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Beware of Guidance Fatigue

Too many instructions leads to less compliance.
March 21, 2020
Beware of Guidance Fatigue
New York State Governor Andrew Cuomo (Photo by Ira L. Black/Corbis via Getty Images)

“There’s just too many requirements, [more than] can be literally accomplished in a given time.”

This complaint feels like it could have come from any one of the millions of anxious Americans trying to cope with the constant stream of evolving recommendations and behavioral admonitions as the nation struggles to manage the COVID-19 pandemic.

But this observation was actually made a decade and a half ago by Leonard Wong, an army veteran turned professor in the Strategic Studies Institute at the U.S. Army War College. And Wong’s research turns out to have important implications for how we should articulate guidelines—and advise anxious citizens—today.

Around 2005, Wong was studying innovation in the ranks of the Army’s junior officers and set out to catalog the requirements put on company commanders—junior officers who lead groups of around 150 soldiers. The overwhelming expectations on this group that accreted over time surprised him.

Intrigued by the imbalance he inadvertently discovered between what was mandated and what seemed to be humanly achievable, Wong then set out to figure out how the company commanders actually managed the dilemma in the field. His research resulted in a 2015 paper (with Stephen Gerras), titled “Lying to Ourselves: Dishonesty in the Army Profession.”

The authors’ thesis is that the imposition of excessive requirements results in officers routinely shading the truth. For instance, in documenting quarterly feedback meetings that often never occurred. Wong and Gerras write,

[M]any Army officers, after repeated exposure to the overwhelming demands and the associated need to put their honor on the line to verify compliance, have become ethically numb…. subordinates are forced to prioritize which requirements will actually be done to standard and which will only be reported as done to standard. As a result, untruthfulness is surprisingly common in the U.S. military even though members of the profession are loath to admit it.

It’s not just the Army that’s drowning in excessive, often confusing and conflicting guidance. Doctors routinely wrestle with this as well.

In 2015, Bill Gardner, a child psychologist and distinguished health services researcher, wrote in The Incidental Economist, “the burden of documentation and compliance for health care providers is comparable to the burden on the military.” He adds, “In some ways, the situation in health care is worse than the military. The military has a single chain of command, but medicine has many bodies issuing standards, many of them redundant.”

Like army officers, doctors must figure out how to use their time most effectively. And while each added requirement might seem sensible in isolation, the cumulative effect can be overwhelming to providers and force them to determine which requirements they’ll really do and which they might just say they’ve done.

In both the Army and in medicine, the result can be a problem that Wong (citing Notre Dame professor Ann Tenbrunsel) calls “ethical fading,” which he describes as what happens when a clear boundary of right and wrong “starts fading into the background and it stops being an ethical decision—it stops being an ethical dilemma—and then turns into an administrative decision or a way to do business.”

As both Wong and Gardner emphasize, that process degrades both people and organizations.

To avoid this situation, Gardner writes, “we need consensus on a minimum set of requirements that are feasible to measure and maximally affect practice.”

While acknowledging that “specifying that minimum set is an enormous and challenging task,” he writes that it’s critical not only to drive the quality improvement the mandates intend, but also for “the preservation of the virtue of integrity in medicine.”

Overwhelming Army officers and physicians with excessive, unmanageable, and occasionally inconsistent demands results in a system of shadow compliance, where individual rules issued in good faith become, collectively, an unfeasible, crushing burden. And this burden results in ever-more selective and intermittent adherence.

And if all of that is true for professionalized, highly-trained warriors and healthcare providers, then are the rest of us supposed to cope with the abundance of behavioral guidance and advice coming our way during this pandemic?

The success of guidance depends not only on the wisdom or intention of the various recommendations, but also, rather importantly, on whether the guided respond. Offering comparatively few guidelines that are clear, consistent, and achievable would be so much more helpful, and likely to do far more good, than the cacophony of suggestions we’re now struggling desperately to parse and to action.

Some leaders, to their credit, seem viscerally to understand this—foremost among them, New York Governor Andrew Cuomo, who continues to acquit himself in an exemplary fashion throughout this crisis. Speaking to the press Thursday, he constantly returned to the theme, “language matters,” emphasizing “communication is important, words are important, say what you mean, don’t say what might alarm people.”

Cuomo took particular issue with the Bay Area’s recent “shelter in place” guideline (which directly affects me, as I live in Silicon Valley), pointing out that the term was previously used in the context of a nuclear threat, when you were supposed to “find a room in your house with no window, where you’d be free from smoke or gasses, and stay there until you get the ‘all clear’ sign.”

Yet, as Cuomo points out, the Bay Area “shelter in place” order allows us to leave the house for activities such as buying groceries, walking pets, and exercise.

Here’s how Cuomo put it:

Shelter in place is a scary term for people, especially when they don’t know what it means, especially when you’re not doing what it means. If you’re not doing that, why do you call it that?

Perhaps this is why on Thursday, Los Angeles county leaders chose to term their similar order, “Safer At Home,” while the same day, California Governor Gavin Newsom opted for “Stay At Home.”

Rather than trying to make our way through a thicket of different terms, guidelines, and mandates, I suspect all of us—wherever we live—would do well to adhere to Cuomo’s basic advice, essentially:

  • Stay home when you can;
  • Go out if you need to;
  • Keep away from other people.

Cuomo, it seems, has internalized a key lesson from Wong and Gardner: When it comes to following instructions faithfully, clear, manageable expectations can drive greater adherence, and—we all hope—achieve a healthier result.

David Shaywitz

David Shaywitz is a physician-scientist at a biopharmaceutical company, an adjunct scholar at the American Enterprise Institute, and a lecturer in the Department of Biomedical Informatics at Harvard Medical School.