The Uncommon Virtue of Common Sense
“But he has nothing on at all,” said a little child at last.
-The Emperor’s New Clothes, Hans Christian Andersen
Sweet is the lore which Nature brings;
Our meddling intellect
Misshapes the beauteous forms of things:-
We murder to dissect.
-The Tables Turned, William Wordsworth
Man is only a reed, the weakest in nature, but he is a thinking reed.
-Pensees, Blaise Pascal
Before continuing on it seemed necessary for me to spill a little ink on an oft-neglected subject-that of common sense. I suspect we are all born with, more or less, some degree of what might be called common sense, however it would appear that whatever fund of this critical trait nature has bestowed upon us, it is thoroughly smothered somewhere along the way during our medical education. I do not think it is altogether killed off, mind you, but rather cast into some forlorn and sublimated state, cowed into submission by years of highly technical training and complex, specialized medical decision making.
A recent case may help to illuminate the problem. An otherwise healthy 4 month old, fully immunized, term infant without any known illnesses who was breast-fed and growing appropriately presented to the emergency department with a chief complaint of a “red eye”. His mother had noticed that he had a red spot on the conjunctiva of the left eye as she was breast-feeding him. The child had had no fevers, runny nose, cough, rash anywhere, increased irritability, prolonged crying spells, unusual activity, shortness of breath or other complaints whatsoever. He was, in fact, entirely normal otherwise but she had never noticed that red spot before. She, not unreasonably for someone who is not in medicine, decided to call her primary care pediatrician’s office.
Seeing as it was off hours she reached the on-call nurse, who was unable to see what she was describing and who recommended a virtual telehealth visit. This was subsequently done and it was decided the patient, who was otherwise healthy and seemingly without any problems, should come to the emergency department to be evaluated.
And so it was that two exhausted parents brought their child to our busy pediatric emergency department at the end of a long day. They sat in the waiting room for several hours, surrounded by an invisible miasma of COVID-19, RSV, croup and various other common respiratory pathogens, before finally getting called back to be seen, at which point my intern went to evaluate the patient. He quickly returned after a few minutes and presented the case to me.
“What do you think he has?” I asked.
“Well, he could have a corneal abrasion though he doesn’t appear uncomfortable at all. He could have some type of undiagnosed coagulopathy? Maybe ITP? Von Willebrand’s? Hemophilia? Or DIC? What about non-accidental trauma?”
“Is he bleeding anywhere else?”
“No.”
“Do his parents seem appropriate? Are there any other concerns you have after examining the child?”
“No.”
“What do you really think he has?”
My intern paused for a moment and shuffled his feet before sighing.
“I think he has a subconjunctival hemorrhage, probably from his own finger accidentally hitting him in the eye. I want to send him home.”
He seemed embarrassed with his own entirely accurate diagnosis and perfect minimalist plan-as if he should have instead recommended labs and a CT scan.
“Perfect!” I replied happily. “Sometimes less is more.”
We went in and evaluated the patient together and, sure enough, he had a small subconjunctival hemorrhage in the left eye. This is like a bruise to the eye and can generally look ugly but generally heals up with a tincture of time. They can arise from violent coughing or vomiting but usually result from something hitting the eye directly, in this case likely the infant’s own flailing hand. It’s a clinical diagnosis and generally no work-up is required. The infant was in no apparent pain and was not irritable and thus I doubted a corneal abrasion, which would hurt quite a bit, and he had no bleeding elsewhere on exam to concern me for any type of new bleeding problem. His poor beleaguered parents were kind, warm, caring and appropriately exhausted after hours spent in the waiting room for what certainly could have waited for a primary care visit the following day at a time that worked for them. I had no concerns for abuse. They needed simple reassurance rather than an evening spent in a crowded waiting room in the middle of a pandemic followed by a costly hospital bill.
If medical costs are skyrocketing throughout the land one reason might be the rapid increase in unnecessary testing. Why should this be so? For one, we feel a certain obligation, not to mention a natural human urge, to harness the magnificent and startlingly complex diagnostic tools at our disposal. In part, this is due to a horrible fear of missing anything at all (FOMAAA), especially, and in large part due to, the fraught medicolegal environment we often find ourselves working within. Alternatively, sometimes patients will come in requesting the CT scan or the MRI they don’t really need. More often than not however, we don’t trust our history and physical exam and we don’t cope well with allowing for any degree of uncertainty to hover around our clinical decision-making. We forget that perfect is often the enemy of good enough and that no test is perfect. The scientist in us demands to know definitively but the doctor in us must learn to be comfortable with inherent uncertainty.
Unnecessary testing harms both patients and their pocketbooks. Allergic reactions, adverse effects, incidental findings that then require more testing (incidentalomas), unnecessary discomfort, increased time and increased costs, radiation exposure and much more are all potential costs of increased testing. Remembering our good, old-fashioned common sense may help mitigate much of these ills however it seems to be a quality that is becoming harder and harder to find in the house of medicine.
In one sense, this loss of something so natural to our being may be due to all of the above-mentioned reasons listed and yet, in another sense, it seems to me to be a direct consequence of how we train future physicians. We have placed so much intense emphasis on the empirical science, on the anatomy and physiology, the pathology, the pharmacology, the hard science of our diagnostics and therapeutics that we forget that we are not dealing with machines but with people. I am reminded of the old saw in which the patient arrives to the emergency department early one morning with a complaint of nausea and vomiting throughout the night. The dutiful physician goes in to see him and after several moments of inquiry and examination, steps back and proclaims that she will order an intravenous line, a liter of crystalloid infusion over two hours, a dose of anti-emetics and another dose of an anti-spasmodic, a plethora of blood work, a urinalysis, a pregnancy test, several x-rays (and maybe a CT scan), telemetry monitoring, an electrocardiogram and continuous pulse oximetry during the work-up.
“Oh no, doc! I don’t want all that!” The patient proclaims, alarmed now at what he has precipitated.
“Well, what do you want?” the crestfallen physician asks.
“A work note.”
The art of medicine is an art because it works for, and in concert with, another human being. The interaction between the two people is a relationship and it is in the relationship where all the action lies. Information flows both ways, as an interactive process, and both parties, the physician and the patient, are brought together on to common ground where the patient may find his needs met within the context of the physician’s experience and training and the physician will find her experience and training hopefully amenable to the specific needs of the patient.
We have amazing and wondrous power at our fingertips-the incredible fruits of our science. To learn how and, perhaps more importantly, when to use this technology takes immense effort and years of training but we must not lose our ability to connect with and talk to our patients. We must remember how to be in a relationship; how to pay attention in the proper manner; how to connect with another sentient being. We shouldn’t forget our good, old-fashioned common sense. We must not forget that, sometimes, folks just want a work note.