CMAJ 1997;156:1685
© 1997 Canadian Medical Association
A great fuss is made over clinical practice guidelines. The champions of CPGs rest their enthusiasm on an impeccable logic: because wide variation between physicians in the management of similar patients is constantly observed, and because clinical standards in medicine are constantly changing, regularly maintained guidelines should allow physicians to keep up to speed with treatments of choice and ensure that patients receive the benefit of the best available evidence. Unfortunately, this does not appear to be the case. Robert Hayward and colleagues asked Canadian physicians what they thought about CPGs (page 1715). Only 52% reported that they regularly used CPGs, and most said that they preferred to obtain guidance about clinical matters from colleagues, review articles, textbooks and other traditional sources. Only 32% reported that the use of CPGs had changed their clinical practice in the last year. Clearly, the rapid proliferation of CPGs is not mirrored by their integration into day-to-day clinical practice.
From a different perspective, Graham Worrall and colleagues were able to identify only 13 studies in the world medical literature that sought to evaluate the effectiveness of CPGs in improving patient outcomes (page 1705). Only 5 of these attributed a statistically significant improvement in outcomes to the use of CPGs. In an accompanying editorial, Hayward laments this situation but suggests a solution: improving our methods of assessing the impact of guidelines (page 1725). In describing the characteristics of the ideal guideline study, Hayward points us in the right direction. Before we slosh more money at the development of CPGs, we need to ensure that our methodology for evaluating guidelines and their implementation is valid.
The floodwaters of the Red River are receding and Manitobans are mopping up. David Square describes the psychological and public-health implications of the disastrous flood of 1997 (page 1742). Although Winnipeggers are grateful that the city's flood controls and the valiant efforts of sandbaggers saved the city from a wholesale disaster, it will be some time before long-term public-health impact along the Red River Valley can be known.
Physician manpower projections are almost always wrong. (In an editorial in the next issue of CMAJ we comment on why this is so.) Nowhere has this been more apparent than for radiation oncologists. On page 1739 Pat Sullivan reports that over the next 4 years Canadian medical schools will produce roughly 120 graduates in this specialty, and that there will be work for only 70 of them. This is a tragic waste of effort and time for these young men and women. We have simply got to do better. -- JH
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