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

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Canadian Family PhysicianLe Médecin de famille canadien Vol 56: june • juin 2010

Debates

I

n many ways, Dr Gass and I are not in opposition.

What I fail to find in Dr Gass’ arguments is any- thing that convinces me that clinical practice guide- lines (CPGs) achieve the goals he claims they do. I found myself nodding my head in agreement with his observa- tions 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 circum- stances.”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, particu- larly at the level of treatment recommendations, actually introduces opacity. Clinical practice guidelines do little to secure consistency in the use of common nomencla- ture for rating the strength of evidence or the treatment recommendations. Even the GRADE and AGREE initia- tives 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 con- clude that CPGs provide limited quantitative information

on benefits and harms and therefore cannot be effec- tively used by clinicians to inform decision making.

Another study of CPGs indicates that many such guidelines are not evidence-based in the sense under- stood by Dr Gass. In fact, only 11% of the recommenda- tions 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 con- siderable 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.

Dr Upshur is Director of the Primary Care Research Unit, Director of the University of Toronto Joint Centre for Bioethics, Canada Research Chair in Primary Care Research, and a Professor in the Department of Family and Community Medicine at the University of Toronto in Ontario.

Competing interests None declared Correspondence

Dr Ross E.G. Upshur, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, E3-49, Toronto, ON M4N 3M5; telephone 416 480-4753; fax 416 480-4536;

e-mail ross.upshur@sunnybrook.ca References

1. Hutchinson A, Baker R, editors. Making use of guidelines in clinical practice.

Abingdon, UK: Medical Press Ltd; 1999.

2. Pardell H; Fundació Educación Medica, editors. The physician of the future. El metge del future. Barcelona, Spain: Fundació Educación Medica;

2009. Available from: http://symposium.medicine.dal.ca/documents/

FundacionEducacionMedica-ThePhysicianoftheFuture.pdf. Accessed 2009 Nov 28.

3. McCormack JP, Loewen P. Adding “value” to clinical practice guidelines.

Can Fam Physician 2007;53:1326-27. Available from: www.cfp.ca/cgi/

reprint/53/8/1326. Accessed 2010 Apr 29.

4. Tricoci P, Allen J, Kramer J, Califf RM, Smith SC Jr. Scientific evidence under- lying the ACC/AHA clinical practice guidelines JAMA 2009;301(8):831-41.

5. Kryworuchko J, Stacey D, Bai N, Graham I. Twelve years of clinical practice guideline development, dissemination and evaluation in Canada (1994 to 2005). Implement Sci 2009;4:49.

6. Mavriplis C, Theriault G. The periodic health examination. A compari- son of United States and Canadian recommendations. Can Fam Physician 2006;52:58-63.

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]).

Ross E.G. Upshur YES

MD MSc CCFP FRCPC

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

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