Introduction

On December 14, 1799, the most revered president in US history, George Washington, was assassinated by his physicians! In the 12 h preceding his death, he underwent approximately 2.4 liters of bloodletting, prescribed by his physicians for treatment of what was very likely a bacterial tracheitis. A new procedure, tracheostomy, recently witnessed by one of his junior physicians was considered and rejected by the senior (managing) physician. Rigid adherence to the 'standard of care' killed the father of our country [1].

Guidelines which seek to define the 'standard of care' are proliferating in medicine (see the National Guideline Clearing House, www.guideline.gov). This is a government agency, in partnership with the American Medical Association and the American Association of Health Plans, which currently lists over 1,500 guidelines dealing with all areas of medicine. Why do we need guidelines for guidelines? Any trend this broad and pervasive should be examined closely. As physicians we need to be aware of not only methodological issues but also of the driving forces behind them, and the risk they present to the practice of medicine as we know it.

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