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In many ways, Dr Gass and I are not in opposition. What I fail to find in Dr Gass’ arguments is anything that convinces me that clinical practice guidelines (CPGs) achieve the goals he claims they do. I found myself nodding my head in agreement with his observations about the importance of family physicians finding balance in judgment and his invocation of Sir Donald Irvine that “clinicians must retain freedom to decide with their individual patients what is best in the circumstances.”1 I completely concur with The Physician of the Future document developed in Mexico asserting that the best professionals are “not necessarily those who follow protocols and guidelines most strictly but rather those that know when and how they should deviate in their application for the benefit of a given patient.”2
Dr Gass makes several claims that overstate the value and scientific status of CPGs. He states that a transparent and collegial process to come to consensus has been used to create CPGs. He also expresses support for the translation of clinical recommendations coded by levels of evidence reflecting the rigour or credibility of researchers and their opinions. He also argues that the use of CPGs facilitates joint decision making with patients.
Here is where we part ways. To me, the introduction of consensus into the development of CPGs, particularly at the level of treatment recommendations, actually introduces opacity. Clinical practice guidelines do little to secure consistency in the use of common nomenclature for rating the strength of evidence or the treatment recommendations. Even the GRADE and AGREE initiatives have not yet solved this problem.
I think it is important that we note that there are still great deficiencies with current CPGs. McCormack and Loewen, in an analysis of 5 nationally prominent CPGs, found that sparse attention was paid to patient values or preferences for therapeutic decision making.3 They conclude that CPGs provide limited quantitative information on benefits and harms and therefore cannot be effectively used by clinicians to inform decision making.
Another study of CPGs indicates that many such guidelines are not evidence-based in the sense understood by Dr Gass. In fact, only 11% of the recommendations were based on the best evidence.4 A study of the guidelines in the CMA Infobase demonstrated that 53% of guidelines did not even grade evidence.5 Another study in Canadian Family Physician demonstrated considerable disagreement between task forces, indicating that CPGs were not consistent in their advice.6
For these reasons I believe that my original concerns are well founded: good medicine and clinical practice guidelines are not synonymous. Notwithstanding these concerns, Dr Gass and I are in fundamental agreement upon some of the qualities and characteristics of good practice.
Cet article se trouve aussi en français à la page e208.
These rebuttals are responses from the authors of the debates in the June issue (Can Fam Physician 2010;56:518–21 [Eng], 522–5 [Fr]).