ditures for inappropriate and unnecessary services, and increase the value received for this country's spending on personal health care. Individual and organizational behavior are amenable to change; progress is possible. Nothing in the course of this project fundamentally undermined this assumption.

Progress in the development and use of practice guidelines will be accompanied by continuing methodological, technical, ethical, political, attitudinal, and behavioral challenges. Perfect rationality, unswerving ethical behavior, and consistently thoughtful compliance with guidelines lie in the realm of ideals. Scientific knowledge will grow but will always be an incomplete foundation for guidelines. Concerns about costs will always be present. Practitioners and policy makers will inevitably face ethical strains as they try to balance the interests of the individual and of society.

Fortunately, the long history of professional commitment by physicians, nurses, and other clinicians to the good of their patients and to the advancement of clinical knowledge is a critical resource for both the development and implementation of practice guidelines. Public commitment to the support of research and training is another essential component of progress.

As a working principle, the committee accepted that its recommendations must be sensitive to the country's strong tradition of pluralism, despite some negative aspects of that tradition (to be noted shortly). Strong political and cultural traditions favor shared roles and responsibilities for the private and public sectors, although the general inclination is to favor private over public initiative.

GENERAL STRENGTHS AND WEAKNESSES OF CURRENT PRACTICE GUIDELINES ACTIVITIES

Efforts to develop practice guidelines can be characterized, somewhat simplistically, as long-standing or embryonic. Many professional and provider organizations have for many years been creating and applying what they construe to be practice guidelines; for them, guidelines development and implementation is not new. Others focus primarily on "modern" efforts to develop guidelines, which they see as dating back only a decade or so. In either formulation, strong and weak points stand out; they must be understood and either built on or overcome as efforts to develop and apply guidelines push forward.

One caution: it is usually easier to spot problems than successes. The committee notes the limitations and problems in a spirit of identifying opportunities for progress. It hopes that this attitude will help to encourage those interested in better development, use, and evaluation of guidelines. Ultimately, this committee is confident that the history of clinical practice guidelines will be a positive one.



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