greater inequity in resource use. In particular, many physicians, especially those longer in practice, see guidelines as a challenge to clinical judgment and resist them as a threat to the most fundamental element of professional autonomy.

Recent public attention notwithstanding, guidelines are not new. Professional organizations have been developing guidelines for at least half a century, and recommendations about appropriate care can be found in ancient writings (Chassin, 1988). What is new is the emphasis on systematic, evidence-based guidelines and the interest in processes, structures, and incentives that support the effective use and evaluation of such guidelines.

Carefully developed guidelines for clinical practice can become part of the fabric of health care in this country and serve as important tools for many desirable changes. Their potential reach extends from improving the quality of clinical care (and its measurement) to helping to reduce the financial costs of inappropriate, unnecessary, or dangerous care. Practice guidelines are among the building blocks for informed patient decision making and rational social judgments about what care should be covered by public and private health benefit plans.

To the extent that guidelines provide well-argued translations of scientific research and expert judgment framed as statements about appropriate care, they will be more readily accepted by many kinds of decision makers. Such acceptance in the domains of physician practice, health education, quality assurance, medical liability, cost management, and elsewhere will provide mutually reinforcing support for the application and improvement of practice guidelines. Guidelines are not the solution to the country's health care problems, but they do have a significant, useful role to play.

As tools and building blocks for positive change, guidelines need to be understood and encouraged in context. That context includes powerful economic interests; changing and sometimes conflicting attitudes about professional and patient autonomy; policy making and implementing institutions that are intensely stressed and sometimes incapacitated; and scientific research that simultaneously expands both knowledge and uncertainty. Above all, the context in which guidelines will be used includes the complex, intimate relationship between individual patients and practitioners who are trying to protect health, manage illness, and preserve dignity under conditions that range from routine to desperate.

Also relevant are other strategies or forces for change that have their own challenges and uneven pace. Better clinical and outcomes research cannot produce results quickly, but the knowledge such studies generate will both strengthen guidelines over the longer term and build structures and processes for more constructive monitoring and feedback of information on performance to clinicians, managers, and others. Generational change, which obviously takes time, should lead to some greater acceptance of standardized, science-based guidelines as it brings to the fore practitioners,



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