We may get this horse to water, but will it drink?

Against this backdrop of constant change we have the guidelines movement and its products. At first glance, guidelines appear to be the answer to everyone's problems. They have been identified as a means to improve the quality of care and address issues of practice variation, to decrease health care costs and address issues of rationing, to deal with competition and improve access, and to promote physician autonomy and enhance patient empowerment.(f.2) Quite clearly, guidelines have the potential to do a great deal -- but what is the reality, and what can we expect from the new guidelines on the management of breast cancer developed by Dr. Maurice McGregor and colleagues and published as a supplement to this issue of CMAJ? The new breast cancer guidelines, as well as guidelines on similar topics from other groups,(f.5,6) are now appearing slightly more than 4 years after the Forum. This is not meant to criticize McGregor and colleagues; the problem of timeliness plagues all clinical practice guidelines. Delays are not surprising when one considers that guideline development represents an add-on to the tasks borne by most physicians and may not be at the top of their priority list. Parallel to the challenge of simply doing the work is the proliferation of groups involved in guidelines and differences in working method: some processes are very detailed,(f.7,8) whereas others are less structured.(f.9) A more fundamental issue shadows the guidelines movement. How good is the evidence that all this work brings about the desired results? Will new guidelines reduce practice variation and increase the confidence of women in their treatment? The evidence that guidelines bring about desired change is patchy. On balance, it appears that the most successful programs to effect change are multifaceted.(f.11,12) Although the lay version of the guidelines is a wonderful addition, it is not readily apparent that a strategy has been developed to make lay guidelines both available and meaningful to women with breast cancer and those providing care for them. Should every patient who is diagnosed with breast cancer be made aware of existing guidelines? If so, how can this be done? Even if a single point of access could be identified, there is no reason to believe that patients routinely acquire information at the same time in the course of their illness or in the same manner. The same comments likely also apply to physicians. If guidelines are the "water," is there a way to in