Monthly Archives: March 2011

There are many common sayings and catchphrases passed among physicians in our daily discussions surrounding patient care. Many of them are meant to be words of power, words that convey a general principle of medicine, a truism, a pearl emerging from a frequently relived debate. More often than not, however, these phrases are cognitive shortcuts, excuses for applying a habitual practice or pattern to the care of an individual patient when there is still room for debate as to the correct action to pursue. Here, I have collected a few:

The better part of valor. – I have been told by multiple Emergency Room physicians that it is “the better part of valor” to admit a patient to the hospital for observation, even when there is no clear indication for further medical care. When there is no clear indication for admission, by corollary there is no clear endpoint to admission as well: it becomes a much harder negotiation between the patient and the physician as to when the patient should go home because the patient, in a world with limited primary care availability, has numerous outpatient issues that they now want addressed while they are in the hospital and have the attention of a physician. In many ways, this confuses and dilutes the value of inpatient care as “acute” care while increasing health care costs (with unnecessary hospitalizations). This phrase implies that the physician using it is somehow brave and chivalrous in taking an extra step to care for the patient when in fact that extra step is merely the act of punting that patient’s problems to another doctor rather than taking the time to solve it at the initial point of care delivery. Emergency medicine physicians complain of patients using the ED for primary care, and the response is to admit patients to the hospital to have their primary care delivered on the general ward. Similarly, this phrase is used to justify ordering extra tests which subsequently exacerbates the component of the health care cost crisis attributable to defensive medicine; the better, less “safe,” and actually braver route might be to actually use intelligent justification and clearly communicated clinical judgment to explain, document, and reason through problems without ordering every available test.

Obvious. – Physicians of all levels and caliber, from attendings to residents to students, love to embellish their statements with the modifier “obvious.” It amazes me that physicians continue to speak to one another in this fashion: in a field where there is such depth of sub-specialization and narrow expertise, is anything truly obvious? Rather, it seems to me that physicians use the term “obvious” to subconsciously make themselves more comfortable and confident with their own levels of knowledge, however deficient, and to bolster the importance of their subset of facts, theories, and practices. Note that physicians never use the term “obvious” to describe something that is universal knowledge: no one says that it is “obvious” that the heart has four chambers or that diabetes is a disease with great morbidity in the American population. However, it is “obvious” that beta blockers must be stopped in an acute decompensation of systolic heart failure. What is obvious to one is likely not obvious to another as our myriad training backgrounds, despite having some commonalities, do not account for differential knowledge the more advanced and narrow our interests become.

The diagnostic imperative. – I have been told numerous times by Medicine residents that “there is a diagnostic imperative to do (expensive, time-consuming, variably sensitive and specific test).” To me, “imperative” sounds excessively bossy and authoritarian. More importantly, however, the need to use this phrase highlights a key point: that there are many instances in the practice of medicine where we do not have a clear guideline or path, a standard of care. The use of this phrase underlines the fatal flaw of almost every physician, especially those in cognitive fields such as Internal Medicine: the need to know. In order to succeed as physicians, we need to have an answer and explanation for the problems of our patients. Sometimes, we pursue the answer at the expense of our patients – financially, physically, and emotionally. We perhaps do not ask ourselves the broader question enough: “What is best for the patient?” This question includes within it the counterpart of our self-defining need to know: “Does the patient want to know?”

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