We may get this horse to water, but will it drink?

Modern medicine is practised under increasingly challenging conditions. The accelerating pace at which new information becomes available can be overwhelming. The physician is asked to function as a dual agent: to serve the patient’s interests and, at the same time, to be responsible to society (through government) for the appropriate management of limited resources. As if this weren’t enough, the structures we associate with modern medical practice are undergoing a revolution. Care is moving into the community with great speed, a change often accompanied by concerns that the foundations to support that care have not been adequately established. Against this backdrop of constant change we have the guidelines movement and its products. At first glance, guidelines appear to be the answer to everyone’s problems. They have been identified as a means to improve the quality of care and address issues of practice variation, to decrease health care costs and address issues of rationing, to deal with competition and improve access, and to promote physician autonomy and enhance patient empowerment. Quite clearly, guidelines have the potential to do a great deal — but what is the reality, and what can we expect from the new guidelines on the management of breast cancer developed by Dr. Maurice McGregor and colleagues and published as a supplement to this issue of CMAJ? The report of the National Forum on Breast Cancer noted that practice variation can make patients anxious about the care they are receiving. Practice guidelines were seen as a way to make care more consistent and, presumably, better. The new guidelines should be assessed against these objectives and against the formidable barriers, such as the need to ensure “buy-in” by professionals and to make the process “broad, participatory and continuing, with . . . regular review and evaluation.” McGregor and colleagues have done important work in compiling a comprehensive set of guidelines for the care of women with breast cancer in a manner that reflects the merit of the information on which they are based. The authors have used the levels-of-evidence approach throughout the document; in doing so, they make it clear that there are areas in which the most basic of notions have not been rigorously investigated. An example is the statement that “Smooth, welldemarcated lumps are usually benign (level IV evidence). It is useful to examine the process by which these guidelines were developed. Was it “broad, participatory and continuing”? Who was involved, and how was each guideline developed? In contrast to provincial initiatives in guideline development, this work, as mandated by the Forum, had a broad Canadian perspective. However, the participation of survivors does not appear to have been uniform from guideline to guideline. To what extent this is an issue may depend as much on the particular guideline as it does on one’s perspective on the contribution survivors make to this process and, through their “buy-in,” to the desired outcomes. Editorial