On Treatment
16. The most crucial step toward healing is having the right diagnosis. We are often asked early in an investigation, what will be the treatment? The most accurate answer comes with having the most accurate diagnosis. Unless the patient may die or endure major morbidity before a diagnosis can be made, pursue as definitive a diagnosis as the clinical scenario requires.
17. Medications only work in patients who take them. Patients fear medications. Studies have consistently shown that approximately one-third of prescriptions go unfilled, and of the ones that are filled, only half are taken correctly.7 Assess adherence in every patient at every visit (without judgment). If the patient is non-adherent, recall that doctor is derived from the Latin docēre, which means to teach: Encourage and empower your patients with knowledge so they can make better informed decisions for themselves.
18. If treatment is not working as expected, challenge the diagnosis. Treatment failure can be a crucial diagnostic clue. Never presume the patient is a slow responder or the disease is refractory without first rechecking the history and physical exam, re-reviewing the data and revisiting the differential diagnosis.
On Consults
19. Always do a formal consultation. Avoid declining a consult request (misdirected though it may seem) or providing curbside consults (busy though you may be). The referring provider will convey the facts of the case as they appear to them, which may be chock-full of biases. Always make an independent assessment before providing recommendations that will affect the patient.
20. They don’t just need us for our knowledge; they need us for our wisdom. A revered colleague and American College of Physicians Master would often joke that “rheumatologists are glorified internists.” Although the expectation for a consultant may be to answer the consult question, a great consultant will also answer the questions the referring provider didn’t know to ask, but should have.
21. Write your notes imagining you are at a morbidity and mortality (M&M) lecture and your note flashes on the screen. For anyone who’s sat in a departmental M&M and seen their note on the screen, it was likely a moment of great pride or great anguish. Well-done M&M lectures that include actual clinic notes have tremendous potential for shifting institutional culture toward clinical excellence. When writing your assessment and recommendations, be self-aware of biases and honest about the limitations of your knowledge; document them accordingly.
