Practice guidelines and cookbook medicine--who are the cooks?

In in era of managed competition, cost-elective medical care becomes a major goal of any health care delivery system. Such a system will generate practice guidelines to accomplish this goal . For example, in our own medical center, the Division of General Internal Medicine has just written guidelines on the proper use of echocardiography in their prepaid and health care populations . Other guidelines are being developed for other diagnostic techniques . On a larger scale, many organizations are developing practice guidelines or position statements on a whole variety of issues. The ACC/AHA Task Force on Cardiovascular Procedures has published a number of influential practice guidelines. Currently, it is working on revising the guidelines on radionuclide imaging and clinical intracardiac electrophysiologic studies and is developing two new onesmanagement of heart failure and cardiovascular evaluation for noncardiac surgery . The ACP/ACCIAHA Task Force on Clinical Privileges in Cardiology is completing three clinical competence statements: Clinical Competence in Invasive Cardiac Electrophysiologic Studies, Competence in Electrocardiography and Clinical Competence in Permanent Pacemaker Implantation. Such statements will have an enormous impact on the practice of cardiology, as, for example, the recent declaration that interventional cardiologists must perform a minimum of 75 procedures/year (1) . At the present time, there are also eight position statements and one policy statement under development by ACC committees . At the March 1994 annual meeting of the ACC, another clinical practice guideline was unveiled to the press and the public: Unstable Angina : Diagnosis and Management . This report was released by the Agency for Health Care Policy Research (AHCPR) and the National Heart, Lung, and Blood institute (NHLBI), both components of the Public Health Service . The guidelines were put together by 19