The clinical practice guidelines (CPGs) are de ned by Field as “the collection
of systematically developed recommendations to assist practitioners
and patient decisions about appropriate health care to resolve a clinical
problem in speci c circumstances” (1). It fundamental purpose is to offer
recommendations to the physician, based on scienti c evidence, to resolve
problems that he/she has to face every day when treating the patients.
These recommendations are a framework that provides the physician with
the best available evidence to perform a better clinical practice, to make
clinical decisions and to offer the patient an appropriate treatment.
The CPGs are documents in which speci c questions are made, the
best scienti c evidences are organized and  exible recommendations are
given. Their objectives are to improve the clinical practice, to educate
doctors and their patients, to reduce professional variability and to improve
patient care and, accordingly, the population’s health is improved
(2). On the other hand, the systematic way in which the CPGs are made
facilitates its critical revision, avoids errors, resolves controversies, and
provides useful information.
There are different types of CPGs, based on consensus, on experts’
opinion and on evidence-based medicine, very much in fashion just now.
In this type of CPGs, the methodology used is systematic, explicit and
reproducible, and follows a series of steps, from the asking of questions,
the search, evaluation and synthesis of literature (evidence) to the drawing
up of useful recommendations for clinical practice.
On the other hand, some situations have been outlined where it is
recommendable to develop and have a CPG (3,4,5):
When there is a big variability and/or uncertainty in the approach to
some entity.
When there is no consensus for the management of an entity.
• When there are clinical problems or situations of high social or economic
impact.
• When an appropriate practice signi cantly reduce the morbidity and
mortality produced by a disease.
• When the diagnostic tests or treatments produce adverse effects or
unnecessary costs.
On the other hand, CPGs do present some dif culties:
• They are expensive to make, because following the evidence-based
guidelines in medicine not only requires a great effort, but also the
availability of specialized groups.
• Some times they do not provide the answer to the questions asked,
they do not have the best evidences or may require some local adaptation.
• They require continuous up-dating.
Now, making a comparison, the CPGs provide the physician with  ight
coordinates, within which he/she has a wide maneuverability, depending
on the patient’s characteristics, the type of problem occurring, the availability
of treatments, the experience, etc. All this leads to characterizing
the physician-patient relationship.
The CPGs have not been, or are, conceived as strict and speci c management
protocols (it is to be remembered that protocols are rigid criteria
outlining the management steps for a single clinical condition); neither
are they strategies to obtain treatment costs (it would be dif cult to do so,
given the multiple  ight routes that may be developed within the CPGs),
and much less they are strategies to penalize ( ne) the physicians or to
de ne whether the medical conduct is ethical or not.
As to these two last features ( nes and ethical reasons), the pretensions
in Decree 131, January 21st. 2010 (Social Emergency) are inadmissible,
suggesting a total ignorance by the government bodies regarding the scope
and purpose of the CPGs.
This is re ected in the drafting of the regulatory decrees. For example,
in the use of the words guides, protocols, standards, technical norms and
medical doctrine (de ned as a “set of conclusive concepts and recommendations
based on the analysis of the scienti c evidence”) there is lack of
word clarity and a mixture of concepts, objectives and scope that only
betrays a terrible ignorance in this matter.
Now, pretending that a CPG should serve a mean to  ne or not a
colleague is ridiculous, and really shows not only the ignorance in the
subject, but also the deviation from the CPG’s purposes. Furthermore,
to bring into the sphere of ethics a matter that is the competence of the
quality committees leads to confusion of roles and of the CPGs’ reasons
for being.
Finally, we can only hope that by the time this editorial is read, the
Constitutional Courts has declared the Social Emergency decree unconstitutional
and that this misstep, to a great cost for the Colombian people,
has served, paradoxically, to join us together around our professional and
our patients’ interests.