A Doctor's Rules for Other Doctors--Part 1


December 14, 2018

Hello and welcome. I'm Dr George Lundberg and this is At Large at Medscape.

Happy holidays! Some of you may recall that my usual annual holiday greetings are Scrooge-like, with some kind of "don't-eat-and-drink-too-much-of-the-wrong-things" message. But my At Large column has dwelt so much recently on what humans put into their mouths, that I thought a complete change of pace—to making a recommendation for the perfect holiday gift for a physician—might be good.

Dr Clifton Meador of Nashville, Tennessee, is a longtime good friend of mine. Clifton is an internist-endocrinologist with a special interest in almost everything, but especially how physicians make decisions and act on them. He has been a medical practitioner for many decades, a medical school dean, a high-level academic administrator, and the author of many articles and books.

He first came to the attention of the general medical audience by way of his quirky 1965 New England Journal of Medicine article, "The Art and Science of Non-disease."[1] This article established the concept of non-disease, which is the study of conditions patients may suffer from, even though exhaustive tests to help explain their symptoms lead to no diagnosis of a known disease.

Pursuing this type of out-of-the-box thinking, Dr Meador published his first edition of A Little Book of Doctor's Rules in 1992.[2] Now out of print, it was followed in 1999 by "Rules II." In 2018, we now may read A Little Book of Doctors' Rules III...For Oslerian Clinicians.[3] In this third edition, Meador lists 371 rules for the practice of medicine, intended especially for doctors who are early into their studies.

According to Meador, there are three tests for rules:

  • A good rule makes intuitive sense. It has a ring of truth.

  • A valid rule has been observed to be helpful in its application or harmful in its violation.

  • 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 of being scientific.

This book is organized into six sections:

  1. Forty rules for listening, talking, and establishing rapport with patients

  2. Fifty-four rules for correct use and understanding of the diagnostic process

  3. Eleven rules for detecting dementia and for use of the mental status examination

  4. Forty-eight rules for correct use of medications

  5. Thirty-six rules for caring for difficult patients

  6. One hundred eighty-two general rules for being a physician and a professional

Let me select and quote two rules from each of these six sections to whet your appetite. Then, in part 2 of this Holiday Gifting series, I will provide many more.

Section 1. Rules for listening, talking, and establishing rapport with patients

"Learn to listen for the 'life narrative' of the patient. Diseases tend to arise from the 'lived life' of the patient."

"Learn to watch the lower lip and then the upper lip."

Section 2. Rules for correct use and understanding of the diagnostic process

"There is no external method to measure how much pain a person is having."

"Once a physician and a patient agree on a diagnosis for a chronic disease, the disease becomes incurable, whether it is present or not."

Section 3. Rules for detecting dementia and for use of the mental status examination

"The social persona is the last thing to be lost in dementia. Do not be fooled by its preservation. It does not take much brainpower to be pleasant, sociable, or carry on a rambling, but polite conversation. Or even to act like the chairman of the board."

"The first clue of dementia may be confusion at night."

Section 4. Rules for correct use of medications

"Stop all drugs if possible. If impossible, stop as many as possible."

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

Section 5. Rules for caring for difficult patients

"Never tell a symptomatic patient, 'Don't worry. It's all in your head.'"

"Illness behavior attracts attention. All illnesses have some secondary gain."

Section 6. Rules for being a physician and a professional

"The 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."

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

Come back soon to see part 2 of Meador's Little Rules. That's my opinion. I'm Dr George Lundberg, at large at Medscape.


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