Doc Xology’s maxims

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After almost 25 years of practise it all boils down to this:
Learning

  • Simple before complex
  • Find the principle behind the instance
  • Learn to ask ‘why’, ‘when’ and ‘what if…’ not just ‘what’
  • Data is not information. Information is not knowledge. Knowledge is not wisdom
  • Connect concepts – past, present and future
  • Consider the implications of everything you learn
  • Construct practical and meaningful goals from your learning
  • You need to know it to understand it but if you don’t understand it, it’s not worth knowing
  • Never listen to a lecture unprepared
  • You can’t learn if you don’t know your gaps
  • What you avoid is what you need to confront
  • Teaching is the best way of learning
  • Don’t be a passive learner. Knowledge is not transferred, it is constructed.
  • The best way to learn is to leave pride at the door and get your hands dirty

Learning medicine

  • “”He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all”
  • Read around every case you see until you think you could do it perfectly

Pre-clinical sciences

  • “The wise are instructed by reason, average minds by experience, the stupid by necessity and the brute by instinct.”
  • The superior clinician asks “Why is this happening?” and “Why now?”
  • Every disease is caused either by impaired homeostasis or overwhelmed homeostasis
  • Drugs restore physiology disrupted by disease
  • Surgery restores anatomy disrupted by disease

Clinical Skills

  • Learn to be systematic before taking shortcuts
  • Recognising abnormal comes from seeing a lot of normals

History

  • A history is a narrative, not a checklist
  • Patients eventually need to be prompted but not led
  • If you don’t ask, you won’t know
  • Wrong answers come from wrong questions
  • Don’t speculate, ask
  • The chronology suggests the pathology
  • The history is a narrative of successive events, not an unordered list of symptoms
  • Recent events and immediate triggers give important clues when evaluating symptoms
  • The drug history includes medications recently started, ceased or altered (and why)
  • Drugs include prescribed, non-prescribed, recreational and alternative
  • Be alert to changes to symptoms not just new symptoms
  • Verify the story before you accept it (especially if it has a major implication)
  • Sometimes the best historian is not the patient

Exam

  • If you don’t look you won’t see
  • Verify that a ‘new’ abnormality is not an old abnormality

Investigations

  • Don’t start testing until you first have generated a hypothesis
  • Do a test only if the result determines if you should act or not act
  • Conversely if you have already decided what you should do then don’t test
  • Verify that a ‘new’ abnormality is not an old abnormality

Diagnosis

  • If you don’t think of the diagnosis, you won’t make it
  • The mind knows what the eyes see, what the eyes don’t see the mind fills in
  • Likelihoods are often determined not only by symptoms and signs but also age, sex, ethnicity and local epidemiology
  • Guidelines and protocols can only work with a good assessment

Assessment

  • The science of differential diagnosis is comparing and contrasting
  • “One should should always consider an alternative. and provide against it”
  • Always ask ‘how sick?’ before ‘why sick’
  • The abrupt onset of severe symptoms generally signify badness
  • Functional impairment is a good assessment of severity
  • Attempt to quantify the severity of any symptom or condition.
  • Find the root cause, not just the diagnosis
  • Causes of problems are often multi-factorial
  • Anticipate and look for the complications
  • Time is often the best diagnostician
  • Watchful waiting includes the watchfulness

Clinical Judgement

  • Garbage in – Garbage out
  • Missing data or speculation results in poor decisions
  • Be mindful of fear or emotions before deciding anything important
  • The most important person in the system is the patient
  • You won’t always be right the first time
  • If you diagnose a zebra it was probably that you were lucky rather than smart
  • You will never be surprised if you consider multiple eventualities
  • If you don’t back your judgment you will never learn
  • Best evidence is applied to individuals, not groups

Treatment

  • Often patients just want reassurance rather than action
  • When to act depends on how low the plane is and how fast it is diving
  • You inform, the patient decides
  • Remind yourself and the patient that nothing is without risk
  • Be able to accept compromise
  • Treat only if the risk is higher than not treating or if the benefit far outweighs the risk.
  • Treat the condition, the cause, the complications AND the symptoms
  • Patient fear, anxiety and confusion can subvert the best laid plan. Address this.
  • Always have a Plan B (and C and D)
  • Continuing a failing treatment is throwing in good money after bad
  • It may be bad if something goes wrong, it’s worse when you don’t respond to it
  • Surgical complications usually occur near the site of surgery

Management

  • Engaging resources to help manage the household makes many health problems bearable
  • Anticipate problems before they occur
  • Disease is dynamic – your responses need to change with it
  • If the patient isn’t getting better, re-consider the diagnosis or verify the treatment is being given/taken correctly
  • Even if nothing else is possible, always treat the symptoms

Medical communication

  • Case presentations are to convert a rambling history and miscellaneous data into a clinically meaningful succinct and orderly narrative
  • Poor communication results in more problems than poor decisions
  • Learn to read between the lines and appreciate the implications

Documentation

  • Proof read your notes and letters as if you were the one receiving them and had known nothing about the patient
  • Anticipate issues and give specific advice on how to deal with them

Disposition and Referral

  • Once you have decided what to do, then who and when is just logistics

Professionalism

  • Ignorance is tolerated. Laziness and rudeness isn’t.
  • Assuming greater responsibility and autonomy is your goal – not avoiding it
  • Acknowledge and learn from your mistakes – don’t make excuses for them
  • Confident humility. Neither bravado nor indecisiveness.

Teamwork

  • Many hands make light work (for everybody not just for you)
  • If you don’t know. Ask.
  • Know your team and their roles. They can make your life easier.
  • Good leadership can’t operate without good follower-ship.
  • Be aware of what is happening around you. Be flexible in your role.
  • People will help you if you help them
  • Remember the team can’t read your mind​

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