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Aphorisms for Self-Management: A Guide to the Inner Life of the Physician

Published:September 22, 2021DOI:https://doi.org/10.1016/j.amjmed.2021.08.031
      Inspired by Alpert and Frishman's July 2021 commentary,
      • Alpert J
      • Frishman W
      The most important qualities for the good doctor.
      I remembered a talk I gave to the Family Practice Residents some 12 years ago. After spending years focusing on clinical care issues with medical students, residents, and colleagues, I decided to try to address the inner life of the physician and how we physicians manage ourselves. Titled “Aphorisms for Self-Management: A Guide to the Inner Life of the Physician,” the talk started with the words I partially remembered sung in a song from the past.
      Charles Wright & the Watts 103rd Street Band
      Express yourself.
      “It's not the way that you look like when you're doing what you're doing, it's more the way that you do what you look like you're doing.” The aphorisms followed.
      Becoming a physician is quite an involved endeavor and is perpetual. As with learning to perform any other skill, one shortcut to remember: Practice does not make perfect; perfect practice makes perfect.
      • Sudo PT
      Zen Guitar. First Fireside Edition 1998.
      Bad habits tend to get practiced and ingrained. Learn good habits.
      Being a professional requires discipline. Discipline is doing what needs to be done, when it needs to be done, as well as it needs to be done . . . and do it every time.
      • Sudo PT
      Zen Guitar. First Fireside Edition 1998.
      No more, no less.
      The main task of the practicing clinician on the front lines is to try to figure out what the patients need and then help them get it. This is your litmus test: If your evaluations, decisions, and actions do not help to promote these goals, then you know you are errant. Hone your efforts. The key to providing high-quality patient care is to care for the patient.
      Compassion, kindness, patience, hope . . . how can you give these if you are sleep-deprived, impoverished, emotionally distraught, and otherwise not feeling well? You need to address your issues. I find that when I am intolerant, my own needs need to be addressed. Achieving the right balances of family, friends, exercise, and fun in combination to your work activities is a career-long task. If your own needs are not adequately being met, then it will be harder for you to provide care to your patients.
      The primary care clinician should be an expert in dealing with things that occur commonly. Focus your efforts on these topics. Develop a deep and broad understanding. Continue to review throughout your career. Things change; half of what you learn in training may be wrong. Think: perpetual learning.
      Medicine is a collaborative effort. Remember that you cannot do it alone and need to work with patients, their families and friends, your staff and colleagues, your significant other and dependents, and others. The cell phone is a useful tool. Communicate, communicate, communicate.
      Uncommon presentations of common diseases are more likely than common presentations of uncommon diseases. If it looks like a horse, smells like a horse, and walks like a horse, it most likely is, even if someone tells you otherwise. Essence of diagnostic reasoning is Bayes’ Theorem; put in the effort to understand it thoroughly:
      Pretest odds × likelihood ratio = post-test odds.
      When making decisions about therapy, do not forget the patient! Therapeutic decisions are 3-tiered: chance of harm or benefit, the patient's values, and outcomes of interest.
      If your inner voice is talking to you (eg, get help, go do the task now, say no, apologize), pay attention. Listen to yourself. You probably give good advice. Listen to your inner voice.
      You often have to prioritize and rearrange your time. Do not take this as a personal shortcoming but as a fact. No one can be in 2 different places at once.
      Figure out where you can find help to address your clinical needs (e.g. poison control center, UptoDate, Cochrane Library, local mentor, translation services, etc.). Know your resources. When things do not add up, when you hear that inner voice, and when you are outside your comfort zone, get help. Trying to care for a patient when you do not know what you are doing or do not have the appropriate backup if things go bad, does not help your patient. Know your limitations, and know your colleagues’ limitations. Welcome other opinions.
      The patient is the boss of themselves. You are their advisor. They do not have to follow your advice; you do not have to do what they request. But both the patient and the physician should listen closely and respectfully to what each is saying. Know your role.
      The only certainty is death and taxes. We all crave certainty. Do not be seduced by your or the patient's need for certainty. Learn some basic statistics to help you manage uncertainty (eg, standard deviation, null hypothesis/alpha and beta errors and power, confidence interval, number needed to treat [NNT]/absolute risk reduction, clarity about what patient subgroups and what outcomes are being considered). You can use this understanding to inform your patients and communicate the limits of your knowledge.
      Use PICO
      • Sackett DL
      • Straus SE
      • Richardson WS
      • Rosenberg W
      • Haynes RB
      Evidence-Based Medicine: How to Practice and Teach EBM.
      to conceptualize your questions and answers: P for patient type, I for intervention (eg, a particular diagnostic test or treatment), C for comparison (a gold standard test or the usual treatment), and O for outcome (for diagnosis: sensitivity, specificity, and likelihood ratios; for treatment: absolute risk reduction/number needed to treat).
      Sometimes listening carefully is the only therapy required. When the patient trusts you and you actively listen, a powerful relationship develops over time. Use your relationship with your patients to help them.

      References

        • Alpert J
        • Frishman W
        The most important qualities for the good doctor.
        Am J Med. 2021; 134: 825-826
        • Charles Wright & the Watts 103rd Street Band
        Express yourself.
        Warner Bros Records, Los Angeles1970
        • Sudo PT
        Zen Guitar. First Fireside Edition 1998.
        Simon & Schuster, New York1998: 53 (57)
        • Sackett DL
        • Straus SE
        • Richardson WS
        • Rosenberg W
        • Haynes RB
        Evidence-Based Medicine: How to Practice and Teach EBM.
        2nd ed. Churchill Livingstone, London2000: 15