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Can Fam Physician. 2010 June; 56(6): e207.
PMCID: PMC2902957

Rebuttal: Can family physicians practise good medicine without following clinical practice guidelines?

David Gass, MD CCFP FCFP

While my colleague invokes Sir William Osler in defense of practice without following clinical practice guidelines (CPGs), Dr Osler was himself an agent of change toward evidence-based medicine. His admonitions to attend carefully to the facts of the case and observe its course in detail began the work that has led to a scientific basis of medicine today. His seminal text, The Principles and Practice of Medicine, was founded on careful observation and description of the natural history of disease and a sceptical approach to many historical therapies. His attentions to observation in both the specific case and in the natural history of common illness have led to the preeminence of the scientific method within the practice of medicine. His text was first among many to provide guidance to his colleagues, much as physicians turn to CPGs today. He was known to say that “He who studies medicine without books sails an uncharted sea.”

Dr Upshur suggests that the fact that CPGs are silent with respect to the management of some clinical problems means that they cannot be of any use in practice even for problems to which they are relevant. Interestingly this argument is followed by a suggestion that there are too many guidelines. While this complicates the selection of appropriate guidelines and disappoints those who might expect guidelines to address all situations, it does not remove their basic utility where they have application. They can be an efficient summary of an even greater domain of primary research literature that informs and supports excellent family practice.

My colleague suggests that CPGs have become the “instantiation” of good medical practice. I had to look that word up to be sure of its meaning. It suggests that practitioners will mistake these guidelines for the practice of medicine itself, the philosophical error of mistaking the menu for the meal. Practitioners, who know their patients, will not mistake these guidelines for the specific clinical decisions they make with their patients in the context of individual cases. The same wisdom that allows them to discern where evidence-based guidelines should be applied will prevent this mistake. They will continue to be grateful, as Osler’s colleagues were in his time, for the scientific information available through CPGs that is based on careful observation of many cases over time, which will ensure that they are offering proven advice to their patients.


Competing interests

None declared

Cet article se trouve aussi en français à la page e209.

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]).

Articles from Canadian Family Physician are provided here courtesy of College of Family Physicians of Canada