Be careful.
227Time is the greatest diagnostician.
Use it wisely.
228There is always a placebo effect acting.
Learn what is placebo about what you do and what is pharmacological.
Keep the two separated in your clinical thinking.
229All patients—those with PhDs in psychology, those who hold high public offices, the illiterate, and the ignorant—want magic from you.
Magic does not require pills or surgery.
230If all you listen to are symptoms, than all you will hear from your patients are symptoms.
All of your patients will have symptoms.
If you can listen to a variety of subjects, then fewer and fewer of your patients will have symptoms. Some of your patients will stop having symptoms.
231Like it or not, there is a little “witch doctor” operating in all physicians.
Use that skill wisely and only for the benefit of your patients.
232There are three kinds of patients.
1.Those who believe every word you say and do everything you suggest.
Be careful what you say and suggest.
2.Those who reflect on what you say, wonder why you said it, ask you questions, and then make up their own minds about
what they do.
Answer all their questions.
3.Those who disagree with everything you say, oppose every suggestion you make, and state that nothing will help them.
Preface every suggestion you make by saying you do NOT think the treatment will work. Lead them to argue that the treatment will work and it will.
Learn to deal with all three kinds of patients.
233Teach patients to be well, not sick.
234There are two types of obese people:
Those who are obese from childhood.
Those who gain weight later in life.
There is a very different prognosis for sustained weight loss for the two types.
235The weight and height tables are not verities.
There are tall people and there are short people.
There are heavy people and there are thin people.
There are endomorphs, ectomorphs, and mesomorphs.
Everybody has to be one thing or another.
236Treat the disease the patient has, not the disease you want the patient to have.
237If you make a mistake in treatment or diagnosis, tell the patient the facts. Say you are sorry and explain what he or she can expect to happen.
Do this no matter how small or large the error.
238Do not tell a patient bad news until you are as certain as possible of the accuracy of the finding.
239Try to leave every patient smiling, no matter how grim the circumstances.
240Never take away hope.
241Never try to predict exactly how long a patient has to live. Above all, do not tell a patient, “You have _____ months to live.”
242There is a fine line between treating a patient and treating yourself.
243You are the patient’s advocate.
You work for no one else.
244With seriously or terminally ill patients, be wary of kin from afar.
They are often trouble.
Some call this “the out of town sibling rule”.
245Avoid all meetings where ex-wives, present wives, and lovers are present. Likewise for meetings with husbands, ex-husbands, and lovers.
246If a wife refuses to leave the room of her husband and makes every effort to prevent you from talking to him alone, then make sure you do talk to the man alone even if you have to arrange it in the radiology department.
247A husband rarely refuses to leave his wife alone with a physician.
Many never even come to the hospital.
However beware of the man who won’t leave the
room of his significant other.
248When a man seeks medical care, there usually is a woman urging him to do it.
Talk with her.
249Never examine a patient of the opposite gender without a chaperone.
250If the patient is a man and there are several women present in the room when you enter, never guess which one is the wife.
And never, ever guess if one of them is the mother. She may be the man’s wife.
251Tincture of time is frequently the best medicine.
252Never let a patient die with a rare but treatable disease.
253Do not worry about missing diagnoses of untreatable diseases.
254Learn to perform a detailed and thorough neurological examination.
255Become an expert on what is and what is not a Babinski response.
It will serve you well.
256A sign is either “present” or “absent.”
Signs are never “positive” or “negative.”
257Avoid use of the terms “negative” or “normal” in describing a physical examination.
Never use “essentially” or “basically” normal.
Describe what you see, hear, or feel and what you do not.
258Use the English language correctly and concisely.
259No verbal presentation of a case should ever take more than five minutes.
Longer presentations mean you do not know what you are talking about.
260Do not say “In my experience” until you have been in practice at least ten years. Even then, use the term sparingly or not at all.
261Learn to check for the name of your patient on all laboratory and other test results.
Reports and results get switched.
262Human biology and clinical medicine are not the same discipline.
Human biologists and clinicians use very different thought processes.
263Most elderly people do better and feel better when they stop taking all drugs.
264A lot of what is called aging is simply disuse and inactivity.
Gently push old patients to stretch all their muscles daily and go for daily walks.
265Make a list of lethal but treatable diseases.
Make a vow that you will never miss a diagnosis of any of them.
Be sure to include the following:
Diabetic ketoacidosis or any acidosis
Hyperosmolar states
Meningitis (bacterial, fungal, or tuberculous)
Cryptic blood loss
Thyrotoxicosis
Addison’s disease
Toxic shock
Rocky Mountain spotted fever
Dehydration
Hypoxemia
Obstructive renal failure
Surgically curable forms of hypertension
Sepsis
Mechanical intestinal obstruction
Ruptured viscus
Subdural hematoma
Hyperparathyroidism
Hypoglycemia, especially that due to hyperinsulinism
Mechanical pulmonary obstruction
Benign resectable tumors of the brain or spinal cord
Heart failure due to arteriovenous fistulas or other high output states
Add others as you learn about them . . .
266Learn to trust your feelings. They can tell you a lot about the emotional state of your patients.
If you feel depressed, the patient may be depressed.
If you feel confused, the patient may be confused or even demented.
267When talking with partially deaf patients, put your stethoscope in their ears and talk into the bell.
They will appreciate your thoughtfulness even if they still cannot hear.
268With severely ill men over 75 years of age who are hospitalized, the absence of one or both hands on their genitals is a grave prognostic sign.
269Don’t get mad at your patients if they don’t improve with your therapy.
Don’t get mad at your patients because of their life style.
Don’t get mad at your patients.
If you do, get some help.
270If difficult patients ask whether they should be
sent to the Mayo or Cleveland or Oschner Clinic, show your wisdom and concern by referring them there.
271Learn how often each patient needs to return to see you. Some patients require weekly visits, some monthly, and others quarterly or annually or even every two or three years.
There is no rule of thumb to help you decide this.
272When you do not have a specific diagnosis and the patient is up and about and not seriously ill, be very careful that you do not make up a diagnosis of a disease that will come to haunt you later.
It is sometimes better to use physiologically descriptive terms or the names of symptoms in these situations rather than disease diagnoses.
273There are no brittle diabetics.
There are only brittle doctors.
274In analyzing a symptom, keep asking questions until you can make a mental picture of the patient having the symptom.
Begin to imagine how it would feel to have the symptom.
If you cannot do this, you probably do not have an accurate description of the symptom and should ask more questions about its nature.
275After you think you understand the nature of a symptom, repeat what you think you have heard. Do this until the patient agrees (with nodding head) that you have understood what the symptom feels like and under what circumstances it occurs.
276Never point or shake your finger at a patient.
If you do that, please stop it.
If you do not know if you do it, ask a friend.
If you do not have a friend, make one.
277THE RESPONSE YOU GET IS THE MESSAGE YOU SENT
If a patient gets mad as you talk,
you said something that angered the patient.
If a patient laughs as you talk,
you said something that was funny to the patient.
If the patient cries as you talk,
you said something that was sad or upsetting to the patient.
If the patient begins to argue with you,
you said something argumentative to the patient.
278If you do not like the response of another person, consider changing YOUR own behavior.
279If you find yourself being frequently surprised by the responses of patients, you may be sending double messages:
One message with your words . . .
A different message with your tone of voice . . .
Another with your facial expression . . .
Still another with your body posture . . .
Only an audio-video tape of yourself will uncover this kind of problem.
280The first step in effective communication is to gain the full attention of the other person.
Sometimes this requires long periods of silence.
281Unless you can repeat what another person says and have that person nod agreement, you have not listened accurately.
Practice this until it becomes natural for you.
282Learn to get the full attention of your patients.
Learn to give them your full attention.
283Anger overlies fear.
Do not respond to anger defensively.
Find out what the patient fears.
284There is a time for action
There is a time for no action.
285Do not throw instruments.
286Don’t ever tell a woman she cannot get pregnant.
287Speak so you can be heard.
288Write so others can read it.
289 Doctor’s spouses CAN have medical diseases.
290If in doubt about what to do, do what your
grandmother would have done.
291Wash your hands.
Do it in front of your patients.
292Before you examine a patient:
Warm your hands.
Warm your stethoscope.
And be sure to warm the speculum.
293When you don’t know what to do.
Do nothing!
294Do know harm.
Do no harm.
295Always observe the patient walking.
296Unfortunately our entire system of health care too often teaches patient to stay sick, not to get well.
297A hospital is a dangerous place.
Use it wisely and as briefly as possible.
298Be very kind to nurses.
They will be kind to you.
Be unkind to nurses.
They will make your life miserable.
299Never tell a patient, “Don’t worry.”
300A bleeding scalp or facial laceration is never as bad as it looks initially.
301Never wake a patient to give a sedative or laxative.
302Confusion is an essential phase of learning.
303The first job of a physician is to determine if a patient is sick or well.
If sick, what kind?
If sick, how sick?
If sick, what treatment? If any.
304Learn about the setting in whch the disease developed. It will tell you much about the diagnosis.
305The physician’s beliefs determine the patient’s beliefs.
306Acquaintances of patients always tell terrifying stories about some person they knew who had the same disease, underwent the same operation, or who took the same drug as the patient.
They will always describe the worst possible outcome, complication, or reaction.
Warn your patient with new diagnoses of serious diseases that this will happen.
This will save you time.
307Only the patient knows how he or she feels.
No one else does.
308A physician who treats himself or herself has a fool for a patient and a bigger fool for a physician.
309The error of making a false diagnosis of a nonexistent disease is hidden from all parties.
The patient is satisfied to have a name for the symptoms.
The physician has a diagnosis, albeit false.
The “disease” cannot progress since it does not exist.
The “disease” will always be a mild form.
The treatment may appear to work.
BE CAREFUL WITH LABELS . . . ESPECIALLY FALSE ONES.
310With chronic undiagnosed complaints, have the patient keep a symptom diary.
Look for correlations with activities, food, people, work time, and location. Later you can add “thoughts.”
If the symptom is said to be “constant,” ask for hourly entries.
If the symptom is daily, ask for twice-a-day entries.
If the symptom is weekly or less, as for daily entries.
311There are two assumptions that are helpful with any patient with a chronic illness:
The patient is doing something (albeit unconsciously) to aggravate the symptoms.
The patient is not doing something (albeit
unconsciously) that would alleviate the symptoms.
312Ask patients with chronic symptoms two questions:
What are you doing that you should stop doing?
What are you not doing that you should be doing?
313All disease labels are abstractions.
Only the patient is concrete.
314Patients who are receiving money for disability rarely get well.
After the first year they never get well even if the money is less than they could earn working.
315Ask your patients what the specialist told them before you tell them what the specialist told you. This will save you and the patient a lot of confusions and re-explanations.
316Assume that unconscious patients (including those
anesthetized) hear, understand, and will remember what you say.
317Reserve resuscitation for WITNESSED Cardiac Arrests.
318Stories and metaphors are wonderful teaching devices. To be effective, they must be closely related to the life and world of the patient:
Golf stories for golfers
Auto repair stories for mechanics
Computer analogies for accountants
Football or basketball games f
or sports fans
Fishing or hunting accounts for outdoor folks
A Little Book of Doctors' Rules III Page 4
