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