Common Sense Is Not So Common.
— Voltaire (Francois Marie Arouet, 1694-1778), Dictionnaire Philosophique, 1764
This essay is the second of 2 dealing with clinical aphorisms that I have derived during many years of clinical experience. contained 8 items and was published in the August issue of The American Journal of Medicine.
Rule # 9: Physician, heal thyself. The physician should be a model of good health habits for 2 reasons. First, patients are unlikely to follow the advice of someone who they believe is hypocritical. A doctor who smokes cigarettes will hardly be believed when informing patients that they have to stop smoking. Secondly, physicians with poor health habits eventually become patients themselves; it is difficult to be an effective health care provider when one’s own health is impaired.
Rule # 10: Respect your fellow health care workers; they are your most important clinical asset. Just as no man is an island, no physician works in isolation. The health care team consists of nurses, physician assistants, technicians, laboratory staff, administrators, and many other individuals who make the health care system run smoothly. It is essential that the physician, as the leader of the clinical team, establish smooth working relationships with the many individuals in that unit. Friction, irritation, and bad humor in the environment lead to poor performance and, in the end, harm the patient. When I was a medical student, Judah Folkman informed my classmates and me that if we had a negative relationship with the nurses in the hospital during our clinical rotations then we would be better off selecting a profession other than medicine (personal communication, Judah Folkman, 1967).
Rule # 11: Admission to an intensive care unit in a tertiary care hospital can be a harrowing experience for the patient. Proof of this aphorism can be obtained easily if one takes an objective and uninvolved look at patients in an intensive care unit setting. Many of these individuals are tied to the bed and connected to a variety of tubes that emerge from nearly every natural orifice as well as many iatrogenic orifices. Patients are often unable to communicate with caregivers because of tracheal intubation. Usually they are given periodic doses of mind-altering substances and often are left by themselves for periods of time even in the intensive care environment. Therefore, it is imperative that we periodically take a step back from the bedside and decide what our goals are for these patients. Is there a reasonable chance that all that is being done to them will result in meaningful survival? If the answer to this last question is “no” or “probably not,” then the time has come to start discussing plans with the patient’s family for discontinuing life support.
An important corollary to this aphorism is that many patients in the United States undergo excessive testing in the name of defensive medicine. One example is the excessive numbers of brain computed tomography scans that are performed on patients with minimal head trauma or vague histories of headache. In a similar vein, many patients with atypical chest pain are admitted to coronary care units. Much of this excessive utilization of diagnostic services could be eliminated if physicians took the care to obtain a comprehensive history from the patient and spent a few minutes explaining to the patient why certain tests are being performed and why others are not indicated. Many malpractice lawsuits arise as a result of poor communication between the doctor and the patient and not because of medical errors. Establishing rapport with the patient by taking a careful history—the “careful listening” referred to by William Carlos Williams (1883-1963)—is the physician’s best defense against liability risk.
Rule # 12: True, true, and unrelated. This phrase refers to a commonly used form of question on medical knowledge examinations. A series of possibly related entities are presented, and the examinee is asked to pair them and state whether they are related or not with respect to causation. Situations often arise in clinical medicine in which one event or one physical finding occurs in close proximity to a second event or finding. However, these 2 events may be related to each other, or they may have occurred spontaneously without any relationship.
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— Joseph S. Alpert, MD
This article was originally published in the September 2009 issue of The American Journal of Medicine.
