Re: Counterpoint: Rationing on the Fly: The Opportunity Cost of Clinical Guidelines

We are happy to see that Dr. Larry Culpepper agrees with our basic premises. Importantly, we appreciate his correct clarification that “the care we provide patients is driven by the number of problems they have, not by the number of guidelines available.” However, he misrepresents some of our key tenets. We believe the adoption of a new guideline may increase care (not that it necessarily will); when the workload is increased, barring other interventions, something must be taken away.

We are happy that medicine is complex enough that we do not know a priori all the problems that will be addressed in a given day, even though this means we cannot plan a learned response to the day's challenges. This means that real-world practice has excitement and challenges that force to us to make decisions on the fly. Thus we disagree with Culpepper when he suggests the decision on what care to provide “is done concurrently as the clinician and patient seek to maximize value.” In addition, when these decisions are made, whether ad hoc or through thoughtful deliberation, we call it rationing. He does not. That is just semantics.

A major premise of our Commentary is that without more work “the true impact of clinical guidelines cannot be known.” We agree with some of Culpepper's proposed solutions, though many have a long-term horizon, but the basic problem persists. In the end, we hoped to spur debate and discussion and are pleased that this has started.