Clinical pearls that you don’t learn during medical training

Al Franken, the humorist-turned-senator, once published a book that was titled “Oh, the Things I Know!” Indeed, by the time we reach parenthood, it is truly amazing what we keep up there in that attic of a brain.

Here is a brief selection of things about the practice of medicine that I have had to discover for myself or never quite figured out, including clinical pearls, aphorisms, dictums, platitudes, mysteries and conundrums that have somehow found their way into my own cranium and are constantly trying to escape.

If you are called for a consult, don’t accept the ostensible reason as it comes from the student, nurse or physician assistant. I have learned that rarely when I arrive is the problem what it was purported to be. As in everything else in life, nothing is as easy as it seems or as simple as it sounds.

Once you are out of your training, you no longer find yourself an object in the chain of blame. You have reached the pinnacle. But if you are not at a teaching hospital, you must devise a new paradigm. My own goes as follows: If anything goes wrong, first blame the patient. Then blame the equipment. If that doesn’t work, blame the anesthetist, and if that doesn’t fly, blame the nurse. And only if all else fails, blame yourself.

I have observed that all patients, even if moribund, look improved sitting up in a chair if the last time you saw them they were in bed.

How come they never teach you how to pronounce someone dead? My first day on the job as an intern, when I was called at 1am to do so, I had to improvise. After entering the vacated room (aside from the dead body) and certifying for myself that the patient had no pulse or respiration, I proceeded to pronounce: “By the authority vested in me by the Johns Hopkins School of Medicine and the New York State Board of Medical Examiners, I hereby pronounce you dead.” I immediately heard raucous laughter from the nurses in the hallway, who informed me that pronouncement only required my filling out a form.

If you become a consultant, always remember what is expected of you. Consults are requested for two reasons only: “Please make this patient’s problem go away,” or “Please make this patient go away.”

Why did they never teach you how to open one of those Johnson & Johnson Band-Aids with the red string? I always end up pulling it out.

Regarding the standard recitation of the physical exam, some things they teach you are just plain useless. If you ever see an adult patient in your office for a scheduled visit who isn’t “normocephalic and atraumatic,” go immediately and buy a lottery ticket. Such occasions are unprecedented and augur momentous events.

What in the world is “walking pneumonia?” I can’t find it in my Principles and Practice of Medicine text and it doesn’t seem to have an ICD-9 code. Maybe they’ll put it in ICD-10. For that matter, I have never made a diagnosis of a “nervous breakdown” or “exhaustion” either.

Never ask a patient if he is feeling better before finding out if he has actually obtained and taken the medicine you prescribed. Otherwise you might say “I’m glad to hear the medicine is working,” and receive the reply “Oh, I never filled the prescription,” or, “I filled it but I was afraid to take it until I saw you again after I read the warnings.”

The topic of how to charm a patient could occupy an entire post in and of itself. Here’s one dictum I have developed: Humor always breaks the ice. If you are a male physician seeing a married man, make jokes at the expense of your wife. If the patient is a woman, make yourself the object of the joke, especially if you can quote your wife. If both husband and wife are present in the exam room, make fun of husband if you know what is good for you. Female physicians have to write their own rules, but Borsht-belt style humor is not generally required of them. As a matter of fact, I haven’t any idea what women patients talk about with their female doctors, but I suspect the topic of husbands doesn’t come up unless they are a problem.

If you are a specialist, when providing all hospital consults, visit radiology before you see the patient, not afterwards. You’ll look smarter, do a better note, and you’re going to have to go there anyway. I have learned over the years through great inconvenience not to follow the usual sequence of history, physical and laboratory data in gathering evidence that I was taught in school. As I tell my students, always visit the radiology department before seeing the patient in consultation. There is much that doesn’t get into radiology reports. That way you won’t have to change your opinion to accord with the facts after rendering it.

This is not a hard-and-fast rule, but patients over 60 can be addressed as Bob and those under 50 as Rob, unless they go by their nickname, which is usually their middle name. If so, enter that in your chart. It impresses patients if you know their nickname.

David Sack is an internal medicine physician who blogs at prescriptions.

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  • http://twitter.com/DrMegs MeganGraybillAnders

    Love it! Laughed so hard on the pronunciation of death. I got it on day 2 of internship, and had to covertly Google it. Now, I teach my medical students. :)

  • http://twitter.com/DavidGelberMD David Gelber MD

    I was once asked by a young woman with a breast lump, what i would recommend if it was my wife with the the lump. I replied, deadpan:. “Oh, in that case I would merely do follow up exams. I could check it every night.”

    • Docbart

      Was she amused?

      • M.K. Caloundra

        I wouldn’t have been.

  • KSDiesal

    As a PA your first axiom on consults is a bit elitist. Sure, many are not perfect and I doubt consults from your fellow docs are 100% on target.

  • Docbart

    Thanks for the laughs. You are right that radiology reports leave much unsaid. I especially like the ones at my hospital when the stated impression is “As above.” To think that someone gets paid for that!