The Last Possum
A Good Diagnosis

"If you take a good history and do a good physical exam, you'll practice good medicine."

That is probably the pearl of greatest value I brought away from medical school.

This shard of wisdom came from Charlie Peete -- at the time an intern in Obstetrics and Gynecology and only several years my senior.

It lays bare the myth that medical students and apprentice physicians -- interns and residents -- are primarily taught by their professors.

Rather, they are much more taught by those of their ilk who are just ahead of them in the pecking order. 

The professors serve a purpose in that somewhere along the line and in one way or another, they make sure the House Staff is passing along appropriate things to one another and to the medical students.

Like most organizations, medical school is a hierarchy of professional gossip that is as much fun and no more reliable on the first go-around than most rumor mills.

This system is notoriously inexact when it comes to passing along "facts," for in medicine, today's facts are no more than current hypothesis -- that is "scientific guesses" -- and they will usually be duly superceded by tomorrow's theories.

As one medical school commencement speaker put it, "We regret that only half of the things we've taught these students are true, but our real regret is that we don't know which half."

However, Charlie Peete's advice concerned process rather than outcome, and thereby has been durable.

This advice has not only served well in working up patients but in approaching all problems that beg for solution.

If you know the history of how a predicament has arisen and then try to examine the facts carefully you have taken the first step towards a satisfactory solution -- so long as you remember several other phenomena.

First you need to look at everyone's needs in the situation -- not necessarily what they want but what they need -- and then try to work out a solution whereby a good part of everyone's needs are met.

We frequently say, when there's disagreement, that a solution lies somewhere between opposing viewpoints -- this never is exactly so.

Opposing recipients don't agree because each is only partially true.

A fuller truth can't lie between part-truths but must lie beyond them both.

By looking at everyone's needs in a situation you're looking toward a fuller truth than one can see alone.

Two thousand years ago the best of men is said to have said, "You shall know the truth and the truth will set you free."

Another phenomenon that needs to be considered is that whereas every problem has a solution every solution infringes on at least three problems.

There's the problem being addressed.

Then there's the problem that will be uncovered once the solution is in place that no one had been prescient enough to see until change had taken place.

And then there's the problem a solution causes.

This means that no solution is permanent, but must be approached again and again -- this is why scientific investigation always produces only temporary theories and never enduring verities.

Many people make the mistake of saying "science says" this or that -- in fact, science measures rather than speaking and the hypothesis the scientist makes only lasts until a new set of measurements proves it to be only partly true.

Thomas Jefferson, reworking some observation of Thomas Paine, both of which were re-worked by the Continental Congress gave us The Declaration of Independence, our guarantee of liberty.

James Madison drafted The Constitution of the United States, which was again modified by The Constitutional Convention, and later amended by the Congress it established -- this document guarantees order.

The dynamic tension between these agreements is the basis of adaptability in our government.

Many cite the division of powers between Congress, the Presidency and the Judiciary as being the arrangement which at once guarantees liberty and order, and this is indeed a mechanism by which this assurance is maintained, but the principle by which it operates is that of adaptability.

In medical school I learned this lesson through when we studied "homeostasis" -- the "steady state" by which change can be both instigated and managed.

Some folk call this balance equilibrium, but this is not so.

Equilibrium is about random distribution, when everything is spread out evenly, and this, of course, is chaos.

Chaos is the obverse side of the coin of creation from organization or order.

This is the natural arrangement of creation, which fortunately our Founding Fathers had the foresight to employ in their deliberations and synthesis.

But even the wisest among them at times didn't recognize the genius of the process.

No less than Thomas Jefferson, when the convocation was considering and revising his writings, impatiently said, "They're ruining my declaration."

Jefferson was, of course, a skillful wordsmith but The Declaration we have today is one many wrote together.

Which brings us to the next phenomenon we need consider when confronting problems.

All being is the balance between chaos and order.

When things are somewhere near mid-point between these extremes we're in a "steady state" which can be maintained if large disruptive change is attacked earlier in small changes.

"Homeostasis" is just this -- substituting small incremental change for large disruptive change.

A living organism does this by maintaining a "steady state" in blood sugar, the acid-base balance of the blood, body temperature or the blood pressure.

But as separate human beings, with feelings as well as intelligence we most often have trouble accepting change until it threatens to become over-whelming.

Sharing knowledge of our needs is more conducive to the understanding of change then is discussion of our wants.

This is the mechanism through which negotiation leads to "win-win" situations rather than maladaptive "cul-de-sacs."

Which brings us back full circle to the business of taking a good history and examining well any conflict at hand.

Somehow I hope Charlie Peete reads this and knows what a profound impression his casual remark made to a medical student 50 years ago, has made to his mind-set toward problem solving, and what a stream of consciousness it released.

This was brought home to me shortly after he made it when I was in the Pediatric service at Duke.

A young farm boy had been referred to Duke with an illness that was puzzling all.  

He had a high fever, swollen lymph nodes, an odd skin rash and desperate malaise and weakness.

The resident physician was presenting the case on rounds to the attending staff physician for the ward and the medical students and other house-staff members assigned then to the service.

The attending, thinking of talavernia or "rabbit fever," asked if the child had been around any sick animals.

The father also on hand, replied, "Yes sir -- we keep 'possums we trap and they have all died off lately."

The resident spoke up and said, "Yes -- we got that piece of information, but it was obvious those 'possums were killing one another off."

"That could've been true, answered the father, "but then we wondered who killed the last "possum." 

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June 1997

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