PRACTICE GUIDELINES

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The variations in the kinds of education and training for CAM practitioners, particularly unlicensed
practitioners, were discussed above. Variation in education, however, leads to variations in clinical
practice. Many CAM practitioners argue that their therapies are individualized to meet the specific needs
of each patient and that variation is good. Conventional medical practitioners also tailor therapies to
individual patients, and when practice guidelines were first proposed, many were concerned about the
negative effects of those guidelines on clinical autonomy, health care costs, and satisfaction with clinical
practice (Tunis et al., 1994). Indeed, both conventional medical and CAM practitioners would argue
strenuously against cookbook clinical practice.
Variation makes it difficult to conduct research on the efficacy or effectiveness of certain therapies
because no practice guidelines have been agreed upon. However, CAM practitioners could develop their
own practice guidelines. Such guidelines would help overcome some of the difficulties
of inappropriate practice variation in research. Practice guidelines are systematically developed
statements to assist practitioner and patient decisions about appropriate health care for specific clinical
circumstances (IOM, 1990). Ideally, good practice guidelines have eight attributes, although, as the IOM
report recognized, it is not anticipated that practice guidelines will score well on each of these attributes.
Rather, they are something to strive for. Guidelines should
be valid; when followed they result in anticipated health outcomes.
be reliable and reproducible; any group of experts would develop similar guidelines given the same
evidence and methods.
have clinical applicability; they should be inclusive of appropriately defined patients as permitted by
scientific and clinical evidence and expert judgement.
have clinical flexibility; the known or expected exceptions should be identified.
have clarity; they should be easy to follow and should use clear, unambiguous language.
be developed by using a multidisciplinary process; all key groups affected should participate.
have scheduled reviews; times for review and revision should be determined.
have documentation of the process, participants, evidence, and assumptions used for guideline
development (IOM, 1990).
Two major approaches are used to develop such guidelines. The first is an evidence-based approach. In
conventional medicineevidence consists of that obtained by Western-scientific type evaluations. Mills et al.
(2002) proposed that evidence-based CAM (EBCAM) be taught to CAM practitioners and outlined the
implications of such education (Table 8-3). They argue that, even though EBCAM is viewed negatively by
many in the CAM community, in reality it is not incompatible with the principles of holism and clinical
autonomy. Research results are only one factor that CAM practitioners consider when they make a
clinical decision. Other factors include clinical judgment and patient values. The essence of the EBCAM
process is the use of data collected on groups of patients to assist clinical judgment. However, ultimately
these data need to be transferred to the individual recognizing that it is likely the patient being examined
will differ from the average patient in the study (Wilson and Mills, 2002). What is needed is a blending of
research findings with the values of patients and CAM providers to improve how clinical decisions are
made (Mills et al., 2002).

TABLE 8-3
Implications of Introducing Evidence-Based Medicine Strategies into CAM Curricula.
For CAM practices for which standard Western scientific research is lacking, experiential evidence and
traditional healing manuals might be used. This could be combined with the second approach discussed
in the IOM report on practice guidelines; the use of professional judgment. This second approach is used
in areas in which the science is weak or nonexistent (IOM, 1992).
A key element of practice guidelines is that their development be undertaken by those who will be
affected by the guidelines as recommended in the IOM report (IOM, 1992). This includes practitioners,
patients, and consumers. Professional societies are also frequently involved in sponsoring the
development of practice guidelines.