Suggestions Provided and Issues Raised by Receptivity While a little more than half of the society and medical association spokespersons reported that physicians predominantly favored guidelines for the reasons discussed in appendix II, representatives spoke of reservations, wariness, resignation, or in three cases, negativism. Opinions and concerns included the following. Physicians already practice good medicine and do not need any help. Information is in textbooks, and existing material is adequate. To say that guidelines are needed implies that physicians are not practicing the best medicine. Guidelines will eliminate autonomy. Guidelines might not be effective. Some physicians are opposed to any kinds of rules or regulations. Guidelines could be improperly written by people who do not understand medicine and who will try to "massage numbers" instead of assessing actual patient outcomes and satisfaction. Guidelines cannot incorporate the many different thought processes used in making diagnoses. Guidelines would be too limiting and, thus, may be harmful to patients if a "cookbook" approach to medicine is adopted. If guidelines are too explicit, physicians will not think about what they are doing. Academicians may create guidelines with unrealistic expectations of available resources (for example, requiring facilities or equipment to which some physicians may not have access). Such guidelines could prevent some physicians from practicing. Guidelines could be used to establish criteria that might be applied unreasonably against physicians in litigation. As we have seen, those medical specialty societies participating in our Suggestions Provided and Issues Raised by the development process. Another representative said that in order to promote receptivity, her society's development committee is taking great care to produce a high-quality, credible initial set of guidelines. Medical society representatives emphasized that their societies are educational, not policing, organizations. Persons we spoke with said that while some behavioral change can be expected from physicians who embrace guidelines because of a desire to practice good medicine, compliance will likely be achieved primarily through the influence of residency training programs, physician licensing and certifying boards, third-party payers, health care regulators, peer review and quality assurance organizations, society self-assessment programs, ⚫ courts and arbitrators, and disciplinary boards. Public Law 101-239 provides that the AHCPR "shall conduct and support evaluations" of the extent to which guidelines developed through the Agency's program have an effect on the clinical practice of medicine. Exactly how such evaluations should proceed is not clear. The AMA, in a report on practice guidelines, argues that "While better patient care is the primary benefit that is expected to result from parameters, there are strong indications that the development and implementation of parameters will facilitate benefits in other areas, such as the improved use of resources, reductions in liability exposure, and improvement of review criteria."1 As this statement makes clear, there are many areas that can be influenced by guidelines. Thus, evaluations that restrict themselves to one outcome (for example, mortality statistics) will necessarily provide a limited picture of the true impact of any guideline. Persons from four societies indicated interest in, or plans to conduct, surveys to assess the impact of guidelines developed by their societies. Others spoke of the need for such studies, but said that their societies "Practice Parameters," Report EE of the American Medical Association Board of Trustees, adopted by the House of Delegates of the AMA, Dec. 1989. Suggestions Provided and Issues Raised by Questions and Questions About Guideline Development lacked the funds, and therefore studies are not planned. Representatives suggested alternative organizations as potential sponsors of impact studies: the federal government, consumer groups, hospital quality assurance or other review groups, and insurers. Since there is no uniform definition, a basic question is, "What are guidelines?" The following questions about guidelines were also raised by society representatives. Cross-Specialty Concerns How can guidelines be sufficiently definitive without inhibiting valuable innovation either directly or indirectly through the health payment system? How can guideline development groups put controversy about medical approaches to rest, without becoming bogged down by debate in the process? How does a medical society include persons and groups outside its organization in the development process and still produce guidelines in a reasonable length of time and at reasonable cost? How can societies with broad scopes of practice best approach guideline development? It is comparatively easy for those societies with limited scopes; for others—such as one society that has 1,600 procedures that it may perform the task can be quite daunting. In appendix II, we noted that some medical societies involve others in guideline development, and some issue joint guidelines. Coordination thus occurs for specific topics; however, society representatives point to a need for an effective, objective clearinghouse to orchestrate guideline development nationwide. They indicated that such an organization is needed to coordinate, integrate, avoid duplication, and achieve a degree of standardization of effort among societies. As one person stated, such leadership would help prevent societies from developing guidelines in a vacuum. Several society representatives spoke of cross-specialty conflicts. One society published guidelines in 1989 to counter the negative impacts on its members of decisions by liability insurers based on the more limiting guidelines published by another society. Other persons spoke of past or potential disagreements with other societies. In some cases, societies see Suggestions Provided and Issues Raised by a need to monitor guideline activities of other organizations to try to counter or preempt guidelines that could adversely affect their members. Representatives spoke of the need, ultimately, to address a broader concern: how leadership will be determined for disease conditions that span several specialties. For example, which physician should lead the potential team of family physician, internist, surgeon, radiation oncologist, and medical oncologist that might diagnose, treat, and follow a breast cancer patient? Society representatives indicated that cross-specialty concerns are difficult to address, but they are important to ensuring that guidelines promote high-quality patient care. Appendix IV Medical Organizations Participating in This Study American Academy of Allergy and Immunology American Academy of Child and Adolescent Psychiatry American Academy of Dermatology American Academy of Family Physicians American Academy of Neurology American Academy of Ophthalmology American Academy of Orthopaedic Surgeons American Academy of Otolaryngology - Head and Neck Surgery, Inc. American Academy of Pediatrics American Academy of Physical Medicine and Rehabilitation American Association of Electrodiagnostic Medicine American Association of Neurological Surgeons American College of Cardiology American College of Emergency Physicians American College of Obstetricians and Gynecologists American College of Physicians American College of Preventive Medicine American College of Radiology American College of Rheumatology American Medical Association American Society of Anesthesiologists American Society of Clinical Pathologists American Society of Dermatologic Surgeons American Society for Gastrointestinal Endoscopy American Society of Plastic and Reconstructive Surgeons American Society for Surgery of the Hand American Urological Association, Inc. Council of Medical Specialty Societies Society of Nuclear Medicine |