Landscape first, not landmarks.

Wise words from an FY1 doctor to medical students

It seems like yesterday that I was a medical student revising for finals and attempting to learn all of the causes of Atrial Fibrillation (AF), right down to the most obscure stimulants that can trigger a paroxysmal episode. Although my drive and determination may have been endearing at the time, now that I am qualified, it sadly seems a little unnecessary. Medicine in practice is unfortunately not about memorising the complete list of 50 rare drugs that can trigger AF (lists as such we will thus define as the specific 'landmarks'). It is instead about being aware of the most common causes that present in the clinical setting (which we will refer to as the 'landscape'). From my own experiences as a student and from now observing medical students as a FY1, we seem to have a common trait when approaching any pathological state or being questioned by Seniors. We all panic, our minds go blank and then a glimmer of learning surfaces and we regurgitate all of the bizarre causes of AF that we had revised the night before, with no regard to how extremely unlikely they may be in the current patient.

Instead our first instinct should however be to focus on the landscape of the disease. We have all heard the terms, common things are common and 'horses not zebras', which underline the point that our initial thoughts should be on the general disease states that present most commonly. For example, when your Consultant asks you to give him three causes of AF, stay calm and always think of broad categories first! Well Dr X, there are many causes of AF. The most obvious would be haemodynamic stress causes, Ccardiac ischemia, and drugs. More often than not he/she will then ask for more specific answers, but by outlining the landscape you have demonstrated that you can think systematically, whilst allowing yourself time to then pick out some specific and more relevant landmarks. If you look at the broad spectrum of any disease, you will never miss out on the important causes.

The landscape approach is an easy way to think about medicine from a systematic perspective. Throughout my training I have come across a number of different ways of using the landscape approach. The first example of this is by thinking: whats the anatomy of where the symptom is originating from? Are there any structures before, within or after the area of interest that could be responsible for the symptoms? The best application for this type of landscape example, is when a patient comes into hospital looking rather yellow. Your Consultant asks you, What are the most probable differentials for jaundice? Instead of saying, Wilson's, Halothane, PBC or any other cause that spurts out of your mouth, you should STOP..... THINK LANDSCAPE.....and then think through the hepatobiliary anatomy. By doing this, you will hopefully come up with pre-hepatic, intra-hepatic, and post-hepatic causes. Depending on the specifics of the patient, you can then add relevant landmarks from each broad heading, such as in an obese, alcoholic female; alcoholic hepatitis (intra) or gallstone CBD obstruction (post). If the anatomy is vague or the symptoms are generally systemic, the next landscape approach is to use a 'surgical sieve'. One example is 'vitamin c':

VITAMIN C: Vascular, Infection, Trauma, Autoimmune, Metabolic, Inflammation, Neoplasia or Congential

The surgical sieve landscape can be especially useful when you are under pressure to think of the possible general causes of any disease. Having a systematic approach will make sure that you dont forget the big red flag differential that we cant afford to miss. So, when preparing for final exams as a medical student or clerking a new patient as a FY1 doctor, by using the lanscape approach we ensure that we consider all possible diagnoses and do not narrow our differentials to the rare and obscure. This organised and systematic approach will guarantee that we never miss an important differential.

Dr. H. Jarvis - FY1 doctor at University Hospital Coventry and Warwickshire