Guidelines in the Mist

The production of clinical practice guidelines to help physicians provide optimal care has to be fundamentally rethought if such guidelines are going to be beneficial. The development of practice guidelines has become a priority for policy makers in recent years. However, the authors of this paper argue that many dilemmas now faced by physicians are not amenable to being more effectively addressed by using guidelines. Clinical practice guidelines are useful where clear direction can be given to practitioners using evidence-based research. But Jonathan Lomas and John Lavis argue that most of the black or white clinical issues have now been covered by existing guidelines and what remains are strongly colored by values. Using searches of the available literature, the paper shows that up to one-third of what physicians do cannot be clearly defined as being either beneficial or harmful. This” gray zone” has been where researchers have traditionally focused their attention in attempts to make medical care more effective by showing whether the intervention is effective or not. The gray zone has become increasingly crowded with areas of medicine where the deci-sion on what to do is governed by patient preferences or judgments based on societal decisions about cost effectiveness. As an example of the type of therapy where patient preferences come into play, the paper mentions chemotherapy for node-negative breast cancer where the risk of recurrence is significantly but not hugely reduced by this treatment but there is also a significant potential for prolonged and unpleasant side-effects. Without providing information relevant to patient decision-making or incorporating explicit collective judgments on economic or ethical issues surrounding value-based decisions, the paper states, continuing the emphasis on practice guidelines will be of limited value to practitioners and patients. For this reason, it concludes, a fundamental rethinking is needed of the types of outcomes assessed in clinical trials and the way information is communicated to physicians and patients through practice guidelines.