A Little Book of Doctors' Rules III Page 5

319Find out who lives in the household with the patient.

  320Human emotional isolation is pathogenic and often lethal.

  321Balance in life is essential.

  Pursue a hobby or some interest outside of medicine.

  322The higher the technology, the greater the need for human contact.

  323Your personal qualities can be as important therapeutically as any drug or treatment.

  324If you should inadvertently offend someone, say you are sorry and remember:

  Everybody gets over everything, eventually.

  325Be wary of patients who say they have hypoglycemia and that nothing helps it.

  326Pay careful attention to patients who say they are going to die.

  327Learn the difference between “informed persuasion” and “informed consent.”

  328If you do something three times and it does not work, it will not work.

  329Physical distance and emotional distance between two people are not the same thing.

  330There is an unconscious mind.

  331It is more important to know the person with the disease than it is to know the disease.

  332Do not confuse benign disorders with serious diseases and thereby expose patients to dangerous and unnecessary procedures.

  333Never ignore an experienced nurse’s observation.

  334A doctor who takes a placebo to treat himself or herself has reached the lowest rung of the therapeutic ladder.

  335Never ask a patient to do a favor for you.

  336Each physician is a drug.

  With each encounter, a physician’s actions can . . .

  produce side effects . . .

  exhibit a duration of action . . .

  induce toxicity . . .

  be indicated . . .

  be contraindicated . . .

  be given in an overdose . . .

  be given in an underdose . . .

  be given at the right interval . . .

  be given at the wrong interval . . . or

  most of all . . .

  produce a placebo effect.

  Learn the pharmacology of being a physician.

  337A response to a placebo has no diagnostic significance.

  Specifically it does not mean the patient is faking, or the pain is not real, or the patient is imagining some illness or symptom.

  338Always leave a diagnostic loophole large enough to crawl back through.

  339Human perfectibility is an oxymoron.

  340The level and intensity of care determine the characteristics of the physician-patient relationship.

  What would be paternalism and domineering behavior in the outpatient setting can be appropriate care in an emergency room.

  No one in their right mind wants autonomy in an emergency or critical care unit.

  Personal autonomy returns with recovery from life-threatening illness.

  341The best prevention for malpractice is rapport with the patient and complete honesty.

  342Be aware of and sensitive to some losses in elderly persons:

  decreased hearing, poor appetite, loss of eyesight, difficulty sleeping, bowel irregularity.

  Be sensitive to their psychological needs and symptoms:

  loneliness, depression, fear of being a burden, fear of death, loss of spouse, loss of friends, debilitation.

  343Any behavior that is ignored will extinguish itself.

  344A map of a territory is not the same as the territory. Do not confuse a model with reality.

  345In medicine, anything that can happen will happen.

  346Many patients do not change.

  They just change doctors.

  347Use it or lose it.

  This rule applies to all parts of the body.

  348The appendix is where the surgeon finds it.

  349The patient who is praying during the examination is probably gravely ill.

  350Any procedure takes longer than the surgeon says it will.

  351A call from a hospital nurse at night is always a plea for help. Help should always be offered.

  352There is an old surgical saw that bleeding always stops. However, it takes a real surgeon to stop all bleeding.

  353A consultant, above all else, is a teacher.

  354A symptom is a ticket the patient thinks he or she must have punched to see you.

  Listen behind the symptoms for the real reason the patient came to see you.

  355Do not hasten death.

  356Surgery for poorly specified chronic abdominal pain will result in permanent abdominal pain.

  357No matter how much time you have spent in a patient’s room explaining the condition, as you start to leave the family will always ask one more question.

  358Good physicians are like good coaches.

  They stay on the sidelines.

  They never get in the game.

  359Psychotherapy is sometimes like riding a well-trained horse down a familiar trail to a well-known destination. The gentlest of pressure on the reins keeps the horse on the trail.

  Only rarely is it necessary to pull the reins one way or another.

  360For most internal emotional states there is a visible and audible external representation in the face, body, and/or voice. The astute physician learns to see and hear these external signals.

  361The mind readily sees and hears differences.

  It takes concentration and effort to see or hear similarities.

  362There are several kinds of what is called noncompliance.

  First, there are those patients who do not take your prescribed drugs because they did not understand the instructions.

  Learn to communicate in their language.

  Second, there are those patients who do not take your recommended drugs because they do not trust your opinion.

  Learn to build trust and respect.

  Third, there are those patients who do not take your drugs because they make them feel bad.

  Learn to hear these people. They are often correct.

  363About the time you think you have seen it all, you will encounter some new unbelievable behavior.

  There is no limit to the strangeness of human behavior.

  364Learn to plot a family tree back three generations.

  Do this with each new patient.

  Look for patterns and similarities.

  365Many people confuse the terms “life expectancy” with “human life span.”

  Learn the difference.

  366Aesculapius is said to have spent most of his time keeping his two fighting daughters separated.

  One was Hygeia, the goddess of prevention.

  The other was Panacea, the goddess of cure.

  367The amount of external commotion at the death of a friend or family member is inversely proportional to the amount of genuine love and affection in life.

  368Language is the most important tool the physician has. Learn to respect and use it wisely.

  370If a patient is clearly lying to you, remember:

  The lie is usually addressed to “the doctor,” not to you as a person.

  That fact, like the lie, are important medical symptoms.

  No patient lie should be held against the patient or cause you

  to be angry.

  371There are three types of questions in clinical judgment:

  The diagnostic question: What is wrong?

  The therapeutic question: What can be done about it?

  The ethical question: What should be done about it?

  372The four fundamental components of good clinical judgment:

  Intelligence

  Knowledge

  Experience

  Continuous critical analysis of results

  373It is usually the second mistake in response to the first mistake that does the patient in.

  374 Every era has its chronic fatigue syndrome equivalent:

  The soldier’s heart in World War I;

  neurasthenia in the 1920s;

  reactive hypoglycemia in the 19
30s and 40s, and again in the 70s;

  chronic brucellosis in the 1940s and 50s;

  and then there were retroverted uteruses and dropped kidneys and the ever-present and popular hiatal hernias.

  We just have to face it.

  Medical diseases cannot explain all of human misery.

  There will always be a group of patients who do not feel good, tire easily, and need a large amount of rest.

  Remember, everybody has to be something.

  375With an undiagnosed seriously ill patient, there is probably a physician somewhere who will know what the patient has.

  Find that physician.

  Acknowledgements

  In early drafts of the rules, I considered giving separate credit for

  each of the rules. I have rejected this notion for several reasons.

  First, a good rule should stand on its own and not rely on any authority. If is a valid rule, it does not matter who introduced it. Second, although I thought I created some of the rules, I could not be sure. After a while it is difficult to separate one’s own thoughts from the accumulation of the thoughts of others. Over the years I have read extensively and therefore would have to list far too many sources if I were to attempt to give credit for all the rules I have drawn from the literature.

  The final reason I am not giving separate credit for each rule is that I do not recall the source of all the rules.

  From my readings, I will begin with Hippocrates then mention Galen and continue with Descartes, Bacon, Sydenham, Laennec, the Hunters, Bernard, Cushing and on to Sir William Osler, whose writings and Aphorisms no doubt stimulated me to update many of his ideas and guiding principles. I have chosen “Oslerian Clinician” as my subtitle to link these rules to his influence. Lewis Thomas and John Stone cover many of the rules in their prose. Garrison’s History of Medicine was a rich source for many of the rules. And then there is the continuing rich medical literature.

  My teachers and mentors directly influenced the creation of the rules in many ways. All were superior physicians. Tinsley Harrison taught the value of listening, dissecting out the details of symptoms, and, specifically, the value of having the patient keep a diary. Rudolph Kampmeier taught the systematic gathering of clinical information and the primacy of the history over all other sources of clinical data. John Shapiro showed me the way to correlate symptoms with pathological findings. Elliot Newman pushed me to doubt and question. Robert F. Loeb, my chief during house officer training, generated most of the rules

  of therapy and those related to the prudent and careful use of drugs. Grant Liddle, my mentor in endocrinology, instilled the importance of measurable data and the essential need of direct observation. David Rogers, my chief in later residency, taught me how to make careful examinations and observations of patients at the bedside. Much later, Joseph Sapira taught me how to listen and to facilitate the patient’s telling of his story.

  Bertram Sprofkin taught me accurate neurological observations and the problems from our deteriorating use of the English language.

  James Pittman taught me high regard for the literature, medical and other. John Freyman taught me the value of historical perspective. Much, much later, there was Stonewall Stickney, who taught me respect for the efforts of modern psychiatry. Many friends and colleagues read the early versions of the rules and gave helpful suggestions. Most shared some of their own rules with me, which I now pass on to you. These include Paul Michael MD, Mark Averbuch MD, Philip Felts MD, John Newman MD, Mary Schaffner JD, Kelley Avery MD, William Stoney MD, Barton Campbell MD, Harry Page MD, Al Roach PharmD, John Dixon MD, Mary Ann Clark, Allen Kaiser MD, John Sergent MD, Clarence Thomas MD, Mitzi Sprouse RN, Curtis G. Tribble MD, Seth Cooper MD, E.E. Anderson MD, Richard M. Zaner PhD, Alice P Meador, Sister Almeda Golson DC, Sister Elise Boudreaux DC, and Sister Colette Hanlon SC. I owe Special thanks to Rosalie Hammerschmidt Lanius RN, who, while in practice with me, participated in the formation of many of the rules.

  Another group of people to whom I owe special thanks are the

  numerous students, residents, and fellows that I have had the privilege of teaching and learning from them through the years. Many have unwittingly added rules of their own through their thoughts and actions. Over the course of 60 years I have had the opportunity to observe just about every imaginable helpful and nonhelpful interaction between physician and patient. Many of the rules derive from these observations.

  I have also had the good fortune to spend time with many practicing physicians across a wide geographic area over many years. My first opportunity came as Dean of the Medical School of the University of Alabama in Birmingham when I traveled up and down the state for a five-year period. My second was while on sabbatical leave at the University of South Alabama School of Medicine when I visited over 20 communities on a weekly basis, meeting with physicians and conducting medical educational programs across most of the state of Alabama. In these meetings I met and examined a large number of patients and observed in detail the practices of many physicians. Many of the pearls of practice I have recorded come from the experiences and wisdom of these physicians. There are too many of them to list, and I have long forgotten which one contributed which thought. I deeply appreciate the chance I had to meet and work with all of these men and women who taught me so much.

  And then there are the patients, the center and purpose of all of our learning. There are far too many of them to name, even if I were allowed to do so. I owe special thanks to all the patients who have allowed me to participate in their care.

  I owe special thanks to Dr. Robert Shearer and Dr. Michael Kaminski, both from younger generations of medicine. Both helped me to change and delete out of date ideas and language. Dr. Ann Price has always been present and available for advice and guidance

  My wife, Ann Cowden, had many suggestions and encouragements to improve my writing.

  I especially appreciate the superb editorial help of Virginia Fuqua

  Meadows. This revised edition of the rules would not exist without her help.

  CKM

  Other Books by

  CLIFTON K. MEADOR, M.D.

  Meador, C.K., A Little Book of Doctors' Rules,

  Hanley & Belfus, Inc., November, 1992.

  Lanius, R.H., Meador, C.K., A Little Book of Nurses’ Rules,

  Hanley & Belfus, Inc., 1993.

  Wadlington, W. and Meador, C.K., Pearls from a Pediatric Practice, Hanley & Belfus, Inc.,1998.

  Meador, C.K., A Little Book of Doctors’ Rules II, A Compilation, Hanley & Belfus, Inc., 1999.

  Slovis, C.M., Wrenn, K.D., Meador, C.K., A Little Book of Emergency Medicine Rules, Hanley & Belfus, Inc., 2000.

  Wadlington, W., Meador, C.K., Howington, M.

  How to Raise Healthy and Happy Children, iUniverse, Inc., 2001.

  Meador, C.K., Med School, Hillsboro Press, Providence

  Publishing Corporation, 2003.

  Meador, C.K., Symptoms of Unknown Origin,

  A Medical Odyssey, Vanderbilt University Press, 2005.

  Meador, C.K., Twentieth Century Men in Medicine:

  Personal Reflections, iUniverse, Inc., 2007.

  Meador, C.K., Puzzling Symptoms: how to solve the puzzle

  of your symptoms, Cable Publishing, Brule, WI, 2008.

  Meador, C.K., Med School, Revised Edition.

  Cable Publishing, Brule, WI. 2009.

  Meador, C.K., True Medical Detective Stories. CreateSpace,

  North Charleston, SC. 2012.

  Meador, C.K. Fascinomas – fascinating medical mysteries.

  CreateSpace, North Charleston, SC. 2013.

  Meador, C. K. Sketches of a Small Town…circa 1940.

  A Memoir. CreateSpace, North Charleston, SC. 2014.

  About the author

  For over sixty years, Clifton K. Meador has been practicing and

  teaching medicine. This revision of “A Little Book of Doctors’ Rules”, his fifteenth book, complements his published writings and his well-
known satiric articles noting the clinical excesses of modern American medicine, including “The Art and Science of Nondisease,”published in the New England Journal of Medicine (1965), “The Last Well Person” also in the New England Journal of Medicine (1994), “A Lament for Invalids” in the Journal of the American Medical Association 1992) and “Clinical Man: Homo Clinicus,” published in Pharos (2011).