Part 2 : The Card System
– Studying a Disease –

“Few people think more than two or three times a year;
I have made an international reputation for myself by
thinking once or twice a week.”
– George Bernard Shaw –

It is the final day of the final year of medical school, and you are sitting your final exam, an oral test, which you must pass to graduate. Your three examiners, Professors Grouch, Grump and Grunt have particularly nasty reputations.
The examination begins and you turn your attention to the patient…
Phew! It is a straightforward case of heart failure! Relieved, you quickly move through your examination. Apex beat shifted, mitral regurgitation, ankle swelling… easy! You allow a pregnant pause, strike a thoughtful pose and state:
“My opinion is that this lady has an advanced case of heart failure.”
Professor Grump smiles wryly…
“Very good. So, student, tell us about heart failure?”
What an easy question! You launch into it.
“Well, your heart can’t pump enough so you get leg swelling…”
“I do not!” Professor Grump glowers at you.
“Oh. Sorry. The patient gets swelling because of their heart. So you need to give them a diuretic. And it’s very common. And you get short of breath when you lie down.
“I do not!” retorts Professors Grouch,
“Oh. Sorry. Anyway, they get tired easily. And when your arteries get all clogged up you have a heart attack and that’s how you get it.”
“I hope I do not!” Sneers Professor Grunt.
“Oops. Well anyway. Swelling. And er, diuretics. Pump failure. Heart attack. Myocardium. Starling. And um, its common. Um, er.”
Oh dear. Your mind starts to spin. Whole books have been written on heart failure! What have I said and what haven’t I said yet??? You try to go on…
“And… and… um… Ankle swelling, well, its like, there’s this, um.”
“Stop muttering!” yell the Professors.
Ooh no… your stomach ties in a knot, you feel nauseous, your knees knock together, beads of sweat break out on your forehead. You’re forced to contract your sphincters. Your mind races… if only you could remember that lecture on heart failure! And then…
Blank. Nothing! Oh no! **Stunned-mullet syndrome** strikes again!
“Um. Um! That’s all I know. Um. That questions not fair! Um. Ask me something else… pleeeeease? I’m really smart, honest! But you, you get all this swelling in your scrotum, and your brain isn’t very well perfused, and you’ll probably be dead in five years.”
Oh dear! The Professors don’t look impressed! Professor Grunt gives you a smirk…
“Well! Clearly you need an easier question, student! How do you spell F?”
Picture the following scenario:

Before being taught the Card System, many students find medicine to be a bewildering mess of information. Facts come and go from every angle and many students study notes reflect this – a disorganised scatter of little use for anything but exam cramming.

The Card System is so named because it works well to write them on index cards, allowing a neatly arranged memory-aid of all your medical notes. The authors’ Card Systems started like this, and so might yours. Alternatively you could carry your card system around with you (like to the bedside) on a tool like a ‘PDA’ – how to do this is explained in the ‘Virtual Cardbox’ section of this site.

On the surface the Card System seems to be just a logical way of setting out medical information, like you would find in well-organised textbooks (Osler set this standard in his own text). However, as we will see, the system goes much deeper, each component being specifically structured to train your medical thinking. It is also a very efficient means of storing and retrieving your knowledge quickly.
Well that was a bit silly. Again this is based on a true story. But how would you have answered as wide-ranging a question? We’re going to need some new methods… so let’s meet the next great tool of the thinking doctor: the Card System. The Card System is your ticket to making sense of medicine. It is the ultimate structural tree to hang your knowledge on. The sieve, which we have already met, is but one branch.
“If you’re up to your neck in it, stand very still!”
Richard NixonAnd if you’re up to your nose in it,
keep your mouth shut.
Write out the following card, and then the subsequent cards that appear in the remainder of this chapter. These are the ‘reference cards’ for a new Card System of your own.

From now on, every time you make notes on a disease, do it in the form of the Card System, using the headings on the reference card, and subheadings presented in the following chapter. Aim to write a card each week at first. You will be slow to start with, but it will become rapid and easy with time. The best time to write a card is after you have seen a patient with the relevant condition – that way the information will stay etched in your brain. Once you get going, cards are fun to do. Just remember to keep at it. After a while, you will be surprised at what you have covered, and will find yourself a much-improved student. With everything hanging conveniently on your tree of knowledge, you will also remember what you have learned. Gone will be the days where you reduced your learning to cramming for exams… the hard work will be neatly arranged in your cardbox. While your friends are frantically scrambling between textbooks and folders the night before a test, you can smile smugly at them from your armchair, sipping a hot chocolate, and leafing through your perfectly organised collection of cards one last time. Unlike the student in our scenario, when asked to write an essay or discuss a condition, you already have a perfectly built structure on which to base your answer. Wonderful!

Perfect happiness for student and teacher will come with the abolition of examinations, which are stumbling blocks and rocks of offence in the pathway of the true student.