Charles Bukowski once said, “Wherever the crowd goes, run in the other direction. They’re always wrong.”
How does one become a master? What process do we use to have the highest probability of success? Here are some examples.
“Picasso was an extraordinary craftsman, even when measured against the old masters. That he chose to struggle to overcome his visual heritage in order to find a language more responsive to the modern world is an important triumph that has had a vast effect upon our world.”
– Picasso’s Early Work
Great musicians practice their scales and learn their chords. They play different time signatures. Only then can they tackle jazz or classical mastery. And yet they continue to practice the fundamentals regularly.
“Success doesn’t necessarily come from breakthrough innovation but from flawless execution. A great strategy alone won’t win a game or a battle; the win comes from basic blocking and tackling.”
– Naveen Jain
So what is my point? Why have I started this rant with a series of quotes and statements about fundamentals?
Too many students, residents, and attending physicians fail to work on mastering the fundamentals. What are the fundamentals? At the risk of being pedantic, this is my personal view.
Learning to take a careful and complete history of present illness. While this seems straightforward, the art involved takes much practice and much knowledge. Without knowing at least basic differential diagnoses, one will not explore carefully enough. One can only improve this skill through deliberate practice. We also must understand that HPI questions should not end at the time of admission, but rather continue as we gain more information.
Learning the fundamentals of the physical exam. While some argue that the physical exam is dead (or dying), I still see patients for whom a physical exam finding focuses our evaluation and sometimes helps make a diagnosis.
Learning how to interpret all the routine blood tests. We spend money on these tests, and yet too often learners and physicians do not really focus on the lab tests or now what to do with an abnormal result.
Look at our patients’ X-rays and ask about findings that bother us.
Many newly minted attending physicians either do not really know the fundamentals, or do not understand that their learners need the fundamentals more than they need to learn the esoteric. Too often residents choose weird patient presentations for morning reports, when they really need to dissect carefully the common.
As attending physicians we often erroneously assume that residents have mastered the fundamentals. But while some have, many have not. We rarely go wrong when we discuss physiology, pharmacology or anatomy that relates to the patient’s problem. Even the best residents benefit from a careful discussion of why the serum sodium is high or low, why the bicarbonate level is abnormal, or why the patient has few lymphocytes. Even the best residents benefit from discussing bedside manner, history taking or demonstrating a physical finding.
So my advice: Work constantly to master the fundamentals, even when you exploring the more esoteric. We can only explore new insights accurately when they are based on these fundamentals.
Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.
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