I do not know Joseph Alpert, but I would love to sit down at dinner with him. He is the current editor of the “green journal”. In last month’s issue and this month’s issue he has a 2-part editorial that all physicians should read. Actually, the suits, politicians and pundits should read these also. “Common Sense Is Not So Common” (What We All Need to Remember)—Part One and “Common Sense Is Not So Common” (What We All Need to Remember) – Part Two
To whet your appetite, I will highlight selections from his 15 aphorisms.
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.
By the way – he is a cardiologist.
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.
You know that I love that one.
Rule # 14: Physician error is often the result of overconfidence. This observation has been documented in a number of studies focusing on root causes of physician error.5 I remember a number of times when I personally made an erroneous diagnosis or initiated an incorrect management strategy because of overconfidence in my first impression of a particular patient’s problem. Fortunately, in each of these instances, subsequent observations showed me the error in my original formulations and allowed appropriate corrective action to be taken. A recent supplement of The American Journal of Medicine dealt with prevention of medical error.4 This monograph, sponsored by the Paul Mongerson Foundation through the Raymond James Charitable Endowment Fund, stressed that physician overconfidence was one of the commonest causes of medical error.5 Therefore, an open mind and willingness to admit one’s fallibility are important qualities for clinicians.
As a colleague often says, never be quick to marry a diagnosis. I see this rule violated repeatedly – and thus we have diagnostic errors. The problem has a fancy name – premature closure. The best physicians remember to keep an open mind.
Rule # 15: It is a privilege to practice medicine. Patients share their most intimate feelings and life events with us, even things they fail to tell their closest family and friends. We are part of a profession capable of doing great good or great harm. Physicians need to recognize their limitations and strive constantly to improve clinical skills and medical knowledge. Of course, it is also important to remind ourselves that when patients tell us intimate details of their lives, these confidences must be kept confidential.
Amen!
Now – please go read the entirety of the two editorials. All 15 aphorisms are important and well stated.
Bravo Dr. Alpert.
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