JUDITH WILSON ROSS
Texts in Search of Authority
Practice guidelines are both a well-established medical practice and a new phenomenon. Although general rules about how to proceed when practicing the art of medicine have a long history, the rigorous formulation of such guidelines is something new. One hope for guidelines, in the face of extensive practice variations observed twenty years ago by Wennberg, was that medical practice could be made more rational and scientific. A more scientific medicine would also produce a more professional medicine. Patients could be more confident that similar illnesses would be diagnosed and treated similarly, regardless of where they received their treatment. Guidelines have also been seen as a way of reducing health care costs because reliance on these more scientific guidelines would eliminate what was thought to be extensive inappropriate treatment provision.
All three of these hopes may prove unfounded. Research data are often inadequate or nonexistent, and thus cannot be used to create a scientific medical practice. Even among those treatments and conditions that have been well studied, research methodologies are flawed or inconsistent; randomized clinical trials—the gold standard—are hard to find. Thus, uncertainty remains. The hope that a more rational medicine would bolster professional values has also been problematic, as physicians have been reluctant to listen to others' views in the face of a history that treated them as individual entrepreneurs and (near) final arbiters of what treatment should be provided to patients. Last, the hope that guidelines would reduce costs by eliminating inappropriate treatment has had to be reconsidered. The practice variations literature has not led to the expected conclusion that variations result from overuse. Indeed, the source of variation remains somewhat mysterious. 1 It is clear, however, that implementation of guidelines might result in increased treatment and associated costs because it would remedy extensive underuse of some treatment, in addition to overuse.