Dr Clifton Meador Offers Pearls for Practice

This transcript has been edited for clarity.

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

I checked my snail mail a few weeks ago and found a small package. I let it decontaminate on my garage floor for a couple of days and then opened it to find, to my delight, The Little Book of Doctors' Rules by Clifton K. Meador, MD, dated 2020. Inside I found a short, handwritten note that concluded: "At 89, I think this is my last book."

According to Amazon, Dr Meador has published 13 books that are available there. Here are the others that I own: A Little Book of Doctors' Rules, 1992; Med School, 2003; Symptoms of Unknown Origin, 2005; Puzzling Symptoms, 2008; Fascinomas, 2013; Sketches of a Small Town, 2014.

This 2020 book is divided into six sections with a total of 365 "rules." Here is a sampling:

  • 34. Rules for Developing Patient Rapport. The interview is the beginning of treatment. While listening to a patient, do not do anything else, just listen. Silence can be helpful. Wait for the patient to break it. It is likely something very important will be said. Never leave the room while a patient is talking. It is all right for a patient to get angry, cry, laugh, or express any other feeling.

  • 51. Rules for the Diagnostic Process. All recurring symptoms are triggered by something. Find out what the trigger is. An acute surgical abdomen is when a good surgeon says it is an acute surgical abdomen. There is no other test as reliable. If you are unsure of a patient's health condition, do not say, "I don't know what you have." Say, "I don't know what you have...yet."

  • 10. Rules for Mental Status Examination. Social skills are the last thing to be lost in relation to dementia. Do not be fooled by the patient's ability to be pleasant, sociable, or carry on a polite conversation.

  • 46. Rules for the Use of Medication. There is no such thing as an organ-specific drug. All drugs affect the entire body. Never treat a drug reaction with another drug unless this second drug is a proven antidote to the first. If you doubt a drug will work, you are probably right. If a patient uses a prescription drug for several months, the patient will be on it for a lifetime, unless a physician stops its use.

  • 32. Rules for Caring for Difficult Patients. Be wary of patients who say they are allergic to everything. There are difficult physicians just as there are difficult patients. We are all human after all. You cannot be everyone's physician. A patient with a factitious disease will not remain with the physician who made the diagnosis.

  • 198. Rules for Being a Professional. Do not discuss your personal life with patients. Most office patients in primary care get well with or without you. A hospital is a dangerous place. Use it wisely, and as briefly as possible. There are three types of questions in clinical judgment: the diagnostic question ("What is wrong?"); the therapeutic question ("What can be done about it?"); and the ethical question ("What should be done about it?")

If you would like to read many more of these rules without buying the book, in 2018 I published these on Medscape.

Clifton Meador's unique way of looking at things first came to public attention from his classic NEJM paper, "The Art and Science of Nondisease ," in 1965. He stated that if a patient has a set of findings that point to an obvious diagnosis but such diagnosis is not corroborated objectively, the patient may have "non-whatever diagnosis." For example, non-hypoglycemia was running rampant by 1974.

Meador has written extensively about the common problem of overdiagnosis and false diagnoses that may last a lifetime. Krieg, Galen, and Gambino in 1975 first alerted the medical profession to the vital nature of sensitivity, specificity, and predictive values of laboratory tests and the huge significance of prevalence of disease in the tested population that comes into play. Meador reminded the medical community about that in 2011 in as simple and understandable an explanation as you will find.

In my thank-you note to Dr Meador for his kind book gift, I protested and urged him not to make this book his last. There is still so much we can all learn from his wit and wisdom. That's my opinion. I'm Dr George Lundberg and this is At Large at Medscape.

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