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PM Pediatrics
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Dr. Christina Johns
Senior Medical Advisor, PM Pediatrics

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Medicalisms

Children are not just small adults.” Most people have heard this expression, stated liberally by people in healthcare worldwide. It is used in several different ways; sometimes as a defense mechanism when non-pediatric clinicians deploy it in (maybe) a patronizing way to suggest that somehow pediatric medicine is easier and simpler because kids are just a scaled down version of grownups. While that assertion is false, the statement itself does have validity however, in the sense that pediatric medicine is 100% different from adult medicine, and most pediatricians have no issue reminding the world of this.

Baby in red high heels of her mother to represent "children are not small adults"

This phrase got me thinking of a few more of these “medicalisms,” which I guess are really medical aphorisms, and while I am certainly not the first to write about them, sometimes it’s good to gather things like this into a list as a bit of a periodic review. I recalled several immediately on my own, such as:

“See 1, Do 1, Teach 1.” And “Things tend to come in 3’s.

The first one refers to undergraduate and graduate medical education, also known as medical school, internship, and residency. During this period you not uncommonly find yourself in a situation where you learn a new skill, then perform the new skill right away, then are expected (and often able) to teach someone else that same skill. Maybe even all in the same day. It can be kindly thought of as “immersion learning” with the acknowledgement that not everyone learns best this way. But I digress; this post isn’t about medical education. Another day.

The number 3 reference is total voodoo but I swear seems to play out for me regularly in my clinical work: see one child with hand, foot, and mouth disease and I’ll betcha I’ll see 2 more before the night is over. Feels the same way for trauma, but I can’t back up that claim with any rigorous data, and you know how I am about the evidence.

So I took to Twitter to ask for reminders of other commonly held medicalisms from my network of fabulous virtual colleagues on #medtwitter, and I got a fairly robust response. Many of the replies I received were phrases that apply more to adult medicine than pediatrics (like “the only reasons NOT to do a rectal exam is if there’s no finger or no rectum”- charming, right?) but there are a few good ones that I think are worth sharing. At least as a volume one.

dr christina tweet asking for medicalisms

When you hear hoof beats, think horses, not zebras.”

This seems more applicable to veterinary medicine than human medicine, doesn’t it? I really love this analogy, though. The simple suggestion is that common things are seen commonly. The voluminous input of knowledge acquisition without a ton of context during medical school naturally lends itself to near zero perspective about the incidence of rare diseases, and consequently at the beginning of many medical careers it seems like all those unusual conditions you learned about as a first year ought to be coming up just a little more often than they actually do… but they usually don’t. So it’s reasonable not to automatically assign someone an obscure diagnosis if it’s more likely to be a common one. That’s not to say to ignore those one-in-a-million cases, but consider the routine stuff first. (I’ve come to know a bunch of medical zebras over the course of my career… and a few unicorns too!)

A zebra and a horse share quality time in South Africa.

What kind of cloud are you?” & “Don’t use the ‘Q’ word.”

This expression has mostly to do with what kind of clinical luck you have. A black cloud (indicating a storm) suggests that when you are working, the highest volume of sickest patients come in, and if something bad can happen, it surely will. People who are known as “black clouds” have workdays where NO ONE has a simple, straightforward, solvable problem. If you are a white cloud (like those seen on a sunny day), then you are that person who gets a full ten hours of sleep on an eight hour overnight shift. And if you put 2 black clouds together, well then you have quite a storm. I was sort of a “partly cloudy” kind of gal: colleagues never ran the other way when they saw me coming on but I was never the guarantee of a good shift either. I suppose I’ll accept the “not the worst weather” description. Could be worse.

Saying the “Q” word (opposite of loud) is a grave error. At any time. In any place. It is universally accepted as an automatic jinx on the whole workday. “Wow, we are not overwhelmed today” is an acceptable alternative to “gee things sure are q____ around here today.” This forbidden word galvanized so much stigma that in fact a study was done whereby the ‘“Q” word was uttered at the hospital and then the day’s patient volume was analyzed, and while I’m compelled to report that saying the word did NOT in fact predict a miserable day, the reputation remains. Not an official or scientific recommendation here, but I suggest you watch your language in the Emergency Department in this regard. 🙂

 

Never trust a newborn.

I mean, do I need to explain this? Have you met one? Newborn humans are squirrely little things. In the beginning they don’t really have reliable patterns other than regular eating and diaper changes, so small, subtle changes can be difficult to interpret and when these changes involve a clinical status change they can get disastrous in a hurry. The newly born can seem fine one moment and require a resuscitation the next. I’m not trying to be inflammatory; that’s how they are. So they’re aren’t to be trusted. They are to be observed, side-eyed, and forced to prove beyond a shadow of a doubt  that they are stable.

image of crying baby

The more you stay; the more you stay.” Vaguely similar to “They can hurt you but they can’t stop the clock.

This one’s really about knowing your limits and practicing a little bit of self-care, and in large part refers to medical training but is universally applicable to all clinical staff. You have to know when to pass the baton and GO HOME. DISCHARGE YOURSELF FROM THE CARE ENVIRONMENT. Your colleague can check that last pending lab value and help disposition your patient, so that you don’t wreck your car driving home because you’re so tired. The medicine machine is 24/7/365, and while sometimes it’s hard to know when to stop your leg of the race you have to do just do it, because the race has no real finish line.

red alarm clock showing 11:55

“If a patient’s nurse is worried, you should worry too.

There is nothing that makes me more nervous than when my nursing partners are concerned about a person or clinical scenario. In fact, when I am in the middle of a loud emergency department and I hear one of their voices calmly saying: “Christina, can you come in here?” I hone in on that like a heat seeking missile and GET. TO. THAT. BEDSIDE. FAST. The nursing staff, with their smarts and experience and awareness and good intuition, are the eyes and ears and fingers on the pulse of the patient collective, and are most often the first ones who identify situations that are rapidly going downhill. They know who, what, when, and where I need to pay attention to, and I respect that wisdom categorically.

 

“If you didn’t document it, it didn’t happen.”

Standards for medical record maintenance have become increasingly rigorous, especially in a litigious society, so we’re taught from day one to document every intervention and response with time and signature stamps. Makes sense from an accuracy standpoint of course, but can often make staff feel like they are slaves to the process and many report that they spend more time documenting the care they give than actually giving the patient care at the bedside itself. (Spoiler alert: it’s a big dissatisfier.)

Closeup shot of an unidentifiable businesswoman filling in paperwork in an office

Treat the patient, not the disease.

There are lots of derivatives of this, including “treat the patient not the xray (or lab result or number)” and “treat the kid not the fever.”  Straightforward message here reminding us to take into account the holistic picture of the human being receiving care. None of us is simply a diagnosis or an xray result or a platelet count, and being mindful of this is absolutely paramount. I’ve always felt that the best care plan considers the diagnosis, the person AND their environment, and how they feel about their medical situation, so this one really resonates with me.

While I’m writing this I have my Twitter timeline up on another screen, and I could really write another ten pages sharing more medicalisms that my comrades in the trenches reminded me of. These expressions are a fascinating cultural slang, one that is generated from incredible hard work, seemingly unmanageable stress, wonderful examples of grace and humanity, and an overwhelming desire to make others feel better.

Maybe I’ll write volume two sometime soon.

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