Practice Guidelines: A Clinician's Perspective

As a busy internist who tries to keep up with current literature, I have always been dismayed at the general acceptance and even promotion of published practice guidelines by the scientific community. As anyone who reads and actually sees patients knows, guidelines are woefully outdated by the time they are published because they are always a compromise based on dated literature. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) is a perfect example. Therefore, I feel that practice guidelines should be viewed by the medical community only as advice to be considered in the context of the information that has been acquired since the guidelines were conceived.

---- John Howard, MD
Owensboro, Ky

I fully agree with you. In medicine's pre-scientific era, a physician was considered learned if he was able to quote authorities like Aristotle and Galen. Now, it appears, one again is learned if one is able to quote-and follow the instructions of-authorities. Although these authorities are generally well intentioned and scholarly, the evidence on which they base their dicta-as we have seen so clearly in the past few decades (PSA screening, hormone replacement therapy for menopausal women, pulmonary artery lines, and so on)-is necessarily transient and often flawed. That is the nature of science. However, it also reflects the influence of the absence or partial publishing of clinical studies, conflicts of interest, and the authorities' emotional "investment in the truth" of what they themselves may have generated in the papers and chapters by which they rose to their prominence.

There are no easy answers that apply to the mythical "everyone," desirable as such answers might be. Guidelines are for disease states (congestive heart failure, diabetes), not for the individual who has the disease. Each proposed guideline must be scrutinized by the practitioner for 2 essential qualities:

• Is it valid? Does it make sense based on knowledge, analysis, experience, and a weighing of conflicting reports?
• Does it make sense for this individual patient, known to the practitioner (but not to the authorities)?

To apply even the best science by rote to an unknown individual in all his or her rich complexity is akin to plating bacteria on an unknown culture medium. It is not good science, and it is certainly not good art.

---- Faith T. Fitzgerald, MD
Professor of Internal Medicine
Associate Dean of Humanities and Bioethics
University of California,
Davis School of Medicine