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The process designed by the Dutch College of General Practitioners (NHG) is an example of the opposite “bottom up” approach, in which practitioners initiate and participate in the whole process. The aim is to achieve a balance between evidence-based guidelines and guidelines that are feasible in practice (Grol et al.,1995). An independent advisory board of experienced practitioners selects the topic. A working party of four to eight family physicians is appointed, representing a mix of scientific and practical experience. The group analyzes the literature, explores clinical experience, and builds a consensus leading to draft guidelines. Because scientific evidence is often lacking or conflicting, the discussions are often extensive. Only 5 to 10 percent of guidelines can be based on scientific evidence (Grol et al., 1995). The draft guidelines are sent for comment to fifty randomly selected general practitioners and to external reviewers who are usually experts in the subject. After this review, the working party has to defend its guidelines before a critical group of general practitioners with high academic and professional standing. The definitive guidelines are then published in the scientific journal for Dutch family physicians, and educational programs are developed. Finally, the impact of the guidelines is assessed by surveys, and updates are provided when new evidence becomes available. About half the members of working groups are general practitioners with academic appointments, some of whom have done research on the subject of the guidelines.. ? The Dutch system would be possible only in a country where general practice research and academic general practice are well supported With the growth of managed care, there are fears that guidelines will eventually become mandatory, thus limiting the clinical freedom of physicians to apply them with discretion. There is a fear also that in legal cases, failure to follow the guidelines may be used as evidence of ma
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