If a patient says, “It started as the ‘flu.’”
You ask, “what was that ‘flu’ like?”
21If a person’s eyes are moving as you talk,
he or she is not listening with full attention.
22It is impossible to think and listen simultaneously.
Listen.
Think.
Listen.
Think.
23Listening requires practice.
Learn to stop thinking.
Learn to listen.
Just listen.
24Talk with, not to patients.
25Silence raises anxiety.
Wait for the patient to break it.
The patient then will say something very important.
26Learn to embed difficult questions in statements.
Instead of asking, “How much whisky do you drink during a day?” Say, “I am wondering how much whisky you drink each day.” Or, “I am wondering if whisky plays any role in
your illness.”
The patient will hear the statement as a question but not be threatened.
27Always face the patient.
Maintain eye contact that is comfortable to the patient.
Do not stare.
Some patients tolerate very little eye contact.
Learn to observe out of the corner of your eye.
(The EMR has obliterated this rule:
a great loss to clinical medicine.)
28There is no substitute for direct observation.
29General unspecified questions produce informative answers.
“Tell me about your breathing.”
Specific questions produce limited information and only “yes” or “no” answers.
“Have you ever had any shortness of breath?”
Learn to use non-specific language.
30Occasionally you can disarm a difficult patient with a compliment and make him or her your ally.
31Listen for what the patient is NOT telling you.
32Never appear shocked by anything a patient tells you.
33Stand up when a patient enters or leaves your office.
34Do not talk to an angry patient about any other subject until you understand the source of his or her anger. Take as long as necessary to diffuse the anger.
35It is all right for a patient to get angry.
36It is all right for a patient to cry,
get depressed,
laugh,
hurt,
or have any other feeling.
37Do not back out of the room as you are talking with the patient.
38The last statement a patient makes as you leave the room is very important.
39Never leave the room while a patient is talking.
40Listen carefully when a patient prefaces a comment with, “This may not be important,
but . . . “
Rules for correct use and understanding of the
diagnostic process
41You often have to throw out some result or finding. Choose wisely what you discard.
42There is no single blood or urine test to differentiate a well person from a sick one.
43The only way to determine if a person is well or
sick is to listen, look carefully, ask good questions, and make a sound clinical decision.
44THE LAW OF PREVALENCE.*+
Under the LAW OF PREVALENCE, false-positive values are the diagnostic pitfall with outpatients in primary care practice.
When a patient is not sick or has come only for a checkup, discard and repeat positive test results.
Under the LAW OF PREVALENCE, false-negative values are the diagnostic pitfall with the critically ill.
When a patient is very ill, discard and repeat important negative test results.
__________________________________________________
*The equation that states the LAW OF PREVALENCE IS:
Predictive Value = ____prevalence x Se______________
(Positive Test) (prevalence x Se) + (1 – prevalence) (1-Sp)
Where Se = sensitivity
Sp = specificity
From its position in the equation, one can readily see the power of low prevalence for producing false positive results.
____________________________________________________
+ 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.
45Prevalence is to the diagnostic process what gravity is to the planetary system.
It has the power of a physical law.
Above all other factors, it controls the accuracy of the diagnostic process.
46Prevalence of serious disease varies widely according to the site of practice.
It is low in community or family practice,
high in a referral diagnostic center,
extremely high in a referral critical care unit.
47Severe, acute abdominal pain always requires a surgical consultation.
48A good surgeon evaluating acute abdominal pain is equivalent to a highly sensitive and specific laboratory test.
49An acute surgical abdomen is when a good surgeon says it is an acute surgical abdomen.
There is no other test as reliable.
50Symptoms attributable to medical diseases tend to get better or worse.
Physical symptoms attributable to psychological disorders tend to stay about the same over time.
51If you catch yourself thinking a patient might have either hyperthyroidism or hypothyroidism, then the patient does not have either.
52Do not go on “fishing expeditions” for diseases that are not dictated by the history, the physical examination or the circumstances of the case.
If you do, you can expect false positives.
53After you make a diagnosis and begin treatment, if the patient does not get better, be willing to throw out your first diagnosis and start over.
Do this in your thinking before you tell your patient.
54There is no external method to measure the presence or absence of pain.
55There is no external method to measure how much pain a patient is having.
56Rare manifestations of common diseases are more common than common manifestations of rare diseases.
57A middle-aged man who suddenly develops what appears to be a character disorder, or a dysphasia, or some new behavior, has a brain tumor until proven otherwise.
58Absence of clinical evidence in not evidence for its absence.
59When caring for a very sick patient, doubt all results of all tests.
60The pathophysiology of the diagnosed disease should explain the patient’s symptoms.
If it does not, you either have the wrong diagnosis or you are missing a second disease that could explain the symptoms.
61Order a sed rate.
It is a useful test when used wisely.
62Use laboratory tests like a rifle not a shotgun . . . one shot at a time and with precision.
Multiphasic screenings outdate and obviate this rule, at the cost of extensive false positive lab results.
63Pyloric obstruction can be an elusive diagnosis.
It can present as constipation or just a feeling of fullness. The classic symptom of vomiting is sometimes not present.
64Thyrotoxicosis without a palpable thyroid gland is rare. When this occurs think of exogenous intake of thyroid hormone.
65Be careful with labels.
They can be very difficult to remove.
66No organ system fails in isolation.
67Once a physician and patient agree on a diagnosis for a chronic disease, the disease becomes incurable – whether it is present or not.
BE CAREFUL WITH LABELS.
68Any lump found by a patient is probably more clinically significant than one found by a physician.
(An exception to this rule is the self-discovered calcified xiphoid process, sometimes reported in panic by middle-aged men
as a tumor.)
69If an internist feels an ovary, it is probably diseased.
70All recurring symptoms are triggered by something. Find out what the trigger is.
71 Solving a difficult diagnostic puzzle as a consultant requires the ability to study the details of the workup and uncover what diseases
were missed. You are looking for something that was NOT done or ordered.
This is very different thought process from thinking about disease possibilities when working up a new patient.
72With very sick patients who are undiagnosed, think of poisoning.
Do this no matter what your impression of the family may be.
Test for poisoning before you discuss it with anyone.
73A careful and detailed occupational history can be helpful in solving diagnostic puzzles.
74A detailed dietary history can be helpful in patients with symptoms of unknown origin.
Ask for details of what the patient ate at each meal over the past three days.
75Do not miss protein malnutrition or dietary deficiency states. Obesity does not rule them out.
76A drug screen does not test for all known drugs.
77Masses are either palpable or not.
There is no such thing as a “suggestion of a mass.”
78There is no substitute for data.
79Measure, measure, measure.
Observe, observe, observe.
80Curiosity is not an indication for diagnostic testing. Curiosity kills not only cats but diagnostic accuracy.
81Do not make the error of accepting the first abnormality found as the cause for the patient’s symptoms.
82The normal limits are not verities.
They are only statistically derived and defined terms.
Remember, at least 2.5% of the public live healthy and long lives above the upper limits of any test.
Also remember, at least 2.5% of the public live healthy and long lives below the lower limits of any test.
Everybody has to be somewhere.
83You cannot diagnose what is not in your differential diagnosis.
84A patient under the age of 50 with several symptoms probably has only one disease.
85A patient over the age of 50 with several symptoms probably has more than one disease.
86When you do not know what a patient has, do not say, “I don’t know what you have.”
Say, “I don’t know what you have . . . YET.”
87A very obese person who is losing weight probably has a disease, even if he or she says they are on a diet.
88If you are doing a screening test that has a high probability of being falsely positive, tell the patient ahead of time that you may need to get a second specimen and sometimes a third one
before you can be sure of the results.
If the first test is positive, do the appropriate second test but do not discuss the results of the first test with the patient. . .YET
Let the patient know the test is complicated and subject to variation before you order it.
89When you evaluate seriously ill patients, shape your list of possibilities to those diseases that are treatable, even if they are rare.
90Glass WILL show on x-ray.
91Weigh every patient on admission to the hospital.
92Weight gain or loss within 10 days is all water.
93Ask patients “How are things at home? How are things at work?
94The assumption of a purely localized disease process in a systemic
disease is a common error.
Here are some examples:
Pericardial effusion in hypothyroidism
Proteinuria in bacterial endocarditis
Edema in hyperthyroidism
Neurological deficits in pernicious anemia
Embolic strokes from atrial thrombi
Constipation in hypercalcemia
Heart failure from anemia
Dyspnea in hyperthyroidism
95The diagnostic process was not invented to determine if a patient is sick or well.
It was developed to determine what kind of sickness is present.
III.
Rules for detecting dementia and for use of the
mental status examination
96There is no blood or urine test to measure mental
function.
There probably never will be.
97If in doubt about dementia, do a mental status evaluation.
98Learn to do a thorough mental status evaluation.
Do it as you go along.
Fill it in later:
mood,
affect,
attitude,
appearance,
disorganized vs. organized,
rapport,
speech content,
delusions, hallucinations,
judgment,
memory, recent and remote.
99The error of missing a diagnosis of dementia in hospitalized patients is common. This occurs because cognitive mental status evaluations are too often omitted.
100The social persona is the last thing to be lost in dementia. Do not be fooled by its preservation.
It does not take much brain power to be pleasant, sociable, or carry on a rambling, but polite conversation.
Or even to act like the chairman of the board.
101Some patients with dementia will do everything possible to hide their disorientation, even to the reading of dates from nearby milk cartons or newspapers when tested for time
orientation.
102A test of orientation to time must include the day of the week, the day of the month, the month, and THE YEAR.
103After midnight all cases get clinically strange.
104The first clue of dementia may be confusion at night.
105Restlessness can come from hypoxemia.
Remember this especially when elderly people get restless at night.
106Assume that the acute onset of confusion in an elderly person is infection.
IV. Rules for correct
use of medications
107Know which abnormality you are going to follow during treatment.
Pick something you can measure.
108If there is no abnormality or symptom to follow,
do not treat with medicines or surgery.
109If a medicine is not working, stop it.
110If a drug is working, keep it up.
This applies to patients with chronic conditions.
111In acutely ill patients who are being treated, do not change anything if the patient is getting better.
112If possible change only one drug at a time.
113Stop all drugs if possible.
If impossible, stop as many as possible.
114Be very careful if you decide to treat a drug reaction with another drug.
A better rule:
Never treat a drug reaction with another drug unless the second drug is a proven antidote for the first.
115There is no such thing as an organ-specific drug.
All drugs work throughout the body.
116Do not get your drug information exclusively from drug salesmen.
117Use as few drugs as possible in your practice.
Know these in detail.
118When a patient comes to you taking medicines you do not know, read about them –
and then stop as many as possible.
119It is usually not worth the time and emotional drain to try to stop obese patients from taking thyroid replacement agents or thin patients from taking vitamin B12 injections.
120It is usually not worth the time and effort to try to stop older patients from abusing laxatives.
A Little Book of Doctors' Rules III Page 2
