Clinical judgment and clinical practice guidelines

Clinicians make judgments under conditions of uncertainty. Decision researc h has shown that in uncertain situations individuals do not always act rati onally, coherently, or to maximize their expected utility. Advocates of cli nical guidelines believe that these guidelines will eliminate some of the c ognitive biases that the practitioner may introduce into the medical decisi on-making process in an attempt to reduce its uncertainty. Other physicians have grave doubts about guidelines' application in practice. Guideline imp lementation lags well behind their development. Studies of practicing physi cians and a survey of clinicians in one specialty and setting indicate that experienced clinicians may be implementing guidelines selectively. Many cl inicians are concerned that guidelines are based on randomized trials and d o not reflect the complexity of the real world, in which a decision's conte xt and framework are important. Their reluctance also may be due to the dif ficulty of applying general guidelines to specific clinical situations. The problem will only increase in the future. The patients of the 21st century will be older and have more complex disease states. Physicians will have m ore patient-specific therapies and need to exercise more sophisticated clin ical judgment. They may be more willing to use guidelines in making those j udgments if research can demonstrate guidelines' effectiveness in improving decision making for individual patients.