Variation in physicians' definitions of the competent parent and other barriers to guideline adherence: the case of pediatric minor head injury management

A lack of consensus regarding the definition of even an everyday term can affect physician adherence to clinical guidelines using that term. We demonstrate this by taking, as an illustrative case, the American Academy of Pediatrics' minor head injury (MHI) management guidelines, which generally recommend at-home observation by a "competent" parent (or the equivalent). The recommendation assumes consensus among physicians as to what parental competence comprises. We systematically examined this assumption. Physicians associated with Children's Hospital, San Diego were mailed a survey asking them to freely list terms defining parental competence. Independent variables were: physician gender, training, specialty, practice location, patient age mix, years in practice, and number of MHI cases seen per year. Dependent variables were: free-list content and length, ease and style of competence decision-making style (e.g., independent or collaborative), familiarity with the guidelines, and likelihood of ordering a computed tomography (CT) scan. Of 112 respondents, 34 (30%) were "not at all" or only "slightly" familiar with the guidelines; 23% (21/112) "frequently" or "sometimes" ordered CTs when the guidelines did not support this. Surgeons were more likely to order discretionary CTs. Office-based, pediatric-trained, and female physicians each found it significantly easier than their counterparts to determine which parents were, in their opinion, competent. Men reported using "objective" criteria significantly less frequently than women. A total of 64 discrete criteria were listed. Individual lists contained an average of 6.5 items. Surgeon's lists were significantly shorter than those of medical physicians. Seven sub-domains of competence were identified. Parental competence is not a unitary construct interpreted similarly by all physicians. Subgroups with distinct models may exist; training and specialization may be key variables. To decrease MHI management variation, guidelines should specify parental competence factors to be considered; they may need to be tailored to different physician subgroups.