF with pulmonary edema. Yet doctors, nurses, and hospital administrators have failed to develop or adopt guidelines for these populations. Instead, they default to an antiquated, one-size-fits-all approach, ignoring the need for purposive sampling or individualized care for vulnerable groups.
This guideline is not without serious consequences. Positioning these patients supine can trigger a chain of physiological events that may lead to myocardial infarction in those with CHF and/or pulmonary edema, and increase aspiration risk.
When adverse events occur, hospitals and liability teams often generate creative explanations to avoid responsibility rather than reexamine flawed protocols. But then again, neoliberal are known for their support for population control (eugenics, abortion-under the guise of women’s rights, contraceptives-to control the reproduction of certain classes of people, human experiments here and abroad, endless wars, alternative lifestyle under the guise of democracy, reproduction-altering pesticides, devaluation of classes of people based on political cleavage, ineffective vaccines that do not eliminate likelihood or lower the risk of contagion low enough or hospitalization, lab made meat, etc. Unlike the culture in your country, the unspoken truth is that death, disease, drinking, drugs, and debauchery are good for the economy.
Another example involves patients with thyroid disease who are on medications that can cause hypertension, hypotension, or atrial fibrillation (tachycardia or bradycardia). Rather than treating the patient holistically, an endocrinologist may refer them to a cardiologist, who also fails to consider the underlying thyroid condition. Both may treat the cardiac symptoms without recognizing they stem from thyroid dysfunction or medication imbalance. They are quick to prescribe two more medications that are bound to make things worse, instead of finding the root of the problem and resolving it. This also comes at a cost to the patient’s health and well-being, as well as to the increasing cost of healthcare. Specialization should not mean siloing, but when a cardiologist or endocrinologist lacks understanding of how one disease affects another, that’s not just a knowledge gap. It’s incompetence. It’s gross negligence.
Thank you for this clear and important analysis of how management control through guidelines creates complex challenges for general practitioners. Your discussion highlights real tensions between professional autonomy and standardized expectations in healthcare. To build on this, it could be useful to explore potential strategies that balance evidence-based guidelines with contextual clinical judgment—such as adaptive implementation frameworks or clinician-led refinements of guideline criteria. This would help readers understand not only the challenges but also possible ways to navigate them in practice.