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 t he quality and reduce the cost of health care. They are recommendations for the evidence-based care of average patients, not rules for all patients. A t 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 af fect recommendations, and take into account all of the issues bearing on cl inical decisions, such as effectiveness, risk, convenience, cost, cost-effe ctiveness, and the resources needed to carry out the recommendations. Physi cians have a mixed opinion of guidelines, believing they are both useful su mmaries to improve the quality of care and potential tools to judge and con trol 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.