The modern age of clinical guidelines began with a 1992 institute of medicine report which defined guidelines as systematically developed statements meant to assist practitioner and patient decisions about healthcare for specific clinical circumstances. The key words there were ‘assist practitioner AND patient decisions’.

However over the course of the last 30 years, this seemingly innocuous and potentially helpful advancement/concept has metamorphosed into something which is far bigger and far more constraining than we ever thought. 

Guidelines have now become commandments and in so doing, have come to define/delineate the boundaries of the comfort zone of healthcare practitioners. As long as the guideline is followed, the doctor feels safe and that is all that matters. It is no longer about the patient anymore. What this means is that medicine has become guidelines centered when it was always meant to be patient-centred. 

The most honest analogy I can use is that of a circus, Doctors have become circus monkeys. Someone tells us to jump and we just go ahead and jump and we chastise our colleagues who are not jumping as enthusiastically as we are and scorn them as poorly performing doctors. No one even dares to ask why we are being asked to jump in the first place. More often than not those that are asking us to jump, our circus masters, have their own vested interest and sometimes even share mercantile relations with the pharmaceutical industry. If a drug makes it into a clinical guideline then it will make a huge amount of money for its manufacturer.

In some ways the guideline has become the box and doctors no longer feel brave enough to think, let alone act, outside of this box. If you are not allowed to think beyond the guideline there can’t be any out of the box thinking and there will never be any innovation or creativity in medicine. 

More importantly, there is a risk of breeding doctors who are lazy, apathetic and unable to think or reflect critically. 

Perhaps most concerningly, the accountability of the doctor becomes to the guideline and not the patient. If a patient dies in our care, then our reflection is more about whether we followed the guidelines to a T or not. We account to the guideline and our reflection stops at that. 

What we should be doing is going that one step further and hold ourselves and the guideline accountable to the patient and unless we start doing so, we won’t learn and we will continue to stagnate in our own self-assured hubris and our profession as whole risks losing the humility and humanity that is so necessary to foster connection with our patients.