The Rubik’s Cube as An Approach to Clinical Medicine Dr Henry Goldstein (robotmuesli@gmail.com)

Introduction; Medical teaching is by its nature complex. Conversely, the practice of clinical medicine is best learned from a simplistic point of view. I urge you to practice a reductionist approach to clinical medicine. Take the most basic problem, things that any person can establish, and move from there. Avoid over thinking; it leads to confusion and a lack of clarity. I’ve attempted to simplify my own thinking into what is essentially Rubik's Cube Medicine. The Rubik’s cube, like medicine, remains a mystery to most people. Both can be better understood with a system, a good eye and a few algorithms. Like the Rubik’s cube, the same set of operations guides you down a path, where you only need to focus on one decision; the next one. The following tips provide a loose framework upon which to base your early practice of medicine. 1. Presenting complaint

What is the single reason for this person seeking medical advice? From this question stems all medicine. Distill the patient’s story to find out what happened first. Do they have chest pain? Shortness of breath? Dizziness? Find one and from there, generate your differential diagnoses. This key point is designed to simplify clinical practice. Even complex geriatric patients present with falls or confusion, each of which has a reasonable list of differentials.

2. The Approach For each problem we strike in practice, we use a system to find a solution. This is a rational, step-wise way of understanding a presenting complaint. A good textbook will usually provide approaches to common presenting complaints. For example, a patient with a fall. The Approach is Mechanical vs Non-mechanical. Within Non-mechanical, there is cardiac, vascular, neurological and other. Have an approach for each presenting complaint, and you will be the master of rational medical practice.

3. Well / Sick / Dying Does this person look sick? This skill develops with time, and the vast majority of patients we see are well. Failing to identify a sick patient is a recipe for disaster. Put simply, anytime you call someone asking for advice, or are presenting a patient, your senior wants to know if they need to see them now, within minutes/hours or later. You can often be guided by…

4. Vital signs Know the patient’s temperature, blood pressure, heart rate, oxygen saturation status before you make any decisions. An abnormality in any of these will change your impression and focused history taking. Consider them in the context of the patient. A newborn can happily have their heart beating at 140bpm, but the same rate is unsustainable for, say, an octogenarian with heart problems. They’re called Vital signs because they are Vital!

5. Observing As a medical student, you’ll have plenty of opportunity to stand still and be quiet whilst your bosses talk to patients; that’s just how the hospital system rolls. Use this time to look around. Patients reveal much of themselves in their belongings. Often they’ve prepared for a long wait. Look for walking aids, spectacles, crosswords, writing implements, photos of loved ones, books, cigarette lighters. These all paint a picture of this person’s usual level of function. Keep an eye out for medical things too; GTN sprays, salbutamol inhalers, PEG feeds awaiting administration all lead to a raft of questions.

6. History History taking is the key skill of a doctor. If you, or your patient, are getting muddled, ask the patient to talk you through their day, their week. Find out what they do on a normal day, from eyes open, getting out of bed, to shower/breakfast/run/cigarette, to whatever happens next, until alarm clock the next day. Try to establish the key changes that have brought them to present to a doctor. Take time to let the patient tell you their story, noting how the story unfolds, their emphasis and focus. Be mindful of leading questions; they can send you down the wrong path. Instead, cast your net broadly at the outset, then sharpen your focus. In Emergency or for Admissions, take a focused history; if a patient is presenting with a gynaecological question, ask the standard gynae questions. There are specific questions for each system, and as a med student, learning these is high yield for the future.

7. Physical examination The basis for examination is the patient’s presenting complaint, and the subsequent differential diagnoses you’ve formulated. In simple terms, the examination is to contribute to the history you’ve already taken. It may refute or

augment your existing thoughts. Remember, find the basic, obvious things first. You don’t have to do all the funky tests and fancy variations. Listen to the heart, then lungs, rashes. Be systematic, thorough, targeted.

One approach to physical examination is to have a particular disease in mind for each system which, in turn, will reveal relevant clinical findings for almost all others. A few are; Cardio – Infective Endocarditis, Resp – Lung Cancer, Gastro – Chronic Alcoholic Liver Disease.

8. Writing notes As a Junior, writing notes is your bread and butter. You should always hold yourself to a standard, because essentially, Medical notes are communication. To late night ward call, to nursing staff & allied health, or even to yourself in a courtroom in five years’ time. There’s no easy way to write a lot of information quickly, but having a structure that is easy to follow and reproducible is essential. The basics are similar to what you’d say to someone you were ringing for advice! State the time & date, who you are, your designation & your boss. Why you are seeing the patient (ward round, reviewing the patient, ward call etc.). Write the patient’s age, sex, presenting complaint and relevant co-morbidities. You should write this every day, as well as the time, date and your name on every subsequent page. Always put a patient identification sticker on every page. At the end of an entry, write a plan. That’s what everyone else relies on the medical team to make, so put some bullet points down, including when the team will next review the patient/plan. Importantly, put something along the lines of ‘Notify concerns’; this permits nursing staff to contact you if they’re worried about your patient.

9. Help! The best people to learn from are Registrars. They run the hospital. The can do all the basic tasks that are the responsibility of interns & juniors, but their decision making is only a few steps off consultant level. These are the people whom have their basic medical thinking at the sharpest. In the manner of studying for exams it’s not appropriate, nor feasible, to take shortcuts, hence Registrars can think and function at all levels of practice. Find one with whom you get on well and respect, and stick with them.

10. Resources You’ll need several references throughout your career. I suggest a good general medical textbook, with both Presenting Problems and Common Diseases for each system – Davidson’s or Kumar & Clark are great. Harrison’s is an old favourite, but probably a touch dense for MBBS3/4. Additionally, On Call (Cadogan et al.) provides an excellent framework for acute presentations in a Ward setting. An examination guide, either Talley & O’Connor or Bates is also an essential tool. Finally, the Oxford Handbook Series can’t be missed for concise & interesting medicine, surgery & subspecialty information.

11. Departmental psychology Each department has their own priorities, and this is important to consider when working in different locations.

• In Emergency, the key question is In or Out? And, if In, under Which Admitting Dept? • In Surgery, the question is Observe, Optimal Medical Treatment or Operate?

And, if Operate, now/today/later? • In Obstetrics, the key question is Baby In or Baby Out? And, if Out, how Out?

And so on. Bear in mind that “What is the patient’s diagnosis?” is not always the first question.

In summary, Medicine is about studying smart. Consolidate your basics as much as possible. Keep your thinking clear and structured. When in doubt return to first principles and the key question;

What is the single reason for this person seeking medical advice? And, if you’re into Rubik’s Cubes, a good solution is at http://peter.stillhq.com/jasmine/rubikscubesolution.html

Check out http://www.robotmuesli.tumblr.com/cubing for the original of this pamphlet! HG 3/4/13