1949 was a momentous year—astronomer Fred Hoyle coined the term Big Bang, the North Atlantic Treaty Organization (NATO) was formed, and Rodgers and Hammerstein’s classic musical South Pacific opened on Broadway.1 Much less recognized was the publication of an essay by Richard Asher, FRCP, titled the “Seven Sins of Medicine.”2
Although it’s over 75 years old, Dr. Asher’s essay seems timeless in the way that it outlines professional (and unprofessional) behavior among physicians and students. In fact, ever since I first read it back in medical school, I’ve been struck by how relevant it is. Indeed, many of the pitfalls that Dr. Asher described, like obscurity, cruelty, bad manners, overspecialization, love of the rare, common stupidity and sloth still plague our modern healthcare systems, despite the advent of new technologies and organizational cultures.
1) Clarity Over Obscurity
The first sin Dr. Asher described was obscurity. A clinician who speaks in convoluted terms can make a patient feel confused, overwhelmed or even diminished. This may be intentional or completely unintentional, yet the end point is exactly the same. In rheumatology, where diseases are often complex and lifelong, clarity is one of the most powerful tools in our armamentarium. Our patients already face significant challenges in understanding their conditions. The least we can do is speak clearly, avoiding unnecessary medical jargon that creates barriers rather than bridges.3
Clarity also extends to the transparency of our intentions. Patients deserve to know not only what we’re doing, but why. If we are adding a new medication, running a new test or suggesting a change in lifestyle, our explanations should be framed with the patient’s understanding in mind. When we communicate with clarity, we empower our patients to take ownership of their health. It is this partnership, built on mutual understanding, that fosters the long-term relationships so critical to managing chronic diseases.
Admittedly, this is easier said than done. With an increasing array of tongue-twisting generic medication names, an alphabet soup of cytokines that are targets for immunomodulation and advances in basic immunology knowledge that confound more than elucidate, you can understand why there’s a tendency for obscurity. Worse yet, we know that poor health literacy compounds rheumatologic disease and leads to worse outcomes. Therefore, we owe it to our patients to simplify our language as much as possible without diluting our message. Personally, in my clinic, I use the three-syllable rule (adapted from mentors in Kentucky where I completed my residency): All words at the bedside should consist of three syllables or fewer, and when that’s unavoidable, a full explanation is mandatory (e.g., immunomodulator, autoimmune).
2) Compassion Over Cruelty
Dr. Asher’s second sin, cruelty, may sound extreme to our modern sensibilities, but the casual thoughtlessness he described remains all too familiar in today’s clinical environments. Whether it’s the insensitivity of a hurried appointment or the lack of awareness of how deeply a patient’s disease impacts their life, cruelty can manifest subtly, even unintentionally. Rheumatology, perhaps more than many other fields, requires a heightened level of sensitivity and compassion because we often treat patients whose pain and disability are invisible to the outside world, but very real to them.
Compassion in rheumatology doesn’t mean passively offering a sympathetic ear. It means truly seeing the patient in front of you—their fears, frustrations and hopes—and recognizing the emotional weight that comes with chronic illness. Our patients are not experiencing physical symptoms alone; they are navigating a complex emotional landscape, filled with incredible uncertainty. Compassion means staying present with them through their struggles, validating their feelings and offering support that extends beyond the clinical encounter.
Moreover, compassion isn’t just for our patients—it’s for ourselves and our colleagues as well. The burnout epidemic in healthcare has highlighted the importance of self-compassion.4 If we cannot extend grace to ourselves, we risk losing the emotional capacity to care for others. It’s an incredibly sad irony that the cruelty and lack of self-compassion Dr. Asher wrote about eventually consumed his own sense of well-being. Altogether, his words and his life story highlight that compassion—toward our patients and ourselves—transcends being a virtue into a necessity for sustaining long-term, effective practice in rheumatology.
3) Good Manners Over Bad Manners
Good manners may seem a small virtue, yet they are foundational in medicine. Dr. Asher’s critique of bad manners is rooted in the recognition that rudeness, even if minor or unintended, can erode the trust that is so essential in the patient-physician relationship. In rheumatology, where our interactions with patients are often lengthy and frequent, good manners become even more crucial. A simple greeting, a kind word or even just listening without interrupting can make a profound difference in establishing our credibility as clinicians who not only provide care, but actually do care.
I don’t need to tell you that rheumatology is a field in which many of our patients often feel like their lives are spinning out of control. Good manners can help empower patients in their quest to restore a sense of dignity and respect. It’s worth noting that politeness is more than just etiquette; it’s an acknowledgment of the patient’s humanity in corporatized healthcare systems that can often feel depersonalized. It is a reminder of a critical asymmetry: We may see dozens of patients each week, but for patients, their appointment is a significant, and often stressful, event.
One way in which Dr. Asher’s paper has not kept up with the times is the increasingly multidisciplinary and interprofessional nature of medicine. Rheumatologists work closely with a range of other clinicians and professionals—from nurses and physical therapists to radiologists and pharmacists. Polite, respectful, inclusive and equitable communication within these teams not only fosters a better working environment, but ensures that patient care remains cohesive and seamless.
4) Holistic Perspective Over Overspecialization
Dr. Asher warned against the dangers of overspecialization—a trend that has only grown more pronounced with the increasing complexity of modern medicine.5 While specialization is crucial for deep expertise, we must also remember the broader context of our patients’ health. Rheumatologists, in particular, need to adopt a holistic perspective because autoimmune diseases often have wide-ranging effects on the body and mind.
Our patients are not just their joints or their inflammatory markers. They are whole people, often dealing with comorbidities, such as cardiovascular disease, diabetes or depression. Taking a holistic approach means paying attention to how their rheumatic condition interacts with these other health issues. It means considering how social determinants of health, such as access to care or socioeconomic status, inevitably influence their disease and its management.
Overspecialization is also a sinful development within the sphere of research. With funding drying up in recent decades, researchers are now concentrated within silos focusing on very specific projects. The overarching scientist who synthesized knowledge by dabbling in this and that is a thing wholly of the past. It’s understandable why that has occurred, but it’s nevertheless lamentable that we don’t have the same broadness of scientific inquiry.
5) Appreciation of the Common Over Love of the Rare
It is beyond a cliché now that physicians are on the hunt for zebras—rare and exotic diseases—when they should be paying attention to the horses in front of them. Dr. Asher criticized this love of the rare, which he termed spanophilia, for diverting attention away from more common, but equally important, conditions. In rheumatology, where we frequently encounter rare diseases, this temptation is even greater. However, we must always remember that rare manifestations of common conditions like osteoarthritis, gout, or rheumatoid arthritis are more likely than common manifestations of rare diseases.
The virtue of appreciating the common extends beyond diagnosis. Common conditions can often be just as disabling as rare ones, if not more so, due to their prevalence and chronicity. Patients with osteoarthritis, for example, may suffer daily pain and significant functional limitations, yet the gravity of their condition is often overlooked in medical settings. Our billing and coding system makes things even worse because medical decision making, the biggest criterion for billing and reimbursement, is driven largely by complexity.
6) Thoughtfulness Over Common Stupidity
Dr. Asher’s “common stupidity” referred to the rote following of protocols without thought or reflection. In rheumatology, our healthcare systems have forced us into fail-first, step therapy, placing costs for insurance companies ahead of therapeutic rationale. Layers of administration and bureaucracy, through tools like prior authorization and peer-to-peer phone calls, have eaten away at our agency to be thoughtful. Despite these developments, thoughtfulness remains the key to providing personalized care, especially in rheumatology, where no two patients present exactly the same way.
Thoughtfulness also means taking the time to consider and acknowledge each patient’s unique circumstances—their history, their lifestyle, their preferences—before making clinical decisions.
It means questioning whether an additional test is truly necessary, or if the information we already have is sufficient to guide treatment. Will that ESR really change our decision making? Do those ACE levels in sarcoidosis even make sense? Will a complete blood count (CBC) with differential provide any more information than a regular CBC? These mundane questions are profound if we embrace thoughtfulness over automatisms.
In many ways, thoughtfulness is about humility. It requires us to recall that medicine is not an exact science. We must remain flexible and open-minded in our approaches because the only certainty that we have is that the patient is sitting in front of us.
By practicing thoughtfulness, we ensure our care is responsive, adaptive and, most importantly, centered on the patient.
7) Diligence Over Sloth
Lastly, modern rheumatology demands unwavering diligence. With diseases whose activity levels relapse and remit sometimes unpredictably, diligent follow-up and meticulous attention to detail are what keep our patients even somewhat stable. Sloth, as Dr. Asher defined it, isn’t just laziness; it’s the failure to engage deeply with the nuances of care—relying on excessive tests instead of engaging in observation thorough careful history taking and physical examination.
Diligence also means keeping up with advancements in our field. The treatments available today, even compared with those from 10 years ago, have transformed rheumatology practice. To offer the best care, we must stay informed, continually learning and refining our approach. But, obviously, I don’t need to remind you of that, regular reader of The Rheumatologist.
As we navigate the complexities of modern rheumatology on a day-to-day basis, it’s vital to remember that the virtues outlined here aren’t just lofty ideals—they are everyday practices that can elevate our care and improve our patient outcomes. Reexamining Dr. Asher’s seven sins reminds us that, at the heart of medicine, and particularly rheumatology, is a commitment to humanism.
Picture this: It’s the year 2099. We’re about to celebrate the arrival of a new century and bid a fond adieu to the ’90s yet again. There’s a preserved digital file of The Rheumatologist that the AI-infused microchip hardwired in your brain pulls up. Will the virtues that we’ve rheuminated about still be relevant in that world? It’s easy to say that only time will tell. It’s harder, but more accurate, to say that these virtues will only survive if we imbue these words with life and treat them with the utmost seriousness.
Fortunately, our field is defined by clinicians who are committed to upholding these virtues and to minimizing the sins that Dr. Richard Asher originally wrote about in 1949.
Bharat Kumar, MD, MME, FACP, FAAAAI, RhMSUS, is the director of the rheumatology fellowship training program at the University of Iowa, Iowa City, and the physician editor of The Rheumatologist. Follow him on X (formerly Twitter) @BharatKumarMD.
References
- Matthews T. 1949 timeline. Historic Newspaper Blog. 2020 Dec 4. https://www.historic-newspapers.com/blog/1949-timeline.
- Asher R. The seven sins of medicine. The Lancet. 1949 Aug 27;2(6574):358–360.
- Gorter A, Bakker MM, Ten Klooster PM, et al. The impact of health literacy: Associations with disease activity and medication prescription in patients with rheumatoid arthritis. Rheumatology (Oxford). 2023 Oct 3;62(10):3409–3415.
- Román-Calderón JP, Krikorian A, Ruiz E, et al. Compassion and self-compassion: Counterfactors of burnout in medical students and physicians. Psychol Rep. 2024 Jun;127(3):1032–1049.
- Cainelli E, Vedovelli L. Over-specialization versus synergy in neuroscience: Professionals’ integration is more than the sum of its parts. Neural Regen Res. 2021 Nov;16(11):2232–2233.
