Over the past few months I have taken on a number of small (at least I thought they would be small) projects in my mother’s home and my own. Some turned out to be bigger jobs than anticipated, some were necessities, and some were small cosmetic issues. I enjoy the challenge of finishing a project about which I know very little at the start.
As a single homeowner I pride myself on owning some decent basic tools—my favorite is an 18-volt power drill that I received from my parents years ago for Christmas. They were quite surprised when I asked for it. I also own tools, picked up over the years, that look interesting and cost a lot of money but have never been touched because, to be honest, I no longer have any idea what purpose they serve. They were likely bought for some DIY project that I Googled or saw on YouTube and had every intention of tackling at the time.
For my current list of projects I again bought more tools, feeling proud that I was ready and equipped to get to work. Many turned out to be fancy gizmos that didn’t help me get the job done more quickly. They mostly served to complicate a simple task and I ended up returning to my old, reliable favorites.
In medical school today students and residents are commonly taught to follow practice guidelines and algorithms for diagnosis and treatment in the belief that they save time and money. We now have clinical practice guidelines set out for a wide variety of medical conditions. Some are excellent but I consider this to be assembly-line medicine. They are useful and work well for straightforward conditions but cannot be relied on to account for all the intricacies of more complex disease processes.
I am of the old school that believes the basic process of taking a good history and performing a good physical examination is the cornerstone of making an accurate diagnostic evaluation most of the time. Obviously, advanced technology in imaging and interventional radiology, tumor markers, and immunoassays, to name a few, have allowed us to hone—but not to replace—our diagnostic capabilities. And sometimes technology leads us down the wrong path. Even with the vast array of these technologies at our fingertips things get missed. If I miss a diagnosis (and unfortunately there have been a few misses) it’s because I didn’t ask the right questions, identify something abnormal in the physical examination, or order the right test. If I’m having difficulty with a diagnosis I have learned to go back to the basics and talk with the patient again as I have likely missed important information. So while I embrace new technologies, I have learned that cutting corners is the fastest way to make errors. As in construction you will usually find a good explanation for every problem if you go back to the basics.
PS: If anyone wants any fancy mystery tools I would be happy to give them away.
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Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.
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