{"id":41714,"date":"2018-03-23T16:36:45","date_gmt":"2018-03-23T15:36:45","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=41714"},"modified":"2018-03-29T14:35:07","modified_gmt":"2018-03-29T13:35:07","slug":"jeff-aronson-when-i-use-a-word-guidelines","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2018\/03\/23\/jeff-aronson-when-i-use-a-word-guidelines\/","title":{"rendered":"Jeffrey Aronson: When I use a word . . . Guidelines"},"content":{"rendered":"<p><a href=\"https:\/\/blogs.bmj.com\/bmj\/2018\/03\/16\/jeffrey-aronson-when-i-use-a-word-criteria\"><span style=\"font-weight: 400\">Last week<\/span><\/a><span style=\"font-weight: 400\"> I discussed Austin Bradford Hill\u2019s 1965 <\/span><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC1898525\/\"><span style=\"font-weight: 400\">lecture<\/span><\/a><span style=\"font-weight: 400\">, \u201cThe Environment and Disease: Association or Causation?\u201d, in which he outlined what he called \u201cnine viewpoints\u201d that he suggested could help in analysing causation in associations between two variables. I pointed out that his viewpoints, commonly called criteria, are no such thing, or at least only one is, and that we might better refer to them as guidelines.<\/span><\/p>\n<p><span style=\"font-weight: 400\">A guideline was originally literally a line used as a guide, synonymous with a nautical guy, a rope used to guide and steady anything that is being hoisted or lowered, or a guide-rope, a small rope attached to an object to be raised or lowered by a crane or pulley, in order to guide it (definitions from the OED). The entry on \u201cguy\u201d in the <\/span><a href=\"http:\/\/www.gutenberg.org\/files\/26000\/26000-h\/26000-h.htm\"><i><span style=\"font-weight: 400\">Sailor\u2019s Word Book: An Alphabetical Digest of Nautical Terms<\/span><\/i><\/a><span style=\"font-weight: 400\"> (1867), compiled by Admiral W H Smyth and revised for publication by Vice-Admiral Sir Edward Belcher, describes the various types of guy that sailors might use:<\/span><\/p>\n<ul>\n<li style=\"font-weight: 400\"><span style=\"font-weight: 400\">a rope used to steady a weighty body from swinging against the ship\u2019s side while it is hoisting or lowering, particularly when there is a high sea;<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"font-weight: 400\">a rope extended from the head of sheers [spars lashed together to support heavy weights], and made fast at a distance on each side to steady them;<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"font-weight: 400\">a tackle used to confine a boom forward, when a vessel is going large, and so prevent the sail from gybing, which would endanger the springing of the boom, or perhaps the upsetting of the vessel;<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"font-weight: 400\">a large slack rope, extending from the head of the main-mast to the head of the fore-mast, and sustaining a temporary tackle to load or unload a ship with.<\/span><\/li>\n<\/ul>\n<p><span style=\"font-weight: 400\"><a href=\"https:\/\/blogs.bmj.com\/bmj\/files\/2018\/03\/jeff_aronson_guidelines.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft size-full wp-image-41715\" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2018\/03\/jeff_aronson_guidelines.jpg\" alt=\"\" width=\"212\" height=\"274\" \/><\/a>By the 1940s the word \u201cguideline\u201d began to be used figuratively. The historian Arnold Toynbee (pictured), in an essay titled \u201cMy View of History\u201d in <\/span><a href=\"https:\/\/archive.org\/stream\/in.ernet.dli.2015.530306\/2015.530306.civilization-on_djvu.txt\"><i><span style=\"font-weight: 400\">Civilization on Trial<\/span><\/i><\/a><span style=\"font-weight: 400\"> (1948), described the national history of England as the \u201cprincipal guide-line\u201d to modern Western history.<a href=\"https:\/\/blogs.bmj.com\/bmj\/files\/2018\/03\/jeff_aronson_guidelines2.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignright size-full wp-image-41716\" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2018\/03\/jeff_aronson_guidelines2.jpg\" alt=\"\" width=\"182\" height=\"273\" \/><\/a><\/span><\/p>\n<p><span style=\"font-weight: 400\">The idea of clinical guidelines originated at about the same time, in <\/span><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/20269157\"><span style=\"font-weight: 400\">Italian<\/span><\/a><span style=\"font-weight: 400\"> and <\/span><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/18110164\"><span style=\"font-weight: 400\">Portuguese<\/span><\/a><span style=\"font-weight: 400\"> publications, where they were described as \u201corientamenti\u201d. \u00a0In English the earliest reference that I have found is in a 1955 <\/span><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC2024441\/\"><span style=\"font-weight: 400\">paper<\/span><\/a><span style=\"font-weight: 400\"> titled \u201cGuidelines to community development programs\u201d:<\/span><\/p>\n<p><span style=\"font-weight: 400\">\u201cIn general. there appear to be two basic types of culture change: One may be called \u2018spontaneous,\u2019 or perhaps \u2018evolutionary,\u2019 in that the change happens without the conscious efforts of individuals or groups, and the otlher may be called \u2018directed,\u2019 or \u2018guided,\u2019 in that group planning and action leads to goals which, it is thought, will promote a happier, healthier, better educated, and independent society.\u201d<\/span><\/p>\n<p><span style=\"font-weight: 400\">\u201cGuide\u201d comes from an IndoEuropean root, WEID, to look at or see. Wit and wisdom give us the ability to see and understand. White things are easily seen. Guise is how you look and disguise an appearance one assumes. In Greek \u1f30\u03b4\u03ad\u03b1, from the verb \u1f30\u03b4\u03b5\u1fd6\u03bd, to see, meant outward appearance or semblance; the Latin derivative, idea, came into English unchanged in the 14<\/span><span style=\"font-weight: 400\">th<\/span><span style=\"font-weight: 400\"> century. And \u201cidol\u201d comes from the Greek word \u03b5\u1f34\u03b4\u03c9\u03bb\u03bf\u03bd, an image, phantom, or likeness.<\/span><\/p>\n<p><span style=\"font-weight: 400\">WEID also gave the Latin word videre, to see, from which we get \u201cevidence\u201d, on which one would generally expect guidelines to be based. When I searched PubMed for papers in which the terms \u201cguideline[s]\u201d and \u201cevidence[-based]\u201d appeared in the titles, I retrieved 3208 hits, but omitting \u201cevidence[-based]\u201d yielded 66,088, not an encouraging comparison. Searching for the same terms as textwords, yielded 74,163 and 387,044 hits respectively, a fourfold better proportion, at nearly 20 percent, but still not entirely reassuring, albeit a crude measure. <\/span><\/p>\n<p><span style=\"font-weight: 400\">As an <\/span><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC3595411\/\"><span style=\"font-weight: 400\">illustration<\/span><\/a><span style=\"font-weight: 400\"> of this, when I joined Robin Ferner and his Birmingham colleagues in a systematic review, exploring published guidelines for monitoring the adverse effects of antihypertensive drugs, we found 19 sets, differing from each other in several details and based on very little evidence. We concluded that \u201cthe current lack of consistent and workable instructions poses serious difficulties for practitioners\u201d. We therefore synthesized a set of proposed guidelines based on the published recommendations for which there was general or at least majority agreement, using clinical judgement to resolve inconsistencies. It would nevertheless be good to have some guiding evidence to support our recommendations.<\/span><\/p>\n<p><a href=\"https:\/\/blogs.bmj.com\/bmj\/files\/2014\/12\/jeffrey_aronson.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft wp-image-32935\" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2014\/12\/jeffrey_aronson-223x300.jpg\" alt=\"jeffrey_aronson\" width=\"79\" height=\"97\" \/><\/a><em><strong>Jeffrey Aronson<\/strong>\u00a0is a clinical pharmacologist, working in the Centre for Evidence Based Medicine in Oxford&#8217;s Nuffield Department of Primary Care Health Sciences. He is also president emeritus of the British Pharmacological Society.<\/em><\/p>\n<p><strong>Competing interests:<\/strong>\u00a0None declared.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Last week I discussed Austin Bradford Hill\u2019s 1965 lecture, \u201cThe Environment and Disease: Association or Causation?\u201d, in which he outlined what he called \u201cnine viewpoints\u201d that he suggested could help [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmj\/2018\/03\/23\/jeff-aronson-when-i-use-a-word-guidelines\/\">More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[5762],"tags":[],"class_list":["post-41714","post","type-post","status-publish","format-standard","hentry","category-jeff-aronsons-words"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Jeffrey Aronson: When I use a word . . . 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