The analysis by Manuel and colleagues creates controversy with headlines, not data

The recently published dyslipidemia controversy (CMAJ, April 12, 2005, Vol. 172, No.8) should be cause for some reflection on the utility of guidelines.

The back-and-forth dialogue was entirely reminiscent of what does, or should occur on a daily basis in the offices of Canada's family physiciains.

Family doctors see patients with varying values, resources, education, understanding, motivations, fears, preferences and risk- aversion.

Their task is to define treatment goals consistent with all the above attributes, and then base management on those goals.

In the ideal primary care environment this occurs. Guidelines, where available, contribute to the discussion, but should rarely themselves constitute goals (although for certain patients, practitioners and health systems, they may do so).

Just as from a population health perspective we must weigh benefit with cost and lost opportunity, so must we do with each individual. For most patients the guidelines are but one piece of the decision-making puzzle. Guidelines must inform us but should not necessarily compel us.

Similar caveats exist with some chronic desase managment strategies. They are most often disease specific, well intentioned, and championed by specialty or other interest groups. Again, within primary care, we must be circumspect in the application of such strategies, and weigh the strength of the evidence with individual applicabilitiy.

While guideline development is important, our health system will be in trouble if strict adherence to guidelines becomes the intended result, rather than the thoughtful and considered application of guidelines to management decisions.

Unfortuantely, as our primary care system comes under more and more stress, the abilitiy ot discuss treatment goals, as opposed to simply applying guidelines becomes more difficult. It is easier to titrate a drug to a guideline or lab endpoint. Furthermore, achievement of such endpoints is often easily measured, and therefore attractive to administrators. This may not, however, be best for patients when evaluated in the context of treatment goals and population outcomes and system costs.

Ultimately, therefore, the dyslipidemia debate may be somewhat specious. Patients need to know (among other things) that lower is better. Doctors need to know numbers-needed-to-treat and other kinds of relevant evidence and pharmaceutical information. Treatment decisions, however, will (and indeed, must)remain much more dynamic than simple application of guidelines. And, the system of care must support this.

Conflict of Interest:

None declared