Clinicians make judgments under conditions of uncertainty. Decision
research has shown that
in uncertain situations individuals do not always act rationally, coherently,
or to maximize their
expected utility. Advocates of clinical guidelines believe that these guidelines
will eliminate some of the
cognitive biases that the practitioner may introduce into the medical
decision-making process in
an attempt to reduce its uncertainty. Other physicians have grave doubts about
guidelines'
application in practice. Guideline implementation lags well behind their
development. Studies
of practicing physicians and a survey of clinicians in one specialty and setting
indicate that
experienced clinicians may be implementing guidelines selectively. Many
clinicians are
concerned that guidelines are based on randomized trials and do not reflect the
complexity of the
real world, in which a decision's context and framework are important. Their
reluctance also
may be due to the difficulty 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 more patient-specific
therapies and need to
exercise more sophisticated clinical judgment. They may be more willing to use
guidelines in
making those judgments if research can demonstrate guidelines' effectiveness in
improving
decision making for individual patients.