When conventional wisdom requires a second opinion

Physicians rely on clinical guidelines every day, but few would follow a guideline blindly without considering the patient sitting in front of them. The same principle applies to the familiar slogans and rules of thumb that shape medical practice. Repeated often enough, they begin to sound like universal truths. Yet when examined under the microscope of experience, many of these maxims require a second opinion. This article will dissect 10 of these age-old adages and how they may be modified and made more applicable to modern health care practices.

If it ain't broke, don't fix it

One of the most enduring expressions in medicine is, "If it ain't broke, don't fix it." The saying encourages prudence, cautions against unnecessary change and encourages maintaining the status quo. But in health care, complacency can be costly. Few physicians would still diagnose pneumonia without a chest X-ray when indicated or ignore the advantages of MRI-targeted prostate biopsies simply because the old methods "worked." Innovation doesn't require that something be broken; it merely requires that something better is possible. In modern medicine, the question is no longer, "Is it broken?" but rather, "Can it be improved?"

This adage may make sense, but it can also be a roadblock to taking action on a new idea. To avoid this trap, consider altering the message to, "If it ain't broke, break it." Breaking it, followed by adjusting, is a method to fix outdated, costly projects that are ineffective and not working. Continuous quality improvement (CQI) is a path to improving existing but outdated processes that may have worked in the past but are not effective today. When the old system is broken and rebuilt, a new and more effective one takes its place.

It was just a few years ago that physicians dictated notes and a transcriptionist converted the text to notes for the chart or to a referring physician. Today, AI-assisted documentation now saves an hour or more each day, reduces burnout and allows more eyeball-to-eyeball contact with patients. The old method of using a human transcriptionist wasn't broken. It just wasn't the best, and it was time to break the old method and replace it with a new approach that is cost-effective and as accurate as a human transcriptionist.

Growth solves everything

Growing a medical practice has been a goal for almost all physicians. Few physicians intentionally seek stagnation, but growth pursued without purpose often creates new problems. Younger and middle-aged physicians hope that increased patient volume will simultaneously increase profit. However, growth can increase problems. This is especially true if the practice is inefficient and cannot support any increase in volume.

For decades, conventional wisdom suggested that bigger was always better. Larger practices promised economies of scale, greater negotiating leverage with insurers, expanded service lines and the ability to spread administrative costs across more physicians. At the same time, solo and small-group practices are disappearing and are often portrayed as antiquated relics.

Practices that grow too rapidly often discover that increased revenue is accompanied by increased complexity. Layers of management, additional regulations, staffing challenges, communication breakdowns and rising overhead can erode many of the anticipated benefits. With uncontrolled growth, physicians may find themselves spending less time caring for patients and more time managing people, processes and tending to administrative paperwork.

Conversely, practices that remain too small may struggle with limited resources, inadequate technology, physician burnout, difficulties recruiting talent and an inability to absorb unexpected financial or regulatory changes.

Somewhere between these two extremes lies the Goldilocks practice: a practice that is not defined by the number of physicians, exam rooms or having multiple locations, but by the alignment of its size with its mission. It is large enough to provide efficient patient care, invest in new technology, attract talented employees and remain financially healthy. Yet the Goldilocks practice remains small enough to preserve strong physician-patient relationships, make decisions quickly and avoid bureaucracy, and offer a positive workplace culture for physicians and staff.

Practices that grow too fast or become unwieldy often see a decline in their online reputation, more complaints from patients and erosion of patient satisfaction. A better alternative is to strive for the Goldilocks or "just right" practice. A better saying might be "healthy growth is better than fast growth."

Know when to hold 'em and when to fold 'em

This advice from a song by Kenny Rogers encourages careful hiring and decisive action when you find that an employee is not the right fit for your practice. However, "fire fast" can lead to premature decisions to dismiss a staff member who did not receive the proper training or onboarding. Firing too fast also creates a culture of fear rather than a culture of development and growth of your staff. A better approach would be to hire thoughtfully and invest the time and effort to properly onboard a new staff member before deciding to dismiss them quickly.

Figures don't lie, but liars do figure

Numbers and data can be powerful tools, but without oversight, data can be manipulated. Data can be incomplete, biased, misinterpreted and even represent past conditions rather than future realities. Practices that rely only on data can miss emerging trends or insights not identified by data.

Consider patient satisfaction scores. A practice may receive excellent ratings because patients receive antibiotics for viral infections or unnecessary imaging studies. The numbers appear favorable, but they do not necessarily reflect high-quality medical care. Likewise, declining office visits may seem alarming until the physician recognizes that telemedicine visits have increased substantially.

A better approach is to use data as a tool rather than depend on it as a crutch. Data should always be viewed through the lens of experience and context. Data becomes more useful and meaningful when it is considered with good judgment and the experience of the physicians.

Time is money

Time has an economic value; however, viewing every minute in terms of its financial value can be misleading. Over-emphasizing this adage may stifle creativity, reduce the value of relationship building and lead to work-life imbalance.

Some of the highest-value time spent includes building strong relationships with patients that ensure patient loyalty and even decrease the risk of litigation. Enhancing the physician's relationship within the community by public speaking and participating in screening programs does not produce immediate returns, but participating in these and other community activities is the foundation for a successful career that ultimately results in financial gain. These activities are not time wasted; they are an excellent investment that will ultimately impact the bottom line.

The physician who spends an extra three minutes listening carefully may prevent a misunderstanding, avoid unnecessary testing or reduce the likelihood of malpractice litigation. Those few minutes often produce dividends that cannot be measured on a productivity spreadsheet.

Competition is bad

Healthy competition is one of medicine's greatest catalysts for innovation. It is natural for physicians to oppose or even resent competition. However, competition stimulates innovation and can set your practice apart from the competition. Historically, monopolies tend to become complacent, while a healthy competitive atmosphere encourages practices to exceed patients' expectations and may ultimately improve patient satisfaction scores and online reviews. Competition in medicine encourages practices to differentiate themselves from competitors by identifying their USP, or unique selling proposition. This may include extending availability, such as early morning or late afternoon appointments, or opening the office on Saturday morning; offering virtual appointments using telemedicine; or demonstrating price transparency so that patients know the cost of care before receiving that care.

The patient is always right

The purpose of this well-worn maxim is to focus on the patient's needs and wants. We all know that patients aren't always right. They may have unreasonable requests such as asking for medication that is not indicated or may be at risk for abuse and addiction. An entirely different matter is verbal abuse of staff, which should never be tolerated. By acquiescing to every patient demand or request, you can undermine staff loyalty and lead to costly staff turnover. A better attitude is that patients need to be heard and respected, but they are not infallible.

You can't manage what you can't measure

W. Edwards Deming introduced statistical process control principles to Japanese industry in the early 1950s. Those methods transformed manufacturing quality and later became the foundation of continuous quality improvement in health care. This approach led to a decrease in production costs, reduced errors and mistakes in manufacturing, and increased the quality of the finished product. These same principles apply to health care, which results in reduced costs and increased quality in medical offices.

Measurement is necessary for process improvement; however, not all that's important can be quantified. In health care, it is not easy to put numbers to quantify quality of care. Reliance only on metrics and data may lead to the detriment of qualitative factors which also matter. The take-home message is measure what you can easily measure, but do not ignore what can't be easily measured.

Failure is not an option

This saying applies more to surgery than to the administrative aspect of the business. From the business aspect, adhering to this advice will stifle risk taking. It is better to assume an attitude that encourages risk taking. Otherwise, the staff will never be able to function independently. For example, every innovation in my practice, from changing scheduling templates to adopting new technology, began as an experiment. Some ideas failed. Most taught us something. A few became permanent improvements. There are no penalties or negative consequences for trying something new especially if the staff tries something new that improves efficiency, productivity or patient satisfaction.

Trust your gut

For decades physicians have been taught to trust their instincts. Today, instinct still matters, but it should be complemented by evidence, data and increasingly AI-assisted decision support. The best physicians combine intuition with objective information rather than relying exclusively on either.

Bottom line

Every physician learns the value of clinical judgment: the ability to recognize when a guideline applies and when the patient in front of us requires a different approach. Conventional wisdom deserves the same treatment. Rules of thumb are useful starting points, not immutable laws. The most successful physicians know when to follow the rules, when to question them, and, on occasion, when to rewrite them entirely.

Neil Baum, M.D., a professor of clinical urology at Tulane University in New Orleans, Louisiana. Dr. Baum is the author of several books, including the best-selling book Marketing Your Medical Practice: Ethically, Effectively, and Economically, which has sold over 225,000 copies and has been translated into Spanish.