Canal Wall Up vs. Canal Wall Down: Symptom of a greater need?

Some argue that guidelines are flawed because not all patients are the same (the “cookbook medicine” argument), which is absolutely true. Appropriate flexibility should be included in the guideline implementation process. And this is exactly why it is important for practicing otolaryngologists to participate in the development of guidelines. If we do not participate, then the guidelines will be developed by those not intimately familiar with the practice of medicine. That said, we must also remember that the guidelines are based on published data and not just someone’s opinion. Nevertheless, I think common sense input is important in the process, particularly when the guideline goes through the review process.

Another important role for guidelines is to provide a method for us to self-assess and improve our performance as doctors. Basic guidelines have been in place for many years in some specialties. Reviews of the use of beta blockers after myocardial infarction and disease screening (including mammograms) permit an analysis of what we are doing well and where we need to improve. Although the outcomes have not been perfect, this type of research has resulted in vastly improved care. This concept of following analysis with practice changes to improve outcomes is at the heart of Part IV of the American Board of Otolaryngology’s Maintenance of Certification (MOC) process. It may prove impossible to have guidelines for all conditions simply because patients with those conditions are so variable or rare that guidelines will prove meaningless. Nevertheless, I believe that many, if not most, situations in otolaryngology-head and neck surgery lend themselves to guidelines.

The American Academy of Otolaryngology-Head and Neck Surgery has been very active in the development of practice guidelines. Under the leadership of Richard Rosenfeld, the Academy’s Guideline Development Task Force has worked diligently to create meaningful, validated otolaryngology guidelines. As a member of this group, I have learned a great deal about the challenges of developing guidelines. These challenges include not only time and money but also the coordination of efforts with non-otolaryngology stakeholders whose input into the development process is critical. I encourage you to visit the AAO’s Web site at http://www.entnet.org/Practice/clinicalPracticeguidelines.cfm to learn more about guidelines and their development. The Academy is seeking partners to help develop their guidelines.

As in any quality improvement program, the loop needs to be closed by determining if the guidelines make a difference not only in costs but also in patient outcomes. Hopefully, Part IV of MOC will answer this question and help refine guidelines further.