EDITORIAL Practice, Malpractice, and Practice Guidelines In an admirable study in this issue of A n n a l s , Karcz and colleagues have persuasively demonstrated that economic savings can result from the use of practice guidelines, also k n o w n as practice standards, practice p a r a m e t e r s , and clinical policies. W h i l e they address m a l p r a c t i c e c o s t s that could also be controlled through appropriate tort reform, they join others who suggest that these savings can accrue even as quality of care improves. ~ Physicians substantially influence the quality and cost of medical care. z Yet as a profession, we have done little except react to i n i t i a t i v e s developed elsewhere. Implem e n t a t i o n of practice guidelines can assure that patients receive what is broadly considered b y p h y s i c i a n s to represent an adequate m i n i m u m standard of care, while providing a means, controlled by physicians, of improving the overall quality of care and incidentally reducing costs. The Standards Task Force of the A m e r i c a n College of Emergency Physicians is already hard at work developing clinical policies? But w h y should we as a profession support the d e v e l o p m e n t and i m p l e m e n t a t i o n of practice guidelines? Simply stated: If we don't, "they" will do it for us. The Conference Board reports that consumers believe that they get "poor" value for their m o n e y with hospital charges. 4 The purchasers of health care are awakening to their e n o r m o u s power and ability to infuence purc h a s i n g d e c i s i o n s , s " B u y i n g r i g h t " is an i n t e g r a l c o m p o n e n t of all proposals to reform health care in our nation; whether premised on a Canadian model or a free m a r k e t competitive model, all strategies include technology a s s e s s m e n t and other programs i n t e n d e d to assure m a x i m u m value for m o n e y expended. See related article, p 865. Some p r a c t i t i o n e r s assert that practice guidelines remove the role of clinical judgment, thus leading to "cookbook m e d i c i n e . " They argue that adherence to practice guidelines encourages a loss of a u t o n o m y and professionalism that physicians should decry. I dispute this assertion because properly developed practice guidelines serve as tools, not as specific step-by-step directions. They do n o t a u t o m a t e the physician. Rather, they assist the physician by providing i n f o r m a t i o n in a more useful, organized, and scientific m a n n e r than a practitioner is likely to obtain on his or her own. 6 Practice guidelines are not a panacea. F u n d a m e n t a l to their success is outcome assessment following application

19:8 August 1990

i n broad-based p o p u l a t i o n s . If i m p r o p e r l y f o r m u l a t e d or w i t h o u t appropriate m e c h a n i s m s for periodic review and updating, practice guidelines will become discredited. It is u n l i k e l y that practice guidelines will ever encompass all complaints and areas of practice. Lastly, they m a y fail " . . . unless account is also taken of the social forces that influence the use and abuse of clinical policies. ''7 Through practice guidelines, we may be able to achieve "... the twin goals of increased health of the A m e r i c a n public and physician satisfaction. ''s We can reinvigorate our role as patient advocate and, perhaps, thereby reverse the decline in respect the profession has undergone in rec e n t y e a r s . 9 We c a n d i m i n i s h t h e m o m e n t u m t h a t threatens to tip our profession over to a mere trade or business.LO Physician support for practice guidelines provides our profession w i t h the best o p p o r t u n i t y to take back the moral high ground while affirming the importance of our role in the ongoing n a t i o n a l debate of who controls health care and to what end that control is exerted. Stevezl / D a v i d s o n , MD, M B A , FACEP Emergerley M e d i c i n e and Pre-Hospital Care M e d i c a l College of P e n n s y l v a n i a Philadelphia

REFERENCES

1. Prospective Paymdnt Review Commission. Report to Congres~. Wash ington, DC: PPRC, March 1988, p 230. 2. EddyDM: Clinical policiesand the quality of clinical practice. N Erlg] / Med 1982i307:343ff. 3. ACEP develops 'clinical policies' Chest pain first. ACEP News 1989;8:4. 4. Asinof L: Business bulletin: A special background report on trends in industry and finance. Wall Street Jourrm] June 7, 1990. 5. McClure W: Unleashingthe potential: Current trends and future policy directions. Bull NY Acod Med 1988;64:84-100. 6. Lcape L: Are practice guidelines cookbook medicine? I Arkansas Med Soc 1989;86:73 75. 7. Dixon AS: The evolution ot clinical policies. Med Care 1990;28: 201-220. 8. Brook RH: Practice guidelinesand practicingmedicine Are they compatible? /AMA 1989;262:3027-3030. 9. Page JR: A preserition for medicine. Arm Emerg Med 1987;120-121. 10. LundbergGD: Cokmtdownto millennium - Balancingthe professionalism and business of medicine; Medicine's rocking horse, lAMA 1990~ 263:8&87.

Annals of Emergency Medicine

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