I hope that smoking a Camel was a joke! As a retired pulmonologist whose mother died of COPD and whose father survived laryngeal cancer, I have been a fierce opponent over the use of tobacco. I have developed a respect for Adam which might be a bit shaken by an unreformed tobacco addiction.
Your guides are familiar - I was trained with similar imperatives (SUNY-Syracuse ‘92)
I know that only very few of my patients will remember my name (my specialty was EM) but some will. It’s enough for me to know that many will remember a man who helped them…
And I focus on these words:
Do not store up for yourselves treasures on earth,where moths and vermin destroy, and where thieves break in and steal. But store up for yourselves treasures in heaven, where moths and vermin do not destroy, and where thieves do not break in and steal. For where your treasure is, there your heart will be also.
“How long, Lord? Will you forget me forever? How long will you hide your face from me? How long must I wrestle with my thoughts and day after day have sorrow in my heart? How long will my enemy triumph over me? Look on me and answer, Lord my God. Give light to my eyes, or I will sleep in death, and my enemy will say, “I have overcome him,” and my foes will rejoice when I fall. But I trust in your unfailing love; my heart rejoices in your salvation. I will sing the Lord’s praise, for he has been good to me.”
I don't know whether the Cifu-Index merits a Wikipedia page; but the Cifu-8 does. If I were given that as a student or resident I would keep it in a place where I could reread it during my working career. I always found it helpful to probe for personal information. In both my personal and professional life, I gained an appreciation for the fact that everyone has some interesting stories to tell. Even when they don't help to make a diagnosis, getting to know their experiences and thought patterns will often help in giving a better quality of medical care to each individual patient.
A propos of "discovering something interesting," I recommend asking patients what they do, or did, for a living. This is much less important as "occupational risk history" than for establishing a relationship and learning something about native cognitive ability or executive function. As a hospital-based general internist, I learned and re-learned this several times, as I realized how unimportant the traditional occupational history was in an urban non-industrial environment.
The best example is what learned from a patient after the senior resident at early morning Emergency Department intake rounds tole me that "we need to go see her immediately, because Gram (-) rods grew from her blood over night."
We proceeded immediately to her bedside, knowing that she had a serious bloodstream infection, but perhaps not yet the source. As attending physician, I found it hard to think of much to add, but the patient seemed rather "out of it" and I wanted to be friendly. So I asked her what she did for a living...
"I manage and A&W restaurant." For any not familiar with A&W, good burgers, root beer for those who like 500 calories or more per glass, and extremely frenetic working atmosphere. Her answer showed me that her normal executive/cognitive function must be high and thus that her actual mental status was alarming. I told the residents/medical students "She's in septic shock," which when I trained was defined by bacteremia + organ dysfunction. I indicated we should fear what might happen next. They laughed at me when I rechecked her BP and HR, while they wanted to get on to the next patient AQAP.
A few hours later, I returned and she was nearing cardiovascular collapse. A senior resident (MD, PhD) from another field was examining her, and asked me how I had known this was about to happen.
This lesson about cognitive impairment in an apparently relatively well patient reinforced classroom lessons about sepsis from the 1970's.
Another good example was when we were demonstrating abdominal examination on a man. As a common courtesy, I asked him about his occupation. When he replied "I'm a retired urologist," I suggested that he take over the lesson on location of the spleen and best physical examination. I figured he must have seen a spleen many times in situ, whereas I had not ...
Another insightful and “Spot On” reflection. One of the greatest failures I see in residents and some practitioners is the failure to establish at least a working diagnosis. The default seems to treat a series of symptoms in the absence of at least a differential diagnosis. Or to order a series of invasive and likely unnecessary tests to again treat symptoms - not a diagnosis. If practitioners followed your rules we would be in a much better place and above all so would our patients. This written as a wind down my 40 year carrier as a surgeon and educator.
I like this a lot. I use many elements from Cifu 8 myself.
I may add a rule that you should always do at least a little bit of your own clinical reasoning and generate at least an attempt at refining a specific question prior to calling a consultant unless the need for consult is purely technical.
I have been increasingly embracing and appreciating number 7 on the Cifu-Eight. A phenomenon that becomes possible only when there is enough time set aside for the patient visit.
"Discover something interesting about the patient.
You take better care of people you know. Investing the time to make a discovery, even with someone you may never see again, pays dividends. It makes the patient feel cared for. It makes the visit more interesting to you. It may even reveal critical information about the diagnosis."
My astral vision of myself is definitely the Luckey strike man. Accordingly, I find myself increasingly sitting with my feet up on the desk, gazing out the window, trying to figure out how the art—and it truly is an art, since it must be reinvented for every patient rather than merely copied—of diagnostic reasoning, critical thinking, and reflective practice in the face of uncertainty can be fused with the power of generative AI.
There is a discipline required to keep these pearls of heuristic thinking top of mind during the clinical encounter. I think of it as a kind of greenlight spectrum: at one end, the no-brainer—the man with a big, fat, ignominiously painful red toe and a history of gout seen as a post-op consult. At the other end, the full stop—the woman with six weeks of crescendo headaches and fever—quietly reminding you to be very afraid of how you handle what comes next.
We are clearly at a moment in time when our excuses for incorrect diagnoses based on lack of knowledge are rapidly diminishing. Can you say Open Evidence? And yet, I’m not convinced we are making comparable progress in training the next generation in critical thinking, judgment, and reflective practice.
Finally, whether the case is a no-brainer or a diagnostic nightmare, asking one extra, simple question about something—anything—in a patient’s life invariably makes the encounter more human. And that, in the end, may be the most important heuristic of all.
#9 could be, when documenting in the chart “WNL”, insure it means “within normal limits” rather than “we never looked”. This happens far too often this day and age since the use of the high-tech diagnostic tools are becoming the norm.
I like the rephrasing to "we never looked" - it feels so true. I read my physician's notes in the portal. Sometimes it states things like "abdomen soft, nontender, bowel sounds good" when my abdomen was never examined. I like my doctor, but I'm not sure what he's actually charting in the computer and what the computer is adding in. I have complained on one of those surveys they send, but I don't think they listen. Be careful what you chart.
I hope that smoking a Camel was a joke! As a retired pulmonologist whose mother died of COPD and whose father survived laryngeal cancer, I have been a fierce opponent over the use of tobacco. I have developed a respect for Adam which might be a bit shaken by an unreformed tobacco addiction.
Your guides are familiar - I was trained with similar imperatives (SUNY-Syracuse ‘92)
I know that only very few of my patients will remember my name (my specialty was EM) but some will. It’s enough for me to know that many will remember a man who helped them…
And I focus on these words:
Do not store up for yourselves treasures on earth,where moths and vermin destroy, and where thieves break in and steal. But store up for yourselves treasures in heaven, where moths and vermin do not destroy, and where thieves do not break in and steal. For where your treasure is, there your heart will be also.
“How long, Lord? Will you forget me forever? How long will you hide your face from me? How long must I wrestle with my thoughts and day after day have sorrow in my heart? How long will my enemy triumph over me? Look on me and answer, Lord my God. Give light to my eyes, or I will sleep in death, and my enemy will say, “I have overcome him,” and my foes will rejoice when I fall. But I trust in your unfailing love; my heart rejoices in your salvation. I will sing the Lord’s praise, for he has been good to me.”
Fabulous insight into the PRACTICE of medicine !!! I’ll take one Marlboro Light but it was better at 25 cents a pack !!!
I don't know whether the Cifu-Index merits a Wikipedia page; but the Cifu-8 does. If I were given that as a student or resident I would keep it in a place where I could reread it during my working career. I always found it helpful to probe for personal information. In both my personal and professional life, I gained an appreciation for the fact that everyone has some interesting stories to tell. Even when they don't help to make a diagnosis, getting to know their experiences and thought patterns will often help in giving a better quality of medical care to each individual patient.
The Cifu-sign reminded me of my mother, who has dementia, randomly saying “mothball!” Strangely, also her animatronic cat’s new name.
I really like the Cifu eight. I might plagiarize it 😅 for nursing students
It's all yours!
Adam
A propos of "discovering something interesting," I recommend asking patients what they do, or did, for a living. This is much less important as "occupational risk history" than for establishing a relationship and learning something about native cognitive ability or executive function. As a hospital-based general internist, I learned and re-learned this several times, as I realized how unimportant the traditional occupational history was in an urban non-industrial environment.
The best example is what learned from a patient after the senior resident at early morning Emergency Department intake rounds tole me that "we need to go see her immediately, because Gram (-) rods grew from her blood over night."
We proceeded immediately to her bedside, knowing that she had a serious bloodstream infection, but perhaps not yet the source. As attending physician, I found it hard to think of much to add, but the patient seemed rather "out of it" and I wanted to be friendly. So I asked her what she did for a living...
"I manage and A&W restaurant." For any not familiar with A&W, good burgers, root beer for those who like 500 calories or more per glass, and extremely frenetic working atmosphere. Her answer showed me that her normal executive/cognitive function must be high and thus that her actual mental status was alarming. I told the residents/medical students "She's in septic shock," which when I trained was defined by bacteremia + organ dysfunction. I indicated we should fear what might happen next. They laughed at me when I rechecked her BP and HR, while they wanted to get on to the next patient AQAP.
A few hours later, I returned and she was nearing cardiovascular collapse. A senior resident (MD, PhD) from another field was examining her, and asked me how I had known this was about to happen.
This lesson about cognitive impairment in an apparently relatively well patient reinforced classroom lessons about sepsis from the 1970's.
Another good example was when we were demonstrating abdominal examination on a man. As a common courtesy, I asked him about his occupation. When he replied "I'm a retired urologist," I suggested that he take over the lesson on location of the spleen and best physical examination. I figured he must have seen a spleen many times in situ, whereas I had not ...
Brilliant Dr Cifu. I read your post three times!
Thanks!
Another insightful and “Spot On” reflection. One of the greatest failures I see in residents and some practitioners is the failure to establish at least a working diagnosis. The default seems to treat a series of symptoms in the absence of at least a differential diagnosis. Or to order a series of invasive and likely unnecessary tests to again treat symptoms - not a diagnosis. If practitioners followed your rules we would be in a much better place and above all so would our patients. This written as a wind down my 40 year carrier as a surgeon and educator.
Keep up the great work!!
I like this a lot. I use many elements from Cifu 8 myself.
I may add a rule that you should always do at least a little bit of your own clinical reasoning and generate at least an attempt at refining a specific question prior to calling a consultant unless the need for consult is purely technical.
Now, it you're going to use those elements, you will have to reference me!
;-)
Adam
The Cifu Shifu, naturally
Another good post. While I always appreciate your humor and the work you put into sharing your insights…those cigarette ads made my whole day.
I have been increasingly embracing and appreciating number 7 on the Cifu-Eight. A phenomenon that becomes possible only when there is enough time set aside for the patient visit.
"Discover something interesting about the patient.
You take better care of people you know. Investing the time to make a discovery, even with someone you may never see again, pays dividends. It makes the patient feel cared for. It makes the visit more interesting to you. It may even reveal critical information about the diagnosis."
Three cheers for the laying on of hands, physical touch and a PE
My astral vision of myself is definitely the Luckey strike man. Accordingly, I find myself increasingly sitting with my feet up on the desk, gazing out the window, trying to figure out how the art—and it truly is an art, since it must be reinvented for every patient rather than merely copied—of diagnostic reasoning, critical thinking, and reflective practice in the face of uncertainty can be fused with the power of generative AI.
There is a discipline required to keep these pearls of heuristic thinking top of mind during the clinical encounter. I think of it as a kind of greenlight spectrum: at one end, the no-brainer—the man with a big, fat, ignominiously painful red toe and a history of gout seen as a post-op consult. At the other end, the full stop—the woman with six weeks of crescendo headaches and fever—quietly reminding you to be very afraid of how you handle what comes next.
We are clearly at a moment in time when our excuses for incorrect diagnoses based on lack of knowledge are rapidly diminishing. Can you say Open Evidence? And yet, I’m not convinced we are making comparable progress in training the next generation in critical thinking, judgment, and reflective practice.
Finally, whether the case is a no-brainer or a diagnostic nightmare, asking one extra, simple question about something—anything—in a patient’s life invariably makes the encounter more human. And that, in the end, may be the most important heuristic of all.
So well said (and I also see you as a Lucky Strike man).
#9 could be, when documenting in the chart “WNL”, insure it means “within normal limits” rather than “we never looked”. This happens far too often this day and age since the use of the high-tech diagnostic tools are becoming the norm.
I like the rephrasing to "we never looked" - it feels so true. I read my physician's notes in the portal. Sometimes it states things like "abdomen soft, nontender, bowel sounds good" when my abdomen was never examined. I like my doctor, but I'm not sure what he's actually charting in the computer and what the computer is adding in. I have complained on one of those surveys they send, but I don't think they listen. Be careful what you chart.
I still remember these and remember you teaching them. You won't be forgotten anytime soon! (Also, I think 'Hikam' should be 'Hickam'?).
Thanks (and fixed).