Oxford dictionary defines “guideline” as “a general rule, principle, or piece of advice.” The Cambridge dictionary similarly defines the word as “a piece of information that suggests how something should be done.” But regardless of which definition you prefer, the point of a guideline is that it is something to guide you.
A guideline is not a law.
A guideline is not the voice of God.
A guideline is a suggestion.
Yes, a good guideline might be a strong suggestion. A guideline author might be imagined as carrying the same look your parents used when referring to you with your middle name. You wouldn’t go to jail if you weren’t at the dinner table RIGHT NOW, but you had better have a pretty good explanation for not being there.
As physicians, we need guidelines. But we are deluged with information. According to the 2018 report issued by the International Association of Scientific, Technical and Medical Publishers, there are 3 million new scientific papers published every year. Even if you were the star of your speed-reading class, there’s no way to keep up.
The Physician Desk Reference was first published in 1947. That slim volume was 380 pages. It was possible for a physician to read it, internalize it, and apply it. The 2017 edition of the same book clocks in at roughly 2,000 pages (and weighs close to five pounds). But don’t worry! Today, we don’t even use paper anymore; we use the Prescribers’ Digital Reference. Online, there is more information than could fit in even a hefty book. Indeed, there is more information than fits in even a hefty brain. Neuroscientists have estimated that the human brain has a storage capacity between 10 and 100 terabytes. The data growth on the internet has been colossal — beyond terabytes. Think petabytes, exabytes, zettabytes, yottabytes. (Those are numbers so big, I can’t wrap my brain around them, but what wonderful words for Scrabble!)
Yup. We need guidelines.
That said, the guidelines are necessary but not sufficient. We also need to use our admittedly limited brains. We shouldn’t need hard stops, but we do need serious pauses. We need strong reminders for many things. An additional click (even recognizing fully that clicks are evil) to bypass a guideline often makes sense. However, the clinicians and programmers creating the warnings must remember that they cannot imagine every scenario that will walk into the exam rooms. The patient is a real human. Humans are individuals with myriad conditions, social needs, and personal preferences. Sometimes even a USPSTF-vetted guideline doesn’t fit the situation.
There is a balance. Yes, when a well-constructed alert provides information about a guideline, it should be followed. The physicians encountering the alert should heed it, while recognizing there will be reasons to click that override button (and provide a rational and lucid reason why the circumstance warrants a different course of action).
We should be able to recognize cogent reasons to stray from the guidelines. Do we need to emphasize this more to the current generation of medical students? Do we need to emphasize this to all physicians, the techno-savvy and the techno-tards?
There are amazing resources today to verify information. Smartphones do more than we dreamed possible even a few years ago. But too often, encountering a guideline is like hitting a brick wall. The computer says, “I can’t do that.” The physician stops. That was, after all, the intent of the alert. But what if in this situation for this patient, the physician shouldn’t stop? Let’s all take a step back and remember that the patient matters more than the guidelines.
To reiterate: Guideline. Noun. A suggestion, policy, a piece of information. Pay attention and then do the right thing.
Lisa Masson, MD, is a board-certified physician in Los Angeles. Her passion for primary care motivated her to take on an active role in clinical informatics. She is a 2018–19 Doximity Author and a proud mother of three daughters.
Image: Ribkhan / shutterstock
