I must especially thank Drs Alan Sherman and Michael Shore, my online bosses and mentors at PRESENT, who have supported me unconditionally all of these years. The work these guys have put into educating podiatrists is first rate, and they should be considered educators on par with any of those in the podiatric colleges. Thank you for your leadership and contributions to the profession. Finally, I thank my wife, Melissa, who has been my muse, helping me to think up topics to write and being a sounding board for my ideas. Writing a new editorial almost every week for 10 years is not easy, and sometimes coming up with an idea can be a challenge, but with her help, I’ve endeavored to write something worth reading every week. This wouldn’t have been possible without her.

Since I have no plans to stop writing until the PRESENT folks fire me, I’m going to take our 500^th issue to discuss the topic that interests me most of all: thought process. I have always felt that if there’s one theme this editorial covers, it is this: to analyze various topics and incorporate that analysis into our individual thought processes. We discuss various topics, and the information becomes part of us in one way or another. Concepts that touch a chord alter our thought processes in large and small ways, changing who we were a minute before, even if just a tiny bit.

The author John Brockman has coined the term “the third culture” in a fascinating book called The Third Culture: Beyond the Scientific Revolution. This term is a reference to Charles Percy Snow’s The Two Cultures and the Scientific Revolution. This book discusses a conflict between the sciences and the humanities (including the literary fields). Previously, scientists did little writing for the masses, which left us in ignorance, and popular writers were unable to clearly explain the sciences. Scientists who could do so were what Brockman referred to as the Third Culture, or one in which there is a merging of science and the humanities. In his book, he asks famous scientists of different fields to discuss in lay terms something they feel should be in everyone’s mental toolbox.

The Why’s Trump the How’s in Our Professional Development

As physicians, our minds (the mental toolbox) are our one greatest instrument. It has always bothered me when one of my students tells me how “good” a particular rotation was because they were able to scrub into a lot of surgical cases. I know it’s fun for students to participate in surgery, but it’s so much more important for them to understand the indications and medical issues surrounding a procedure – the “whys” rather than the “hows”. Developing their mental skills is much more challenging – and important - than developing physical skills.

Surgical Failure Usually Due to the Head, Not the Hands

Similarly, the vast majority of failed surgical procedures I see from other physicians (and my own) hinge on a failure of cognition. For example, the most common reason for failed bunionectomy I see in practice results from incorrect procedure choice. I rarely see a poorly executed head osteotomy resulting in a nonunion. Rather, I do see plenty of patients who should not have undergone the head procedure in the first place and should have had a more proximal procedure to correct the deformity.

Another situation I see fairly commonly is a second opinion patient in which the prior treatment failed due to an incorrect diagnosis. In all cases, there is some detail that does not fit into the typical clinical script. An example is plantar fasciitis, which is actually lumbosacral radiculopathy. For instance, a complaint of heel pain that is not first step with a history of lower back pain or surgery should have clued the prior physician into suspecting this diagnosis. Similarly, continued forefoot pain after Morton’s neurectomy, which was actually a lesser metatarsophalangeal joint problem, is a common complaint. These errors result from a failure to use their logical cognitive processes – an all too common problem.

Step Back and Ask Yourself - Does it Make Sense?

When I speak with trainees, I sometimes feel they lose their sense of logic when trying to figure out a diagnosis. This is not unusual, since many novice physician trainees are still trying to figure out the basics and become lost in the details. When this occurs, I find myself saying, “Just think about it logically.” If something doesn’t make logical sense, then it probably isn’t true. A patient who doesn’t describe her heel pain as a result of a recent trauma is incredibly unlikely to have a joint depression calcaneal fracture. Similarly, a patient with heel pain after a fall from a ten-foot height is unlikely to have plantar fasciitis. Do the clinical facts that you have gathered and the conclusion you’ve drawn make sense?

The lower extremity is a machine that does not have a mind of its own. It is a conglomeration of very specific anatomical parts that fail in a generally predictable manner (not always, but most of the time). I try to teach my students to think this way and to apply the same thought process to their physical exam. They are taught to palpate specific anatomical structures and find out which of them hurt. Determining what is injured after an ankle sprain, for example, simply requires manual manipulation and testing of specific anatomical structures. This is, of course, true unless the patient has a major psychiatric illness such as malingering, severe anxiety, or Munchausen’s disease (among others). In that case all bets are off!

Having a legitimate thought process and logical reasoning are the keystone to successful clinical and surgical practice. With that skill set, I hope you’ll all Practice Perfect patient care! On to Issue #1000!

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