Voltaire (Francois Marie Arouet, 1694-1778)
Dictionnaire Philosophique, 1764
This editorial is the second time I have discussed clinical aphorisms that have proved useful for me during more than 30 years of inpatient and outpatient attending at 4 US medical schools.1 The last time I put this list of aphorisms together, it contained 10 items. The current commentary will be published sequentially in 2 parts with 8 aphorisms in part I and 7 additional items in part II for a total of 15.
Rule 1: Common things occur commonly. I make this point continuously to medical students and residents. Sometimes young clinicians will suggest an unusual diagnosis for a patient with the hope of being the only doctor to make the correct diagnosis. More experienced clinicians believe the correct diagnosis is usually something common. For example, consider a patient with an enlarged spleen. In North America, splenomegaly rarely results from entities such as primary lymphoma of the spleen or malaria. Rather, splenomegaly is often caused by portal hypertension or mononucleosis. One of my first, and best, residents during my internship told me “If it looks like a horse, whinnies like a horse, and smells like a horse, don't expect a zebra to appear” (Stone N, MD, personal communication, 1970).
The experienced clinician is aware of the relative incidence of various illnesses in his/her community, and, unless there are unusual features in a particular patient's clinical picture, one should always seek one of the diagnoses most common in the community where one practices. For example, on moving to Arizona, I was amazed to discover how common coccidiomycosis pneumonia was in our hospital population. I had learned about this illness while studying and working in Boston. However, I had never seen an example of this disease entity and thought that it was a rarity. This is definitely not the case in Arizona where coccidiomycosis pneumonitis is common and should always be considered in the differential diagnosis of a pulmonary infiltrate.
Rule 2: Common sense occurs uncommonly. This aphorism is usually attributed to Voltaire. Over the years, I have seen many violations of this important rule in clinical medicine. Physicians should exercise common sense before ordering tests or performing therapeutic interventions. Examples abound in support of this rule. Recently, I saw a 60-year-old diabetic woman in my office. She had been admitted to our hospital several weeks earlier with a single bout of rest angina. Her cardiac catheterization revealed modest coronary arterial stenoses, and she was placed on medical therapy with brand name medications by another cardiologist: a statin, an angiotensin receptor blocker, and clopidogrel. Subsequently, I first saw her in my office. At that time, she and her family told me that they had paid more than $500 for 1 month's supply of the medicines that had been prescribed in the hospital. I quickly altered her regimen to include generic forms of a statin and an angiotensin-converting enzyme inhibitor, as well as 325 mg of aspirin. These new generic prescriptions would cost the patient less than $20 per month. Common sense should have been used earlier by the inpatient attending physician simply by informing the patient that generic brands cost less than brand name pharmaceuticals. As noted by Harvey Cushing (1869-1939), “Three-fifths of the practice of medicine depends on common sense, knowledge of people and of human reactions.”2 I would add knowledge of the patient's ability to pay for the medicines prescribed.
Rule 3: The less a procedure is indicated the more likely that its use will be accompanied by complications. This rule advises clinicians to ensure that every procedure or test ordered has a reasonable probability of altering patient management. An example of this aphorism in practice involved a healthy 55-year-old man without coronary heart disease risk factors. He became anxious when a neighbor had an acute myocardial infarction. His doctor suggested that he undergo a coronary calcium computed tomography scan. This test revealed modest coronary calcifications. The patient became more anxious when he heard the results of his computed tomography scan, and he convinced his physician that he needed a coronary angiogram. The angiogram was unremarkable, but the catheterization resulted in a large groin hematoma and pseudoaneurysm that required vascular surgical repair. If I had been involved in this patient's initial care, reassurance or, at most, a Bruce protocol electrocardiographically monitored exercise test, would have been my approach.
Rule 4: Listen between the lines. Many patients tell their physicians that everything is fine when they first enter the examining room. However, often the most important part of an outpatient visit occurs right at the conclusion of the session when it is not rare for the patient to say, “Oh, by the way, doctor,” followed by a statement that enunciates what is really bothering him or her. At these times one may discover sexual dysfunction or physical or psychologic abuse. Given the time pressures involved in clinical practice these days, such issues are often not heard.
Rule 5: Seven minutes is an inadequate amount of time to spend on a patient visit. Recently, I was informed that in a survey of a large number of US physician office work schedules, the average length of a primary care office visit was 7 minutes. I find it inconceivable that any in-depth understanding of a patient's condition could be gained in such a short period of time. In our current managed care era, physicians experience considerable administrative and financial pressure to limit the duration of patient visits to a specified minimum. I believe it is unrealistic to diagnose or treat adequately all but the most minor internal medicine symptom in 7 to 10 minutes. It is possible that the technical components of the visit could be performed in this brief period, but I doubt that an adequate history, including questions about the patient's home and family situation, travel plans, and so forth, can be accomplished in 7 minutes. In addition, an excessively short patient/physician encounter decreases the opportunity to invoke the beneficial therapeutic environment that develops with a longer interaction.
I am personally unable to perform a new patient visit in less than 40 minutes and a follow-up visit in less than 20 minutes regardless of what is said by so-called experts in the delivery of managed care medicine.
Rule 6: Practicing good medicine requires a triad of equal doses of hard work, kindness, and honesty. Practicing good clinical medicine is hard work. Industriousness is a sine qua non of good doctoring. Kindness is the second essential ingredient for achieving excellence in clinical medicine. No one should be admitted to medical school without this personality trait. Kindness and empathy are close allies. If someone is not intrinsically kind and empathetic, he or she will not be empathetic for the sick individuals in front of them, and thus will be unlikely to listen to the patient with care.
Honesty is, of course, required for clinical success. When the physician is honest in all aspects of his/her conduct toward a patient, a sense of trust is built between the doctor and the patient with an eventual excellent outcome for both parties. Conversely, if there is mistrust between the caregiver and the care receiver, a beneficial result is unlikely. A corollary to this aphorism is “Never be afraid to admit that you don't know something” (Dalen JE, MD, personal communication, 1972). Allowing yourself to admit ignorance is the first step toward effective learning.
Rule 7: No individual has a monopoly on truth. Even after years of experience, study, and hard work, I still learn new things every time I attend on the inpatient service of our hospital. I learn from both residents and students, and I tell them at the beginning of each rotation: “Please don't be afraid to question what I tell you or to add something that you think is important. I do not profess to have a monopoly on truth.”
Rule 8: Obtaining informed consent from a patient for a procedure can help or hurt the patient. Appropriate informed consent for procedures is one of the most important ethical precepts in modern clinical medicine. The process itself can help or harm the patient. On the positive side, a well-informed and prepared patient is the physician's best ally. I am convinced that complications are less likely when patients are well informed and anxiety about the procedure has been alleviated.
Negative aspects of obtaining informed consent involve a formal recitation of potential complications in a blunt and direct style that terrifies the patient. When performed in this manner, giving informed consent is a frightening experience. This is particularly true when potential complications are presented without an accompanying explanation about the relative rarity of such events and the myriad fail-safe mechanisms that are in place to protect patient safety. I always imagine an analogous scenario involving an individual who is about to buy a new car. The salesman confronts the potential buyer with a list of all the horrible things that can happen to drivers and passengers when there is a major car accident. Would anyone want to buy a car after hearing such a frightening litany of potential problems?
Conclusions
The 8 aphorisms or rules listed here together with 7 more that will be published in The American Journal of Medicine next month are just part of the advice that I offer students, house officers, fellows, and junior faculty early in their careers. The principles on which this advice rests have mostly come my way from experienced, empathetic, and skilled clinical teachers. They have stood me in good stead through many years of practicing and teaching clinical medicine.
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