Learning to think backwards

As you may have gathered by now, I like lists.

Lists of symptoms,

Lists of clinical features

Lists of investigations.

 I like lists.

Even more than that, I like lists that someone else has written.  So I went out, and I bought a lot of revision books (or got them from the library, if I could fight off the medical students…) that contained lists.  I copied them out, I re-wrote them with my own comments, I amalgamated different  lists, I split them into different components…

(It was just an excuse to buy more notebooks, honestly.  I have a notebook thing, not a list thing.  Not the lists, just beautiful stationary.)

My lists looked something like this:

Clinical features of Trisomy 21:

• Brushfield spots
• Sandal toe
• Hypotonia… etc, etc, etc

If I was being really organised, then I had them arranged by system.

Or head to toe.

Or with a diagram (not reproducing those – drawing is really not my strong point).

Or chronologically if the features changed with time…

And then I realised how pointless this all was.

We don’t walk into clinic or clerk a patient with a diagnosis, and then try and find all the features that go alongside it.  Patients don’t come with nice labels attached to them, neither in real life nor in the exam. (And yes, someone is going to point out that some patients have diagnoses, like Trisomy 21.  They do – but that’s not why they’ve come to hospital at 3am on a Friday morning.)

What I had to do was learn to think backwards.

I’d been starting with the diagnosis, and learning lists of features.  What I needed to do was look at a presentation, or a feature, and work backwards from there.

Rather than thinking that Trisomy 21 is associated with hypotonia in neonates, I needed to think about hypotonia in neonates and what caused it.

Maybe this seems obvious to you (in all honesty, it now seems completely obvious to me!) but it changed how I approached the exam.

I didn’t walk in thinking it was a disaster if I couldn’t remember all the features of Trisomy 21.  I did think I needed to understand how to check for tone in a 3 month old, and what the possible causes of low tone in that infant would be.

This is how we work in real life.  It’s how the exam works. (It also meant that I had to write new lists… which meant more notebooks… Ah well)

I’ll post some examples this week, once I get my notes back!