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To the Editor: Dr Cabana and colleagues¹ provide a helpful analysis of the failure of clinicians to follow existing practice guidelines. However, they overlook the possibility that such behavior may be deliberate, reflecting clinicians' disagreement with the nonscientific value judgments of the guideline writers.

Clinical practice guidelines necessarily incorporate not only the beliefs of the guideline authors about the medical facts, but also a set of evaluative judgments about whether the anticipated outcomes are good or bad (and how good or bad they are). These evaluations of outcomes reflect the value judgments of the guideline authors. A practitioner or patient who evaluates the outcomes differently may have a perfectly rational reason for refusing to follow the guidelines.

For example, if guideline authors believe that the only value of antibiotics or tympanostomy tubes for otitis media in children is to prevent long-term damage, they are likely to produce a practice guideline . . . [Full Text of this Article]

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