Screening is not as simple as it may seem.

The first is that the guideline and the defense of the guideline reflect an attitude of paternalism toward both primary care physicians and the patient. It is unfortunate that the guideline recommends an intervention without quantifying the benefit or the harm. We recognize that the weight of evidence suggests lipid screening is a good idea, but when a mother asks, “How effective is this? What difference is this going to make?” how is the primary care doctor supposed to answer? Instead of providing the information needed to have a collaborative discussion that would quantify the risks and benefits (such as number needed to screen, number needed to harm), the primary care physician is left to simply answer that it seems like a good idea but no one knows how big a difference this intervention is going to make. In the past, a paternalistic guideline may have been readily accepted, but we are moving toward an era in which patients and families, with increasing health literacy, are expecting to make decisions with the physician in a collaborative matter. A guideline that does not give the physician the ability to explain why an intervention is worthwhile will undermine the authority and credibility of the physician to provide tangible information. I understand that without a specific screening trial which tests these guidelines in a real population, the current evidence does not lend itself to calculating a number needed to screen/ number needed to harm, but that should be recognized as a weakness of the guidelines. For harms data, telling a parent that a 2-year trial showed safety when the child may be on a medication for decades is unlikely to be reassuring. It is better to have data. We think guidelines need to reflect that both the primary care physician and the patient would like to know not just if an intervention is effective but how effective it is.