COMMENTARY

A Doctor's Rules for Other Doctors - Part 2

Disclosures

December 19, 2018

Hello and welcome. I'm Dr George Lundberg, and this is At Large at Medscape. This is part 2 of my annual holiday message, this one without Scrooge. Happy holidays!

Nashville's Dr Clifton Meador first became well known for his 1965 New England Journal of Medicine article, "The Art and Science of Nondisease."[1] In other words, if you are thought to have a disease but you don't, what do you have?

Keenly interested in how doctors think and act, Meador has published A Little Book of Doctor's Rules in three editions—in 1992, 1998, and now in 2018.[2] In part 1 of my annual message, we spoke much more about the author and how the rules were developed, with a few samples. Here are more samples of the rules, selected by me from the total of 371.

This book is organized into six sections.

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

"Let patients ramble for at least 5 minutes when you first see them. You will learn a lot."

"Listen for what the patient is NOT telling you."

"Always examine the part that hurts. Put your hand on the area."

"Always face the patient. Maintain eye contact that is comfortable to the patient. (The electronic medical record has obliterated this rule; a great loss to clinical medicine.)"

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

"There is no single blood or urine test to differentiate a well person from a sick one."

"Severe, acute abdominal pain always requires a surgical consultation."

"Do 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, expect false positives."

"Ask patients, 'How are things at home? How are things at work?'"

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

"If in doubt about dementia, do a mental status evaluation."

"There is no blood or urine test to measure mental function. There probably never will be."

"Assume that the acute onset of confusion in an elderly person is infection."

4. Rules for correct use of medications

"Know which abnormality you are going to follow during treatment. Pick something you can measure."

"If there is no abnormality or symptom to follow, do not treat with medicines or surgery."

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

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

"For 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."

5. Rules for caring for difficult patients

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

"You cannot be everybody's physician."

"Factitious fever does not elevate the pulse rate."

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

"Be wary of patients with itching teeth."

6. General rules for being a physician and a professional

"Being a physician is a high privilege. Do not abuse it."

"Respect everyone you meet, especially those who work at menial jobs in the hospital. They make it possible for you to be a physician."

"Do not throw instruments."

"Don't ever tell a woman that she cannot get pregnant."

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

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

"Never examine a patient of the opposite gender without a chaperone."

"With 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."

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

I wish I could just keep going, but there are 371 rules. Buy the book; savor the wisdom; become an even better doctor.

That's my opinion. I'm Dr George Lundberg and this is At Large at Medscape.

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