Last time, I wrote about moving from just being able to make simple decisions to more complex situations, and how we become more comfortable with making said decisions with experience and confidence.

With experience and time, one operates at what is essentially a higher level of thinking. The majority of questions are essentially 'no-brainers'. You're flying on autopilot, you do the safety checks and keep zooming along. Being aware that you're on autopilot is essential, because then your sensors are on; if a warning pops up; you'll notice it.

When you're unaware is when danger strikes. My pharmacist colleagues agree that the most dangerous phrase in pharmacy is "That's fine." It's so easy to say that you barely notice any of the surrounding warning signs. A good example of this would be a shop assistant asking; "This bloke's on Coversyl(R). Can he take Nurofen Plus(R) ?" You glance up, he looks about fifty. It'd be very easy to say 'That's fine', and that may well be right. But, has the pharmacist considered: a) What strength is the Coversyl(R)? It's seldom prescribed alone in the higher doses. b) Diabetes? c) Diuretics? d) Renal failure(!), e) What's the Nurofen Plus(R) for? and so on. It's important to think about, if it's a fast, effective consideration of the information, then so be it. Just because you know the odds, doesn't mean you need less information.

Sometimes a situation arises that requires faster or more complex decisions, or both. These are stressful situations, where if your basic game isn't sound, you're most likely to wobble or screw up. Or get flustered. When this happens, it's essential to keep cool and revert back to first principles, because they don't change. One of the first pharmacists I worked with said to me;

Capt. every time you look at a 'script, read out the name, doctor, drug, strength, quantity and directions out loud. It can be in a tiny voice in your head - just make sure you say it. Don't stare at it. Say it. Say it once for the original, once for the label, once for the box and once for the repeat. If you do this every time, you will never make a dispensing error. No matter what else is going on in your life, all you have to do is say it out loud.

This is possibly the best advice I received as a pre-reg. Obviously, there's not a lot of reasoning happening when you check a script. Clearly, though, it's essential to be able to perform the core tasks. In Medicine, clinical reasoning is one of these tasks. Your skill in weighing the relevance and mechanisms behind this information is key. Sometimes there will be huge amounts of information, much of it conflicting. What to do first? What about the Sodium channels? What's with the tachycardia? (Flustered, much?) How to prioritise?

With no formal clinical experience and not much direction, it's an ongoing challenge to sort the sweet chocolaty goodness of information from the other brown stuff. And it seems sometimes that one can morph into the other without a moment's notice. Again, Murtagh's General Practice has come to the rescue; the first page of the emergency care section states;

1. The practitioner must be aware of life-threatening situations.

Gold. After seeing relatively sparse numbers of patients to this point in medicine, all of which had multiple, complex comorbidities and were managed by various specialist teams, this single sentence really crystallised what's most important; to simplify. Work out what the primary complaint is, and then everything else. On the myriad of information to be processed, I was offered this salient ray of light by one of my Docs;

In medicine, you only have to think about one decision; the next one.

And that's what I will remember; Remain unflustered and simplify.