The “Four A’s” of Medicine

        I saw a patient last month, and her situation reminded me of the four “A’s” of medicine.  The lady stopped me at the grocery store to ask a medical question.  She was not my regular patient, but had seen a Neuse River show, and knew I was a Doc.

        It took three sentences and four questions to know what she described had potential serious consequences.  For reasons I don’t understand her regular doctor could not see her for a month, even though she gave his staff the exact history she told me.  (They wouldn’t let her speak to the Doc or even give the message to the nurse- I promise you Lynn or Myrd woulda known exactly what to do.)  I was reminded of the old “Four A’s,” some of which I learned from my Dad.

        I suspect the “A’s” are also important in many other professions.  They are, and not necessarily in order of importance, Ability, Accessibility, Affordability, and Affability.

        I can only speak to being a general Doc with any authority, and I realize with different specialities the order of importance might change some.  We used to have a Neurosurgeon at the Medical Center who was gruff and bordered on mean, but the guy was such a good surgeon I didn’t care.  My patients would often complain, but I reassured them.  “Look, he’s there to take out your astrocytoma, and he is great at it.  Ya’ll don’t need a Family Neurosurgeon, he’ll turn you back over to me as soon as you are over the surgery.”  On the other hand, if your Family Doc ain’t at least somewhat of a friend, I’d think that over.

        I have one consultant, a lung specialist, who is notoriously difficult, and I use it to my advantage.  He is extra tough on the smokers, and if I can’t get someone to quit, I’ll threaten to send them to him.  “Now Ms. Smith, your lungs are getting worse.  If you can’t quit smoking, I might have to send you over to Dr. Rales for a pulmonary cussing out consult.”

        “Oh please don’t, Tommy.  I promise I’ll stop.  Give me a script for that Chantix you’ve been talking about.  I’ll see you next month.”  I try to give my folks good advice, but I never could bring myself to be mean about it- I left that to ones who did not deem all the “A’s” to be important.  

        It did occur to me with the grocery store case, though, that ability might not always be number one.  The Doc whose office turned her away is a very bright fellow.  I’m certain he knows the answer to the question at hand.  I bet he never knew anyone asked it.  (Of course, if every time his staff asks him to disrupt his appointment schedule he chews them out they might quit asking- I do not know the circumstances.)  But even if he is smarter than me, he sure missed the diagnosis, or even any chance to make it.  So, in this situation, accessibility trumped ability.

        I am a gregarious sort of fellow, and have more friends than any one man deserves, but I don’t rank affability that high.  I’ve had a number of people come to see me ’cause they like my mandolin playing, and that is an error.  If that were a good criteria, they should choose Darrell or Ben as their Doc, not me- I can not begin to approach their level of play.  This time the mandolin did come in handy, ’cause the woman felt comfortable enough to approach me at the dog chow aisle. 

        As far as affordability, with all the high tech demands we have now, I find it more difficult than ever, but I try to keep the costs down.  Most of patients think I’ve been fair enough, but sometimes when I see the bill they get I don’t know if I’d go see me for that!  Certainly for the indigent, or even the middle class folks with one serious illness and no insurance, the system is broken.

       Well, going back to my lady at the grocery store, she did fine.  The diagnosis was a TIA (trying to have a stroke) but she had some surgery and dodged it for now.  And to be honest, she might have been O.K. without intervention, but I wouldn’t have rolled the dice on my own people if they had her symptoms.  (Another rule I have: try to do for your patients like you truly believe you would do for your own family- can’t go wrong there.)

        Ya’ll think about those “A’s.”  I’m curious as to your perspective.  Which ones do you find important in your Doc and why?

        My agent said I was gonna learn a bunch from my readers.  So far, that has proved true, so I will be interested in your responses.

        And for mrschili, how the heck do you write the “A’s?”  Is that right?  I had no idea.

Dr. B

Explore posts in the same categories: Advice- Five Cents

14 Comments on “The “Four A’s” of Medicine”

  1. pandemonic Says:

    I’d like to say I would prefer to “like” my doctor, but when push comes to shove, I think I’d rather have one that has an enormous amount of ability.

    In my business, you’d have to have those same four As.

    Come to think of it, you’d need all of those just to live your life right.

  2. drtombibey Says:

    I agree Ms. Pande. For me ability trumps, but the others can sure be helpful.

    Dr. B

  3. bobleckridge Says:

    I’ve never seen these 4 A’s before Dr B. I guess cos I’m living in a country which has socialised medicine, I never learned about Affordability – we Uk docs don’t know much about the price of medicines! (you might think that’s a terrible thing, but I’m just saying that’s how it is).
    I agree that Ability is the top but I think Medical Training should ensure that all docs have ability. If you can’t do operations well, you shouldn’t be a surgeon! The other two A’s seem to me to stem from caring – if you care about people then you make your self accessible – and isn’t Affability a kind of Accessibility? I’ve always thought it’s a shame that some specialists think Ability without Affability is OK – what does it cost to be human? Would being affable make a doctor less able? I reckon it’s the other way around – an inability to be affable seriously impedes your abilities!

  4. drtombibey Says:

    Dr. Bob is right – almost everyone has ability, and at least starts out well trained.

    Some fall victim to pressures and quit learning or caring, but they are the exception.

    Often affability is VERY important, because the patient is able to feel open to the discussions needed to make a good diagnosis.

    I agree ability is number one, but then again these other factors make it possible to tap into the ability factor. After all, the other Doc in the story had plenty of ability, but missed the opportunity to exercise it and help the patient.

    I know one thing. This is a hard enough business without going around being mean all the time. You are right- it didn’t cost anything to be nice, and it made life much better.

    Dr. B

  5. mrschili Says:

    Doc, you’ve got the spelling of “A’s” right. Usually, I don’t like putting apostrophes in anything that isn’t a possessive or a contraction, but with letters, you kind of have to put an apostrophe in there. Grammatically, you’re all set here.

    For me personally, I think that my doctor’s order should be ability, accessibility, affability, and affordability. My doctor should know what s/he’s doing, I should be able to get in to see her/him so s/he can actually help me, s/he needs to do his/her fair share of establishing a congenial relationship, and I’ll figure out how to pay for it somehow – affordablity is really low on my list, but that’s mostly because I’m not sure how I feel about a for-profit health care system (any more than I like for-profit education, or anything, really, that takes a profit from basic human needs).

    As a teacher, I think my answers are the same – I owe it to my students to be capable and available – that I’m personable and friendly puts them at ease and helps foster a conducive learning environment. I’m not being paid nearly what I deserve (no teacher is, I think), but I’m not in it for the money, anyway.

  6. Ted Lehmann Says:

    Jerome Groopman talks alot about listening, deep listening, to his patients. I guess that falls under the heading of accessbility, but accessibility may have two meanings. One is that the doc should be accessible to the patient. But perhaps even more important, the doc needs to be accessible to self, to be able to listen to what hunches are suggesting, but even more deeply to what resistance is coming from inside. For instance, does the doc find the patient to be annoying in some way? If this is so, can he admit that he’s annoyed and put it aside to make himself accessible? Just a thougnt. – Ted

  7. drtombibey Says:


    So I got an “A” on the “A’s”! Either I paid attention to my English teacher mama or, as we say when a bad golfer makes a good shot, a blind hawg finds an acorn every once in a while.

    I hear you on the thoughts about profiting from human need. I have always felt strange about it too. (One consultant told me I spent too much time thinking about my patients and not enough ordering for profit tests- I considered it a high compliment- I am not sure he understood why.)

    I always had a soft spot for educators- my wife was in that line, as were all her people. I thought they had a lot of education and put in much time for what they were compensated. I am not gonna change my mind till we cut the salaries of second string shortstops dramatically. (And I love baseball.)

    Dr. B

  8. drtombibey Says:


    As always, you have some good observations. Most of my patients are easy enough to work with, but some are difficult.

    I try to recognize it in myself, and discipline myself to be a pro and put in a good effort regardless of the circumstances. It has been years, but every once in a while I have had to find a polite way to tell someone I didn’t think I was the best Doc for them. Usually this was when they began to cross some line that I could forsee was headed for trouble- inappropriate use of meds, lost scripts for controlled substances, patient drifting towards an attempt to establish an inappropriate relationship, etc. I could get mean in a hurry about those.

    I figured if they got me in a spot where my license could be in jeopardy, I couldn’t help anyone, so I could be tough about those things.

    You are right- with true accessibility you reach as deep as you can into both intuition and training, and hope to give the best answers possible.

    Dr. B

  9. amberfireinus Says:

    One of the things that I have definately learned through my own medical drama is that having your GP on your team is invaluable. Nothing and I do mean nothing happens without this person there for you. There is a trust and a bond there. Only that person understands if you are a seriously ill person or a “Church window patient” (a hundered little panes).

    Even though my own GP does work in a big city hospital environment, she has MADE SURE that I have access to her at all times. I have her private phone number, her email, etc. I don’t have to try and get through via anyone else. Of course I respect this priveledge and don’t call her every moment either. Also, I can show up at the hospital at any time and be seen by her. She will make the time for me, as will all of the nurses.

    I am insured with the “K” system. Negotiating it is often really frustraiting for those who don’t know what the rules are. Its a huge system to understand. Without a good GP in it, you are dead. The insurance is literally only as good as the GP.

    I also would like to point out that people do not tend to take responsibility for their own health. Instead they don’t tell the truth to doctors (I can’t stand that). They make their symptoms either sound like no big deal, or a huge drama. They don’t follow up either for themselves. For some reason, they don’t see that like any business there is paperwork involved and many individuals and things slip through the cracks. So they have a test, and don’t bother finding out the results. A year later when they revisit their GP or whomever, they find that actually their cancer test was positive, and that it could have been caught in the early stages. They blame the doctors then. But why couldn’t they have chased it up for themselves I wonder? Where is the personal responsibility here?

    Had I been that patient that you spoke of, and I was concerned, I would have marched myself down to the office and demanded to speak to the doctor for a moment if that was what was going to get me heard. Having to ask someone else……. there is something wrong there. That doctor needs to look at the way he runs his practice and make time to respond to questions at the end of the day or at a convenient time.

    Ok, Im getting off my soapbox now…. 🙂

  10. drtombibey Says:

    Ms. Amber,

    You make some dang good points.

    The role of the G.P has changed. One of our main roles now is to be sure our patient is not short changed by a system that often treats them like a number. If you have a strong lead Doc like you have then you have a chance. You are right- without that kind of Doc you are lost in a sea of numbers people.

    Regarding point number two. My daughter is a grad student who wants to go to med school. (she is very smart and might be a medicial missonary and not just a country Doc like me) In an undergrad class on medical systems the Prof asked the question, “Who is responsible for a patient’s health care?”

    All the kids guessed goverment, doctors, insurance, nurse, all sorts of things, but my little Marie was the only one that got an “A” that day.

    Her answer? “The patient.”

    Of course, the question was rhetorical, and without a Doc to be your advocate the system is hopeless to negotiate, but he was making exactly the same point you outlined today.

    So, I guess you get an “A” for the day, too.

    I recently saw an article in The American Family Physician which agreed with your position on test results. They endorsed what I have been doing for years- partnering with the patient to be sure nothing falls through the cracks. I am forever telling my people, “If you haven’t heard from this by Thursday, call back.” NEVER assume no news is good news- the test could even be lost and the Doc never even saw it.

    And finally, again you are correct in your last point. The patient does have to stand up for their own self. Every so often I’ll not hear it out right, but my people feel comfortable enough with me to say, “Wait a minute, Tommy…” and then we get in right. I high five ’em and keep going- you have to let ego go and be thankful for everything that worked out right, regardless of how you get there.

    Thanks much for your comments. I enjoyed. As my agent says, the reader will often make the points better than the writer of the post. Please come back and visit again.

    Dr. B

  11. rahmama Says:

    Dr. B:
    It’s been 20 years since our family had a doctor with the 4 A’s. He retired about 6 months before our health care system became a ‘system’. Twenty years ago we could call up our doc (also known as Dr. B) and go see him immediately. We had no insurance. He charged us something ridiculous like $20 per visit.

    He was accessible, affable, and obviously affordable. His diagnostic ability was tops. He figured out a strange condition of my husband’s that turned out to be aluminum poisoning. He scored a ’10+’ on all 4 -abilities.

    Now our doctor is whoever happens to be on-call at Urgent Care. Being sick hasn’t been as fun since.

  12. drtombibey Says:


    You get the award for comment of the week.

    “Being sick hasn’t been as fun since.”

    I tell you friend, with the injection of all the insurance people and a variety of other third parties in between me and my patient, being a Doc hasn’t been either.

    Nowadays we have hospitalists, and I am semi-retired, do office work, and have what folks would call a normal life. I know the “system” is more rational, but it ain’t nearly the fun. We used to race around the county day and night trying to do eveything for everybody. (Believe me it is was us or nobody- we did not have anyone else to help) I wouldn’t trade the experience for anything.

    Those days are gone forever, but it sure was fun, so much so I decided I wanted to write it all down before I was gone from this old world.

    If your Dr. B is still living I hope you will tell him that I had heroes like him, and did my best to be that kind of Doc.

    Dr. B

  13. rahmama Says:

    We lost contact with Dr. Billerbeck. He moved out of state, so I don’t even know where to start looking. Wish I could tell him how much we miss him.

    Glad you are writing this blog. It’s very refreshing. Didn’t realize you were a house call doctor. What a concept! Is this just not even possible anymore?

    My great uncle was a horse and buggy doctor in St. Joseph, Mo. a few eons ago. Never met him, but I know I woulda’ just loved him.

  14. drtombibey Says:

    Believe it or not we still make a few house calls. I have several patients who are unable to get out except by ambulance and I check on them.

    I’ve often thought if I ever retired, doing more of them would be a good community service.

    I’ve heard the Docs like your uncle could go out in their buggy late at night, and the horse would know the way home. Sometimes they’d find the Doc asleep in the buggy out in front of the house come morning.

    My son served as my horse a few times and drove me to the hospital in the middle of the night. It was a great luxury- he’d wake me up when we got home, so I didn’t have to sleep out in the car!

    Dr. B

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