Residency Insight -- A PRESENT Podiatry eZine

Volume 6 - Issue 3

This piece is a monologue on the nature of medicine, in which I try to explain how I think I work.

I like to think that my work in medicine is based on fact. I work hard to keep it as such. My training was in the allopathic tradition and I have always thought of myself as a scientific man. A scientist, as it were. Yes, some of this is due to the fact that my undergraduate career started out in engineering, even if I ended up with a degree in history. My prerequisites for podiatry school were decidedly fact based: inorganic and organic chemistry, biology, lots of advanced math, as well as physics due to the engineering. They are all based on observation and description of what happened – fact. The interpretation of what happened, why it happened and predictions for the future were theory. Theory is often another word for opinion, though it should be informed opinion.

I was watching the medical examiner’s testimony last week during a well-publicized trial. At first, I thought that his manner of speech was odd. But then I realized that he was being exact and making sure that everyone knew that. He took great pains to differentiate ‘fact’ from ‘opinion’. The doctor even went so far as to explain the plasticity of memory and how it changes over time. What we remember one day can be different from what we remember months or years later.

FACT, he pointed out, was what was real - what occurred. The notes he took were fact. They are what he observed during the autopsy and exam and what he dictated. That was all he could testify to, he said. When asked a question by a lawyer, he repeatedly wanted to know if they wanted to know the fact or his opinion. His recorded observations are his facts. They don’t change over time. They are what was there in front of him at that moment and will stay the same no matter how long it is after they had occurred.

OPINION is what people thought it all meant and is very different from FACT. Opinion allows room to make inferences. Opinion changes over time, based on experiences that occur and the doctor gave an example of this.

What, you may wonder, does all this have to do with medicine and podiatry? I consider podiatry to be based on the mainstream model of medicine. This means observation, recording of facts, and treatments based on such past observations. Allowing opinions to guide treatments is like reverting back to the medicine of the Dark Ages. This is a bit extreme of an example, but it gets my point across.

When you are learning to take notes and interview patients and are trusted to create treatment plans, please do so based on facts and not opinions. When a patient says ‘I gotz da gouch’ write that down as their chief complaint and then ask them questions. Does it hurt? How much? Swollen? Red? And so on. Record their responses and decide later if they are fact or opinion. Record what you see, not what you want to see. You see a contracted toe at the proximal interphalangeal joint, not a hammertoe.

The contracted toe is an objective finding. The hammertoe is your assessment. The deviated hallux is objective, bunion is the assessment.

Keep your objective findings fact based and your assessments as your diagnoses and your notes will be great. It’s a habit to start now and to keep forever.