Common Sense and Medical Practice

 

“Common sense is not so common.”

—Voltaire (Francois Marie Arouet, 1694-1778)

“Three fifths of the practice of medicine depends on common sense, knowledge of people, and of human relations.”

—Harvey Cushing (1869-1939), first chief of surgery at the Peter Bent Brigham Hospital in Boston

“Between the patient and the guidelines there needs to be a doctor that is using his/her brain!”

—Joseph S. Alpert

Common sense is defined in the Merriam-Webster dictionary as sound and prudent judgment based on a simple perception of facts.¹ In other words, it is a judgment that is based on life experience rather than on scholarly activity. During many years of practicing and teaching internal medicine and cardiology, I have observed that the use of simple common sense usually results in the best patient outcomes. Unfortunately, I have also been impressed by how many times each day I find myself telling trainees, and at times, even colleagues, that common sense would suggest that a planned intervention is not in the patient’s best interest.

I have noted that there are 4 areas in which common sense is often not being applied, increasing the chance for a resultant bad outcome: Daily patient care by physicians; daily patient care by the patients themselves; hospital protocols; and medical administration. In this commentary, I will cite a real-world example for each of these 4 scenarios in which common sense should have come into play.

Scenario 1 (daily care of patients by physicians): A 59-year-old man with a history of a transient ischemic attack (TIA) undergoes a right carotid endarterectomy. Fourteen hours after the procedure, he complains of substernal chest “pressure.” An electrocardiogram (ECG) shows a new ST segment depression in leads 1, AVL, and V4-6, and the first blood troponin value is 1.1 ng/ml. The resident on call correctly diagnoses a non-ST-elevation myocardial infarction and initiates the following guideline directed therapeutic protocol: intravenous heparin, 81 mg aspirin, 25 mg BID metoprolol, 5 mg lisinopril, and atorvastatin 80 mg. The patient develops a large hematoma in the neck and has to be taken urgently to the operating room. Clearly, anticoagulation, and possibly even aspirin, should not have been administered to this patient. This is an example of failure to use common sense in instituting a guideline-directed therapy. My teaching point at that time, repeated multiple times over the years, is “Between the patient and the guidelines, there needs to be a physician that is using their brain.”

Scenario 2 (daily patient care by the patients themselves): A 53-year-old man was recently discharged from the hospital following an acute anterior wall ST-segment elevation myocardial infarction treated with angioplasty and guideline-directed medical therapy. The patient tells you that he is not taking his prescribed atorvastatin and will not take it in the future because his neighbor told him that “this drug will kill your liver.” As physicians we know that the most important agent for this patient after infarction is a statin.² A 25-minute conversation ensued, but I was unable to convince him to make atorvastatin part of his continuing medical program even when he was shown the scientific data favoring statin therapy.² This is a clear example of a patient not employing common sense and not accepting a particular therapy that was in his best interest.

Scenario 3 (hospital protocols): Many times during the day when rounding in the hospital, my trainees and I doff paper gowns and latex gloves in an alleged attempt to prevent hospital transmission of resistant bacteria. Unfortunately, there is substantial evidence that with the exception of Clostridia difficile infection, this exercise is without value.³ Once again, common sense dictates that we should not be performing protocols that are useless and expensive.

Scenario 4 (administrative decisions): The medical complex where I work has 2 sections: the university medical school with laboratories, offices, and classrooms, and the hospital itself. These components are joined by hallways on every floor. During the evening hours, doors are locked so that it is impossible to walk from the hospital into the medical school area. This makes common sense because we do not want individuals visiting the hospital to wander into the medical school area. However, the hospital security staff do not have key access to the university medical school areas. So, imagine the following unfortunate events:

An assault or some form of vandalism occurs in the medical school area, and the security staff in the hospital are alerted. Unfortunately, they do not have key access to the medical school, and they have to summon the university police force who are not on site. Many minutes pass before the university police arrive on the scene, thereby allowing a criminal act to proceed. Again, common sense would dictate that the hospital security team should have access to the medical-school zone in an emergency.

The take-home message from this commentary is that careful thought and consideration should be given to clinical and administrative decisions to combine guidelines or corporate rules with a healthy dose of common sense.

As always, I welcome comments on this commentary on our blog at amjmed.org or via e-mail to jalpert@shc.arizona.edu.

To read this article in its entirety please visit our website.

-Joseph S. Alpert (Editor in Chief The American Journal of Medicine)

This article originally appeared in the November 2019 issue of The American Journal of Medicine.