Full text of DOI:10.1017/S0266462300103022

International Journal of Technology Assessment in Health Care, 16:4 (2000), 957–958.
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Copyright 2000 Cambridge University Press. Printed in the U.S.A.
INTRODUCTION: PRACTICE
GUIDELINES
Helpful Aids or Paradigm Shift?
J. Jaime Caro
Caro Research and McGill University
The profusion of clinical practice guidelines has been remarked on by many (3;6;8) and
ascribed to a need to address the wide geographic differences in practice documented in the
last quarter century (9;10), as well as to the increasing concern with the cost of health care.
The idea is that guidelines, by outlining efficient care strategies, will enhance the quality
of care and reduce unnecessary or unproductive expenditures. Others hold that guidelines
are simply a means of transferring the results of research from the literature to clinicians
(2;5). A darker view of guidelines sees them as instruments of control of medical practice
by uncaring administrators concerned solely with cost reduction (4;7).
There is an alternative, however, that has received less attention. Perhaps guidelines are
the first step in a change in the paradigm of medical practice—from that of an individual
physician as artful autonomous arbiter of the course of action to that of a practitioner of a
learned profession concerned simply with implementing the standards of practice. In the
still prevalent paradigm, each patient is unique and so too is the presenting problem. Thus,
the patient and the problem are thought not to be readily amenable to norms of care. The
physician is viewed as a scientist required to embark upon a process of discovery of the
“right” diagnosis and the “best” treatment, generating hypotheses and testing them based
on knowledge of the “basic sciences” coupled with ingenuity. The alternative paradigm
is that medicine, like other professions, faces recurrent problems that are alike and thus
should be handled in the same way. The physician, from this perspective, is required to
recognize the type of problem and then enact the proper, predefined steps to achieve an
expected result. In doing so, the physician faces no requirement to understand the evidence
that supports the recipe, much less any pathophysiology, biochemistry, genetics, and so
on that may underlie it. Viewed this way, medical practice is not just aided by guidelines,
it demands them for professionalism—and these standards come not from practitioners
but from a cadre of nonpractitioners who are skilled in the required disciplines such as
epidemiology, biostatistics, and modeling.
The authors of the papers in this section were asked to consider how clinical practice
guidelines will affect the practice of medicine and the role of doctors in the 21st century.
Will respect for the individual doctor’s independence in diagnosis and treatment continue
or will doctors be forced to adopt a more “cookie cutter” approach regulated by guidelines?
What will be the impact of widespread access to guidelines through computer technology?
The response to this request is reflected in the papers in this issue, which cover a wide
spectrum of topics. Included are the cognitive, ethical, economic, and social assumptions
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underlying guidelines (Garfield, Giacomini, McGuire, O’Brien); the requirements for de-
veloping a guideline that will be accepted by a medical specialty society (Connis); the
methods of appraising guidelines, measuring their effectiveness, and addressing their qual-
ity (AGREE Collaborative Group, Graham, Marshall); and ways of encouraging imple-
mentation and adherence (Garfield, Marshall, O’Brien). This broad swath across the cur-
rent guidelines scene shows that the movement is still far from taking over the practice
of medicine. While many guidelines are promulgated and some may be put into practice
(Browman, Durieux, Garfield, O’Brien), they do not yet dictate most practice even within
an HMO (Richman), and it is not clear that in their present form they will have the power to
do so. Nevertheless, the situation in France may be a harbinger of central control of practice
(Durieux).
After a decade or more of enthusiasm, guidelines seem to have more of a presence
in academia, journals, and professional societies than in everyday clinical practice. A re-
cent extensive review of the literature (1) identified a framework of barriers that prevent
physicians from following guidelines—the majority related to physician attitude. Thus,
widespread use of guidelines requires changing the physician’s beliefs, through either per-
suasion or coercion. Medicine is taught both academically and in an apprentice system.
Perhaps as the current teachers, steeped in medical autonomy, are replaced, a generation of
young doctors will emerge who view guidelines not as useful suggestions but as an inherent,
indeed central, normative component of professional practice.
Paradigm change or helpful aids? Even after examining these 10 articles written from
very different perspectives, we find that the questions with which we approached this special
issue of the Journal remain. The answers won’t be found until the third generation hence,
our professional grandchildren, starts practice.
REFERENCES
1. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines?
A framework for improvement. JAMA. 1999;282:1458-1465.
2. Cook DJ, Greengold NL, Ellrodt AG, Weingarten SR. The relation between systematic reviews
and practice guidelines. Ann Intern Med. 1997;127:210-216.
3. Grilli R, Magrini N, Penna A, Mura G, Liberati A. Practice guidelines developed by specialty
societies: The need for a critical appraisal. Lancet. 2000;355:103-106.
4. Korcok M. Medical-management guidelines being developed with a vengeance in US. Can Med
Assoc J. 1994;151:1625-1627.
5. Leape LL. Practice guidelines and standards: An overview. Qual Rev Bull. 1990; February:42-49.
6. Lohr KN. Guidelines for clinical practice: Applications for primary care. Int J Qual Health Care.
1994;6:17-25.
7. Naditch MP. Practice guidelines and the emperor’s new clothes. Journal of Healthcare Resource
Management. 1995; December:24-27.
8. Shaneyfelt TM, Mayo-Smith MF, Rothwangl J. Are guidelines following guidelines? The method-
ological quality of clinical practice guidelines in the peer-reviewed medical literature. JAMA.
1999;281:1900-1905.
9. Welch WP, Miller ME, Welch HG, Fisher ES, Wennberg JE. Geographic variation in expenditures
for physicians’ services in the United States. N Engl J Med. 1993;328:621-627.
10. Wennberg J, Gittelsohn A. Variations in medical care among small areas. Sci Am Med.
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INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 16:4, 2000