The Thinking Doctor
( thethinkingdoctor.org )

Rex G. Carr, MD FAAPMR
Renee Boyka,
RDCS (AE, PE), RRT, MSOL

"Anyone who has never made a mistake has never tried anything new"
--Albert Einstein
     This web page is dedicated to helping clinicians get back in to touch with why they became clinicians.

     We became clinicians to help people. We enjoy determining what is wrong with them, putting together a plan to make them better, and initiating that plan. At some point, the patient comes to the office and says, "thank you" or "I am feeling better".

     For this to happen, we must think about what we do, and not just react by partially following guidelines or what we were previously taught. We gather information about our patient (meds, history, symptoms). We then come up with a diagnosis or list of possible problems. Then we initiate a plan of action (treatment).
   
     Here is the hard part... Sometimes our first try fails! What must we do? We must admit that we made a mistake, and be OK with that. We must reassess the situation. What is wrong? The data we used to draw conclusions, the diagnosis, the pathophysiology that we think is going on, the choice of treatment, or the treatment, itself. Yes this happens!

The Thinking Doctor Journal Article

     In my patient population, the two most common reasons for failure are an incorrect diagnosis given by a preceding clinician and the failure of a generic version of a drug that I prescribe. The most common problem that I need to find and solve, is that a medication given to help a patient or a supplement the patient is taking is resulting in the worsening of some of the patient's symptoms.

     Patients and clinicians do not adequately monitor the changes that occur with the starting of a new treatment. There is a multifactorial set of changes that occur. E.G. Antidepressants can be both stimulating and relaxing. B12 can both give energy and make a person feel worse. We give blood pressure medications and monitor the blood pressure in the office, but not at home. We do not assess for feeling more tired or assess for reasons for having higher than normal blood pressure in the office, other than the illness "hypertension".

"You never fail until you stop trying"
--Albert Einstein

    
What patient's really want is to feel supported, by you. You have their back. Just like any other relationship, they want to feel like you care about their welfare, no matter what. They want you to care about what they care about. This may not be an easy thing to convey to them, with short appointment times, a busy schedule, and certain things that need to be done at each appointment for quality assurance or making sure you are not causing harm with your treatment. Or, worse, yet, "missing something".

     What you can do is: DO NOT GIVE UP ON THEM!

    Back to basics. Is the diagnosis correct? Is the treatment correct? Do I understand why the patient is having the problems that they are having? If I do not know the answer to any of these questions, who might be able to figure it out? What do I need to do to know the answers to each of these questions?

     Remember, it is not their fault that they are not getting better!

     Just because a person has a mental illness, along with a physical set of symptoms (that you do not completely understand), doesn't mean that the mental illness is the cause or that it is their fault.
     In the many years that I have been treating people for their chronic pains or fatigue... there has not been a single one where they did not have a physical illness leading to both the physical symptoms and the mental/cognitive symptoms. I have always found a physical illness, that when treated properly, fixes or improves on the psychological symptoms.

     Stresses in the patient's life can lead to increased symptoms, even if a physical illness is the cause. This might be a physical illness that you are not familiar with or that you do not completely understand.

“The only source of knowledge is experience.”
--Albert Einstein

     If you do not know the answers to the above questions, or the patient is not getting better, Dr. Einstein would suggest that you send them to someone that would understand and would be able to help your patient feel better, or perhaps, just feel better supported. IE, send them to someone for consultation with the question that you cannot properly answer or for management.

“The only source of knowledge is experience.”
--Albert Einstein

     Yes, this is the same quote twice! Several individuals have been quoted as saying, to the effect of: "Insanity is doing the same thing over and over, expecting a different result". If you are finding the medications or treatments are not resulting in good outcomes, question them. Below are some clinical pearls that you can use to gain more experience and therefore more knowledge, should you wish.

CLINICAL PEARLS

"The Devil is in the Details" or "The practice of medicine will go much better, if you go Back to Basics, and your early training.

The most common reason for chronic or recurrent loose stools with or without abdominal discomfort is an undiagnosed milk/lactose intolerance. Carbohydrates will have a tendency to cause constipation. This is the basis for what has been called "IBS". Effectively stopping the intake of Lactose will, usually, cause the loose stools to go away.

If your patient develops loose stools... stop the lactose intake. Since the lactose is acting as a laxative, and carbohydrates are constipating, the lactose intake may need to be regulated, like a drug, to avoid constipation. I have not had problems with C. Diff. but, my suspicion is that it can be prevented by stopping all lactose intake immediately, especially, if the antibiotic can be stopped.

Question what you have been taught or what you have read. Compare that to what you see in your practice, with your patients.


We only have few tools that we can use to effect change: medications, surgery, and counseling/education. We need to know how to best use our tools and when to use them. In my practice, medications and education are the ones that I use.

In forming a differential diagnosis, the one at the top of the list should be the one that best explains all of the symptoms or problems the patient is having.

Get a complete list of all of the patient's symptoms. It doesn't matter what level of problem the patient thinks it is. If they experience it... it goes on the list. Ask the patient to tell you "Every Way Your Mind Body, or Spirit is Complaining".

Lab tests can have a false negative and false positive rate. What diagnosis fits the complete list of clinical symptoms best, even if the test is negative?

Do not try to fit a "complicated patient" into a small time slot. That is not doing justice to the patient or you. You need time to "work the problem", whether it is education, counseling, assessment of the treatment, or most importantly... for diagnosis. Take control of your schedule.

Journal articles and experiences that other clinicians have had, are only as useful as they are clinically relevant to the patient and your practice. If, clinically, a medication takes 3 months to work and only temporarily... Then an article that says "two months doesn't help" is not useful. If the wrong medication or antibiotic is given, and the response is limited, that doesn't mean medications won't help or antibiotics won't help. Just, maybe not those ones, given in that way.

Remember the basics. For example, the flu is supposed to last for 3 - 10days. There can be bad flu seasons, but if the illness is not improving enough, think secondary bacterial overgrowth!

All generics are not the same. Clinical efficacy can vary from company to company. Generics may not be the same as a Brand Medication.

Know the pharmacology, side effects, and interactions of the drugs you use.


     Know the Half Life of the drug. If you use a TID drug BID, and there is a withdrawal or discontinuation syndrome effect of that drug, the patient will seem like there is an issue, but it is just the blood level getting too low. I see this with the ADD drugs and pain medications, including Gabapentin, Lamactil, and Narcotics all of the time.

     Many of the newest drugs will interact with other, commonly prescribed drugs. Always check for interactions. Know the drugs you use.


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