In 1978, the authors of this commentary co-authored the Manual of Coronary Care,1 one of the earliest and most durable (6 editions) clinical guideline books in the spiral-bound manual series founded by Little, Brown and Company. The enormously popular The Washington Manual of Medical Therapeutics was the first and most well-known book in this series.2 At that time, a number of my colleagues in academic cardiology criticized the Manual of Coronary Care as being an example of “cookbook medicine.” In other words, clinicians who followed the protocols in our book need not think deeply about the diagnosis and therapy of individual patients. All they had to do with this manual was follow the suggested recipe. Of course, we responded that this criticism was unfounded because physicians caring for patients still had to exercise considerable thought about each individual patient with an acute coronary syndrome despite the protocols provided in our book.
With time, the concept that we and others had pioneered, that is, easy to use clinical protocols that assisted physicians in their diagnostic and therapeutic planning, became an accepted and widely applied venue in daily patient care. This approach spawned many offspring in the form of clinical guidelines commonly used today in medical practices throughout the world. In cardiology, guideline preparation and revision have become major activities for a variety of cardiovascular professional organizations, including the American Heart Association, American College of Cardiology Foundation, European Society of Cardiology, Heart Failure Society of America, Heart Rhythm Society, and many others. The preface to each clinical guideline emphasizes the fact that these publications are presented as aids to clinical care and should not be used as a “one size fits all” recipe for clinical care of all patients. Individual patients will have a variety of contraindications and comorbidities that could and should result in an individualized approach to diagnosis and therapy that might differ importantly from what was suggested in the published guidelines.
Unfortunately, a number of clinical environments, such as urgent care centers, emergency departments, and ambulatory care clinics, have begun to focus their diagnostic and therapeutic planning primarily using what we term “check the box medicine,” a severe exaggeration of the use of clinical guidelines.
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– Joseph S. Alpert, MD, Gary S. Francis, MD
This article originally appeared in the December 2013 issue of The American Journal of Medicine.
