Rule 107: Know which abnormality you are going to follow during treatment.
Pick something you can measure.
This rule comes from Dr. Clifton Meador’s A Little Book of Doctors’ Rules, a book I received early in med school. What follows is a deep dive of Dr. Meador’s 107th rule: Know which abnormality you are going to follow during treatment. Pick something you can measure.
If you like this post and want to support me - click the little heart (either at the bottom or top of this article), leave a comment, and/or subscribe for free if you have yet to subscribe!
Subscribers - if you received this as an email and want to read this post on my website, click the button below!
It’s important to take this rule in its context. This rule is in reference to prescribing and taking medications. So when Dr. Meador says “treatment,” he’s really meaning “medication.” Which is an important distinction still to this day due to the growing number of people wanting “natural” treatments and shying away from pharmaceuticals. On the flipside, there’s also an increase in controversial medications (that will remain nameless), which begs the question – what are the rules of using medications? It’s from this perspective that we dive into Rule 107.
With any treatment we must start with its purpose – so what is the purpose of a medication? To elicit a desired effect. This effect should improve your patient’s life. For example, let’s look at a patient “Bob.” Bob is a 57 year old man with a BMI of 34 and a 30 pack-year smoking history coming in for a follow up regarding consistent elevated blood pressure readings.
Side note: pack-year = packs smoked per day per year. So Bob most likely either averaged a pack of cigarettes every day for 30 years or 2 packs a day for 15 years.
As the provider, you’ve done your appropriate workup and there’s no discernable secondary cause for his blood pressure readings, meaning the most appropriate diagnosis here is “primary hypertension.” You have both talked and think the best course of action now is to start a medication. Like most reasons for doing a particular thing, people should not take meds willy-nilly. This is where this rule comes in – it’s part of a framework protecting against incautious medication collecting (and prescribing). You must only take meds that work and to make certain your med is working you must do two things.
The first thing? You must understand your goal in taking it, i.e. understanding what you’re trying to accomplish. To do this, you must acknowledge the need for treatment. In other words, why is prescribing Bob this medication better than letting his blood pressure remain elevated? Answer: if his pressure remains high, over time he’ll be more likely to suffer a stroke, heart attack, etc… which is bad. This answer is accurate and true, but it’s also a science-minded answer. In other words, if you offer this answer to Bob it’s not as likely to hit home with him because has no connection to the medical field or those adverse medical events.
It's important to note that there’s a common mindset that could be at play here. The mindset of “these foreign medical things would never happen to me…” Examination of that mindset is for another essay.
To Bob, a family man and lifelong expert mechanic, lowering his blood pressure (via this med) means increasing his longevity. Without treating his blood pressure he won’t be able to play with his grandkids, help his family, or work his business for as long. So yes, he’s taking this medication to lower his blood pressure, but that’s not really why he’s taking it. He’s taking it so he can put himself in a better position to provide for his family and enjoy his life. Clarity on a deep level for what you are doing and why is imperative to effective treatment.
Second: you must be consistent. You must consistently take your medication and consistently measure its effect. Let’s break that down with our bud Bob again. Why must Bob consistently take his medication? Well, let’s look at the opposite – what would happen if he took it inconsistently? Inconsistency brings uncertainty – he wouldn’t be giving his new med the best opportunity to lower his blood pressure. Its potential effect would be lessened, and Bob and his doc wouldn’t be able to say with any degree of certainty whether or not this new medication is working. This is important because it hampers your ability to make the decision to continue or cancel the new med. In being consistent, you give yourself the best opportunity to see its true therapeutic potential…to see if it actually works.
Ok so we understand why we’re consistent in taking the new med, but why measure it consistently? Well…if Bob doesn’t measure his blood pressure at home, then how can he track it over the course of his treatment? The answer is he can’t. Bob should track his blood pressure at home because he’d able to see if it’s eliciting its desired effect. It’s like if I went to the gym and committed myself to a 10-week training program, but I didn’t track any of the weights I used. At the end of the program, I wouldn’t be able to point to any specific thing that I improved on…which was the whole point of starting the exercise program in the first place. This is also the point of treatment. How can you say your condition improved if you don’t have the evidence?
So when prescribing and taking meds…be clear and be consistent. These are two concepts that are instrumental, not just in this context, but in the broader sense of goal-setting. Goal-setting is what ultimately drives medical treatment. For example - Bob has the goal of lowering his blood pressure and to accomplish this he takes his medication. Since setting goals (and then following through with those goals) requires an inordinate amount of effort, it stands to reason that patients starting new medications also require a great amount of effort to “follow through.” Why is this? Because they are attempting to make change and any change that is lasting needs applied effort, like fire needs fuel. Understanding this allows you, as a physician, to equip your patients with the fuel - clarity, consistency, and effort - necessary for success.
If you enjoyed reading this post and want to help support me and this blog - consider sharing with your friends and family, leaving a comment, or hitting that like button! Thanks and see you next Wednesday…
- Tyler