I have often heard the above headline quoted by politically conservative friends here in the United States. I think of it more and more these days not with respect to any political issue, but rather with respect to my daily rounds in the hospital. When I cite this quote to residents and friends, I am often told that it originated with Winston Churchill. I would honestly love to attribute it to Churchill, who is one of my heroes. However, a brief search of the web proved that although Churchill might have said it, he was not the first. According to the Quote Investigator, the first person to say this memorable epithet was a French academic jurist in the 19th century:
“Celui qui n’est pas républicain à vingt ans fait douter de la générosité de son âme; mais celui qui, après trente ans, persévère, fait douter de la rectitude de son esprit.”
“He who is not a républicain at twenty compels one to doubt the generosity of his heart; but he who, after thirty, persists, compels one to doubt the soundness of his mind.” Anselme Polycarpe Batbie (19thcentury academic jurist).
Through the years, this quotation, in various forms, has been attributed to King Oscar II of Sweden, Benjamin Disraeli (distinguished 19th century British statesman), to other lesser known individuals, and finally to Winston Churchill.1 It is very possible that all of these individuals actually said this quotation in one form or another, but it seems to have originated with Batbie, who was referring to the changing political positions of Edmund Burke.
So why I am spending valuable space in The American Journal of Medicine to review the history of this quote? The reason is simple: it reflects my changing attitudes over the years as a clinician. When I was fresh out of training and proud of my skills in the catheterization laboratory, I would often recommend diagnostic catheterization to patients that I was following in the outpatient clinic. Years later, I now realize that I am much slower to advise an invasive approach to diagnosis or therapy then during my younger days. Thus, I have become an example of the politically oriented quote stated above.
Further support for this more conservative attitude comes from recent well-done clinical studies such as the COURAGE trial, which documented that a more conservative, medically oriented, and evidence-based approach for patients with chronic ischemic heart disease was just as effective as an initial strategy involving angioplasty.2 Of course, when patients in the COURAGE trial developed symptoms of incapacitating or unstable angina or a non-ST-elevation myocardial infarction, invasive therapy was used almost universally with a good result. The clear conclusions from this trial supported a more conservative initial approach to such patients, and that has become my mantra for the many patients that I follow with chronic coronary artery disease.
I hope that these comments are not misinterpreted. I am not a therapeutic nihilist, and am strongly in favor, in the absence of contraindications, of adequately dosed, evidence-based, medical therapy for patients with coronary artery disease. I use the same conservative algorithm for patients that I follow with slowly worsening aortic stenosis. I question patients closely for any symptom suggestive of angina, heart failure, or near syncope, and I thoroughly educate patients to watch for these warning advisories of impending deterioration. In addition, I advise these patients that I want to hear from them the moment such a symptom develops.
There is another aspect of clinical care with which I have become more conservative over the years, and that is how aggressively I advance the dosage of medications. For example, I was trained that in managing hypertension, the best strategy is to start 1 agent and keep increasing the dose until you have achieved a satisfactory blood pressure or reached the maximum allowed dosage. If the patient was still hypertensive with the maximum tolerated dose of the initial medication, then, and only then, I was to add a second drug to the program. I have learned through experience that this more liberal use of higher doses of a single medication often led to unacceptable adverse events, so-called side effects. My current approach to treating hypertension is to use lower doses of 2 or even 3 medications to achieve blood pressure control. In an attempt to increase patient compliance, I try to prescribe only once-daily medications.
So, even though my political views have not changed much as I have aged, my clinical attitude has indeed become more conservative with age. I would like to believe that, like the epithet quoted above, this is the result of using my brain more than my heart!
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-Joseph S. Alpert, MD (Editor in Chief, The American Journal of Medicine)
University of Arizona College of Medicine, Tucson
This article originally appeared in the July 2016 issue of The American Journal of Medicine.
