A Little Book of Doctors' Rules III
ISBN 9781720155553
Copyright 2018 Clifton K. Meador, M.D.
A LITTLE BOOK OF DOCTORS’ RULES III
… for Oslerian Clinicians
New Revised Edition
TABLE OF CONTENTS
Preface to the New Revised Edition. . . . . . . . . . . . . . . . . . . . . 6
Preface to First Edition: 1992 - Excerpts. . . . . . . . . . . . . . 10
List of Categories of Rules
Rules for listening, talking, and establishing
rapport with patients . . . . . . . . . . . . . . . . . . . . .13-19
Rules for correct use and understanding
of the diagnostic process. . . . . . . . . . . . . . . . . . 21-30
Rules for detecting dementia and use of
the mental status examination. . . . . . . . . . . . . . 32-33
Rules for correct use of medications. . . . . . . . . .35-42
Rules for caring for difficult patients. . . . . . . . 44-49
General rules for being a physician and
a professional. . . . . . . . . . . . . . . . . . . . . . . . . . . 51-80
Acknowledgements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81
Other Books by Clifton K. Meador, MD . . . . . . . . . . . . . . . .85
About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87
On reading Clifton K. Meador’s “A Little Book of
Doctors’ Rules III”
All cultures have their sages. The job of the sage is to codify and pass on nuggets of wisdom gained through experience, observation, and reflection. Dr. Meador is our sage and this little book of rules for clinical practice is just so: a collection of proverbs carefully rendered and trustworthy, offered as
guidance for the clinical encounter that we may avoid folly, proceed expeditiously, render comfort, and see our patients safely through. My advice: read the entire volume over a week-end, then begin again, reading a few at a time over coffee before work, or at the end of the day – to great profit for yourself and your patients!
John Leonard, MD
Professor of Medicine Emeritus,
Department of Medicine, Vanderbilt University
Former Residency Program Director, Internal Medicine
Another reading of Clifton K. Meador’s “A Little Book of Doctors’ Rules III”
This book is so valuable because Meador reminds doctors that they are treating a person, not a disease. With that in mind, he stresses the importance of listening to the patient, observing him, and even touching him.
First, listen for clues: "Most patients can tell you why they got sick. . . Let a patient ramble for least 5 minutes when you first see them. You will learn a lot."
Then, be sure you are facing the patient. "Learn to watch people's faces and eyes. Learn to watch their lower lip and then the upper lip."
Finally, "Always examine the part that hurts. Put your hand on the area."
Then, based on what he has heard, seen and felt, the doctor is in a
position to begin ordering tests-- but not a battery of tests: "Use laboratory tests like a rifle, not a shotgun."
Over-testing can lead to over-treating.
Maggie Mahar,
author of Money-Driven Medicine:
The Real Reason HealthCare Costs So Much.
A LITTLE BOOK OF DOCTORS’ RULES III
…for Oslerian Clinicians
Preface to the New Revised Edition
It has been 26 years since the first edition of A Little Book
of Doctors’ Rules was published in 1992. The book is now out
of print. Colleagues have urged me to publish a revised edition.
There have been many major changes in the science and practice
of medicine. In making these revisions I have tried to preserve
those rules that are at the core of medicine as a healing profession. I have adopted Sir William Osler as our guide, naming this edition after him, focusing on his admonition to “treat the patient with the disease” - rather than treating only the disease.
As you will see, most of these rules remain directed at medical students, residents and physicians in primary care - general internists, family physicians, and pediatricians.
In primary, first contact medical care many patients do not have a
definable medical disease. Some say nearly half. Yet, they almost
all have physical symptoms. Even though there is not a medical
disease behind every symptom there IS a definable cause if one
listens and observes the patient carefully, engaging the patient in
the search. It takes undivided time and attention to identify the
hidden cause of the symptoms, sometimes over a period of several visits. These causes for hidden symptoms vary greatly: stressful relationships at home or work; exposure to toxic substances (inhaled, ingested or in skin contact); or self-inflicted illnesses and injuries (factitial diseases). These causes, whatever they may be, are often buried in the unconscious mind, out of awareness of the patient.
The largest group of patients with symptoms but no disease, are
those patients who have adopted illness as a way of life, whether
labeled hysteria or somatizing disorder or even psychosis.
All patients require establishing trust and rapport which demand
the physician’s full attention and ability to listen. Anything that
distracts attention or reduces direct contact time with the patient
will prevent discovery of these hidden causes.
In reviewing the changes in medicine since 1992, I am struck with how many of the changes move in a negative direction of separating the physician from the patient.
The appearance of the Electronic Medical Record (EMR) leads the list, mandating total time and attention to typing into the record. In my own visits to my personal physicians, I am taken with how little direct attention I am receiving. Face to face contact seems to be disappearing. In my waiting room times, the most frequent complaint I hear from other waiting patients is “My physician just doesn’t listen to me anymore.” Sadly, I have no solution to the EMR problems.
The reorganization of medicine from single or small group
practices into a corporate or hospital owned models has also
brought changes that reduce contact time for listening and
establishing trust and rapport. The demands on the employed
physicians for high volume of visits, even daily quotas, virtually
eliminate time to explore deeper causes for symptoms.
And then there are the tsunamis of new diagnostic technologies –
CT Scans, MRIs, arteriograms, echocardiograms, ultrasound
visualizations, EKGs, EEGs and on and on. All of these are
visualizations, pictures of organs and vessels. If these visualizations fail to reveal an abnormality then the patient is often considered well or free of disease. Are these very powerful and useful diagnostic tools leading us to say, “If we cannot see it then there is no disease or cause”? There ARE diseases and causes that are auditory and must be heard to be found. Again these visual tools can lead us away from listening and observing the patient.
There is an even more insidious effect from premature reliance
on these visualized tests. In many cases these visualizations
are ordered as screening tests on the general population. Whenever a test is ordered on a population with a low prevalence of disease, then the majority of positive tests will be false positives. Low prevalence of disease is the most determining factor for generating
false positives. Once the positive test results are reported, the physician must then do further tests to define the disease, driving up costs (and profits); or worse, he unwittingly accepts the false positive as real and assigns a nonexistent diagnosis to the patient. Both create unneeded demands and expenses for medical visits. Once a diagnosis is given it is almost impossible to get rid of it, even if incorrect. (1, 2). The corporate model, as a money driven enterprise, encourages such excessive use of expensive tests.
All of these factors – EMR entry distractions; the move to corporate practices with employed physicians and volume demands; or the false positive problem from lack of attention to prevalence of disease—all move physicians away from a healing profession to medicine as a commodity.
There is one more distracting feature from the changes in practice
over the past 26 years. The profession is now further and further
divided and separated into more and more subspecialties. Each
specialty now sees its own patients, independent of any generalist. Patients move from one specialist to another with no one to take on the whole patient. Leaving no one, in Osler’s words, “to treat the patient with the disease” not just the disease.
There is even more division of care – the ER physician, the hospitalist, and the general doctor who no longer sees patients in the hospital. The patient must float on his or her own. After 5PM the only choice for care is the Emergency Room. Those patients with symptoms of unknown origin are lost in the fragmented system of medical commodities, often falsely labeled with non-existent diseases.
There is an encouraging change in practice beginning to appear –
the concierge general internist who devotes him or herself to
complete care of an enrolled group of patients. MDVIP.com is a
welcome national movement by these physicians who will provide overall care of the patient, not just the disease.
These rules cannot reverse all of the adverse changes in the practice of medicine. I can only hope they will encourage more to return to the general practice of medicine or pediatrics. I also hope they illustrate the need for medicine to be a healing profession and the need for healers to listen carefully and directly observe their patients.
Clifton K. Meador, M.D.
July, 2018 - Bayside Maine
Symptoms of Unknown Origin: A Medical Odyssey, Clifton K. Meador, M.D., Vanderbilt University Press, 2005.
Meador, C.K. and Lanius, R.H. The Cryptic Error of Nondisease: The Hidden Power of Prevalence of Disease. Journal of the Medical Association of Georgia 1995; 316-319.
Preface to First Edition: 1992….Excerpts
I have often thought there should be a set of rules for the
practice of medicine. In medical school, residency, and later, I
hoped to find such a collection. I believed it would assist me in
developing my skills as a physician. I never found one that
met my needs. Of course I read the aphorisms of Hippocrates,
Osler and others. All were dated and, from a practical sense,
outdated.
Through the years I heard or read concise and useful ideas
about the practice of medicine. I made mental notes, testing
these clinical notions in my teaching and practice.
This book is my effort to compile these rules, observations and helpful tips. I hope they will be useful, especially to those just entering the study of medicine.
There are three tests that I have attempted to apply to each
of the rules:
First, a good rule makes intuitive sense. It has a ring of truth.
Second, a valid rule has been observed to be helpful in its
application or harmful in its violation.
Third, a sound rule is stated in a manner that allows
affirmation or refutation by direct, systematic observations of
others. This last consideration fulfills the important and
essential potential for being scientific.
Although I did not make it a requirement, I have also
selected rules that expose the humorous side of the practice
of medicine. I trust I have not offended too many with this
effort. It is almost (but not quite) a rule that we physicians take
ourselves far too seriously, sometimes forgetting we are human.
I have found the practice of medicine to be a highly entertaining
activity and I wish to convey some sense of that in these rules.
My fascination has always been more with the nature of the practice of medicine than with its actual practice. I have often wondered what it is that constitutes the real stuff of the practice of medicine. What are its essential elements? What is it we do that is helpful? What do we do that is harmful? Is there a way to codify and describe these necessary elements? Can we tease out the unspoken and unwritten rules by which we operate and which
determine our behavior and make us physicians? Can we begin to explore the hazy art of the practice of medicine in some systematic way? Can we create a science of the art of the practice of medicine?
Clifton K. Meador, M.D.
Vanderbilt University School of Medicine
1992
Rules for listening, talking, and establishing rapport with patients
THERE IS NO RULE WITHOUT AN EXCEPTION.
MOST RULES CAN BE BROKEN.
1 Learn to listen for the “life narrative” of the patient. Diseases tend to arise from the “lived life” of the patient.
2Sit down when you talk with patients.
Don’t talk with patients with your hand on the door.
3Always examine the part that hurts. Put your hand on the area.
4Touch the patient, even if you only shake hands or feel the pulse, especially with seniors.
But not with paranoids.
5When you are listening to a patient, do not do anything else. Just listen.
6The interview is the beginning of treatment.
7Learn to watch people’s faces and eyes.
8Learn to watch people’s nostril size.
9Learn to watch the lower lip and then the upper lip.
10Learn to watch facial expressions including the skin color.
11Notice the change in respiratory rate of the patient as you discuss different subjects.
The top edge of the shoulders moves with each inhalation.
12Give the patient permission to discuss unusual or deviant behavior. Do this in a specific manner:
If you think a patient may be abusing laxatives, say, “Some people take only a tablespoon of milk of magnesia a day, some take 2 or 3 bottles a day. How much do you take?”
If you think a patient is abusing enemas, say, “Some patients I know take an enema once a month, others several times a day. How often do you?”
13Whatever subject the patient is most comfortable
discussing is probably not the real trouble.
14Most patients can tell you why they got sick.
15Most patients can tell you what their sickness is.
16Let patients ramble for at least 5 minutes when you first see them.
You will learn a lot.
17Some people have fast brains, others have slow brains.
Adjust your thinking to the pace of the patient.
18THE SHOCKING WILD GUESS METHOD
For the patient who repeatedly says, “I can’t talk
about . . . THAT”:
If the question was about the husband, you make a
wild guess that he is a felon or some equally startling notion. If the question is about a child, you make a wild guess that he tortures pets with fire or something equally abhorrent to a parent.
There are two possible results with this method:
Your guess will be correct and you will appear clairvoyant, permitting the patient to talk more freely about the taboo.
or
Your guessed an
swer will be so much worse than reality, the patient will feel relieved and more comfortable about telling the truth to prove you incorrect.
The taboo is defused either way.
19Avoid “organ” talk.
Do not ask,
“How is your colon?”
or
“Your stomach?”
or
“Your sinuses?”
or
“Your heart?”
or
any other organ.
Ask how the patient feels. Do not let patients use
organ talk. Patients know only how they feel or what they think. Insist on a language of symptoms, feelings, and thoughts.
20If a patient talks about a disease diagnosis, ask about the diagnosis.