A Little Book of Doctors' Rules III Page 3

  121When taking a detailed drug history, start with the drugs taken

  today,

  then the day before,

  then the day before that.

  122Medicines should make patients feel better, not worse.

  If a medicine makes a patient feel worse, stop it and find a suitable alternative.

  These rules do not apply to patients receiving

  chemotherapy for cancer.

  123Do not treat acute anxiety with drugs, except in real emergencies.

  124Depression comes in two forms:

  There is little “d” depresison. We all get that. It is a part of grief or worry. It passes. Do not treat little “d” depression with drugs.

  There is big “D” DEPRESSION.

  It is a disease that requires antidepressant drugs, with the dosage adjusted carefully to the level needed.

  125Tell patients who are taking antidepressants for DEPRESSION that they must take the drug all the time, not just when they feel depressed.

  126The progress of many symptoms (for example, pain or depression) can be followed by use of a self-rating scale from 0 to 10.

  127If a patient gets sick taking multiple drugs,

  one or more of the drugs is causing the symptoms.

  Stop the drugs and observe.

  Does not apply to patients receiving chemotherapy for cancer.

  128Few, if any, pharmaceuticals cannot be safely stopped.

  129Learn which pharmaceuticals should be tapered before they are stopped.

  130Learn which drugs require titration of the dosage.

  131Learn the difference between titration and tapering.

  132Never use a potentially toxic drug when the benefit is minimal or zero.

  133For patients with acute, severe, incapacitating pain, use enough narcotics to relieve pain. Do this intravenously until the patient

  is comfortable.

  134For patients with chronic pain, no matter how severe, do not use narcotics unless the patient has a terminal disease. Then use all that is needed to relieve pain.

  135Do not give a drug intravenously or intramuscularly if it can be given orally.

  There is at least one exception:

  Intravenous narcotics in a patient with severe pain from an acute myocardial infarction.

  136Any new abnormality that occurs with the administration of a new drug is due to the drug until proved otherwise.

  137There is no manifestation that cannot be caused by any given medication.

  or

  Any medication can do anything.

  138There are few clinical trials of patients taking more than four drugs and very few of patients taking three.

  Any patient on more than four drugs is beyond established medical science.

  139The likelihood of an adverse drug reaction rises exponentially with an increase in the number of drugs administered.

  140The absence of a reported specific toxicity of a drug does not mean it cannot or does not occur.

  141Drug reactions can be unique to a single patient.

  142Learn what treatments are futile.

  143If a treatment is futile, do not use it.

  144Elderly people are fragile and decompensate easily. Work them up gently.

  Treat them carefully with drugs, if drugs are necessary.

  145Enemas, sedatives, and use of multiple drugs can cause nighttime falls.

  146There are more people taking thyroid hormone who do not need it than people taking it who do need it.

  147If you doubt a drug will work, it probably will not.

  148Patients often take pharmaceuticals from several physicians simultaneously.

  149Periodically have the patient or a family member bring in all the drugs the patient is taking.

  With some ceremony, throw away any that can be stopped.

  150If a patient takes a drug for several months,

  he or she is on it for life, unless a physician removes it.

  151If you add a drug, try to remove one.

  152Be alert for denied hypnotic-sedative abuse, in old people. Withdrawal symptoms such as a seizure may be the first clue.

  153On each return visit, ask elderly patients taking several pharmaceuticals to describe:

  The color, size and name of each pill or capsule . . .

  The time of day they take each dose . . .

  The number of each pill or capsule they take.

  The few minutes it takes to hear this will save hours of problems later.

  154Patients frequently do not take pharmaceuticals as prescribed.

  155The less often a patient has to take a medicine,

  the more likely he or she is to take each dose.

  V. Rules for caring for difficult patients

  156Be wary of patients who are too complimentary of you as a physician, especially on the first visit.

  157You cannot be everybody’s physician.

  158Learn to distinguish those patients for whom you can be their physician from those for whom you cannot.

  Refer the latter to another physician.

  Do it sooner than later.

  You might say, “I do not have the training to care

  for your problem.”

  159Patients with factitious disease (secretly self-inflicted disease) do not remain with the physician who makes the diagnosis.

  160If you do not know what is wrong with a patient after you have taken a history, then take another history. If you still do not know, take a third history. If you do not know then, you probably never will.

  161Never tell a symptomatic patient, “Don’t worry. It’s all in your head.

  162Never tell a symptomatic patient, “There is nothing wrong with you.”

  It is demeaning and insulting.

  When the patient insists on having a diagnosis:

  163the patient has multiple complaints;

  you do not know what the patient has;

  the workup has been thorough but negative; and you suspect there is no demonstrable medical illness to explain the symptoms;

  Say “I KNOW what you DO NOT HAVE.”

  Then slowly list every disease that you know the patient does NOT have. Be sure to include a long and tedious list of every known disease you can think of. Do this until you are sure the patient is bored.

  164When you are telling patients what they DO NOT HAVE, be sure to include those diseases most feared and especially those that killed close members of the family.

  Do this only if you are sure you have excluded those diseases.

  165Never reassure a new patient with multiple chronic complaints too early about the absence of a specific disease. Wait a few days. He or she will believe you then.

  166Be wary of patients who smile:

  when they describe pain,

  or severe symptoms,

  or misfortunes in life,

  or the failures of doctors to help, so far.

  167Always be careful of hysterical patients.

  They can have several diseases.

  168Anger, when repressed, is often linked with depression.

  169Some patients are beyond existing medical knowledge.

  170Some patients are beyond all knowledge.

  171FOR ADVANCED STUDENTS ONLY

  For those rare patients who have multiple chronic symptoms and who jump from one symptom to another, here is one way to contain them:

  Put labels on several chairs in the exam room. Label one “head,” another “legs,” still another “chest,” and yet another “stomach.”

  Then say, “I am confused with all your symptoms. It will help me to keep your symptoms straight if you will sit in the appropriate chair when you talk about

  each one.”

  After a few chair changes, patients often begin to talk about what is really bothering them.

  They may drop all mention of symptoms.

  172Any juvenile diabetic patient with recurrent admissions for ketoacidosis is omitting insulin until
proven otherwise.

  Confrontation of this is rarely ever helpful.

  Knowing this, however, can be very helpful.

  173Illness behavior attracts attention.

  All illnesses have some secondary gain.

  174Factitious fever does not elevate the pulse rate.

  175Paired or butterfly-shaped bruises on the skin are caused by pinching and are usually self-inflicted.

  176Factitious skin lesions do not appear between the scapulae.

  177Factitious disease or poisoning need to be considered in all patients who are undiagnosed or who have unusual findings.

  178Factitious disease can occur as a collaboration between two people: the patient and a friend, parent, or spouse.

  179Think of factitious disease when there are unusual findings, especially when caring for a physician’s spouse or any health care worker.

  180The drugs taken by close relatives can be clues to some factitious diseases.

  Some examples are insulin and anticoagulants.

  181Be wary of patients who say they are allergic to everything.

  182Be wary of patients who say they cannot take any drugs.

  183Be wary of patients with itching teeth.

  184Be wary of patients who complain of “gas” in anatomically impossible places.

  185Some psychotic patients present with bodily symptoms. The somatic symptoms attributable to psychoses will have unusual and bizarre descriptions, such as water running out

  of the ears, drippings from the fingers, or pain like a red belt choking the brain, and so on.

  186Alcohol on the breath does not mean the patient is an alcoholic or even that he or she is intoxicated.

  187Alcoholics can have serious medical diseases.

  188 Be wary of patients who have had multiple surgical operations.

  189Never refer to patients with pejorative terms like “crock,” “shad,” “turkey,” or “gomer.”

  It only reveals your inability to understand the world of the other person.

  190Some diseases are idiosyncratic and peculiar to one patient.

  191If there are difficult patients,

  then there are difficult physicians.

  We are of the same species, believe it or not.

  192A few patients seem to be saying, “I want you to help me, but I won’t let you.”

  General rules for

  being a physician and a professional

  193Much disease is self-inflicted, wittingly or not.

  194The good clinician knows what he or she does not know.

  195The absence of a demonstrable medical disease in a symptomatic patient does not automatically establish a diagnosis of mental illness.

  Contrariwise, the presence of a demonstrable medical disease in a symptomatic patient does not automatically rule out mental illness.

  Violation of both rules is common and a source of great error.

  196Most office patients in primary care get well with or without you.

  197You do not have to like a patient,

  but it sure helps.

  If the dislike is severe, the patient may have a serious personality disorder or may be acting out an aspect of yourself that you despise or disown.

  If you still do not like a patient after three visits, refer him or her to someone else.

  198All patients will lie about something.

  Some will lie about everything.

  199Being a physician is a high privilege.

  Do not abuse it.

  200The medical school curriculum is a poor format for learning anything about life.

  201Respect everyone you meet, especially those who work at menial jobs in the hospital.

  They make it possible for you to be a physician.

  202The odds of you as a physician

  committing suicide,

  getting addicted,

  getting divorced,

  becoming an alcoholic, or

  going off the deep end are very high.

  Find out why before you burn out.

  203Know those things you can change.

  Know those things you cannot change.

  Develop the wisdom to tell the difference.

  204Do not refer to patients as diseases.

  Do not say, “the gallbladder in room _____.”

  or the “cardiac”

  or the “kidney failure”

  of the “chronic lunger.”

  205Just because you know a lot of physiology, biochemistry, and anatomy does not mean you know anything about life or people.

  Let your patients and other people teach you.

  206Learn something from every patient you meet.

  207There is no such thing as an uninteresting patient.

  They are all fascinating in some way.

  Discover what that is.

  208If you do not like clinical medicine, get out of it today.

  209Learn to say “No” tactfully.

  Just say “No.”

  210Say “No” at least once every day.

  211Never explain why you are saying “No.”

  212Do not discuss your personal life with patients.

  If you feel an urge to do that, make some new friends or reconnect with your family.

  213Be wary of seductive patients. Learn how to deal with them in a straightforward manner. If the behavior continues, refer the patient to another physician.

  214Never, ever, have a sexual relationship with a patient or with an office employee.

  215Many general physicians undertreat depression and over treat anxiety with drugs.

  Both conditions can be passing phases of the human condition.

  216Many patients who come to see you will not have a demonstrable medical disease but they will have symptoms.

  217If you are going into a career in academic medicine, spend at least one year away from an academic center in the private practice of medicine.

  218Subscribe to JAMA or The New England Journal of Medicine.

  Read it every week.

  If you do not read it, at least scan it.

  219If you do not know what a sick patient has after a thorough workup, get a consultation.

  If you do not know after the first consultation, get another one.

  Then, if you do not know, refer the patient to a well-known medical center.

  If you practice in a medical center and still do not know, refer the patient to another medical center.

  220Consultants should discuss recommendations only with the referring physician and not with the patient.

  This rule is no longer followed.

  It should be.

  221Some diseases are not treatable, but all patients can be given care.

  222Untreatable diseases should not be treated unless the patient agrees to be included in an experimental protocol.

  223Develop a list of physicians you trust and respect, nurture your relationship with them, and contact them about difficult cases.

  Select one in each of the specialties and call them as often as you need.

  224There are only three ways to answer a question:

  I don’t know.

  I don’t know, but I’ll guess.

  I know.

  225If you need time to think, ask older patients to describe their bowel habits.

  226Almost all diseased patients look sick, talk sick, and act sick. A few diseased patient look well, talk well, and act well. A few people without disease can look sick, talk sick, and act sick.