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Practice guidelines and the practice of medicine: is it the end of clinical judgment and expertise?

Clinical practice guidelines are an increasing part of efforts to improve the quality and reduce the cost of health care. They are recommendations for the evidence-based care of average patients, not rules for all patients. At best they are developed by panels representing a wide array of expertise and experience related to the clinical question, are based on comprehensive, critical review of scientific evidence, make clear how value judgments affect recommendations, and take into account all of the issues bearing on clinical decisions, such as effectiveness, risk, convenience, cost, cost-effectiveness, and the resources needed to carry out the recommendations. Physicians have a mixed opinion of guidelines, believing they are both useful summaries to improve the quality of care and potential tools to judge and control them. Although guidelines may point out the best research evidence to guide the care of average patients, they are not a substitute for clinical judgment, which should be applied to each individual patient.