PERIPHERALIA

The page number in the footer is not for bibliographic referencingwww.tandfonline.com/ojfp 50

In general practice we often use many peripheral little bits of 

information to help us make our diagnoses and to organise 

our management plans. Like the title of this column they 

are the peripheralia and marginalia that we glean, almost 

subconsciously, from items or artifacts that are apart from 

the patient’s grand narrative. It might be a photograph, 

a throw away comment by a staff member or a relative, a 

letter written to us by the patient or a paragraph in a local 

newspaper or some form of self-observation or reaction that 

one has to a patient. These sources of information from our 

peripheral vision and practice background are called non-

obtrusive sources and the persons who interact with the 

index patient and ourselves are called secondary actors. 

These tangential external sources may have a tendency to 

confirm the diagnosis that I am forming in my mind or have 

the opposite effect of throwing a spanner in the works and 

explode a theory that has been nicely building up. It is the 

problem we have with collateral information that may be 

relevant or unrelated to the case in question. I have usually 

formed an opinion one way or the other and suddenly I am 

being told another narrative from another angle and have to 

change tracks or revisit the original ground.

As a control freak, who likes everything to fit into the box, 

I find these extra bits of information tend to disrupt my 

thought processes until I have had a chance to weigh or 

balance the new information. If you work with families, for 

instance, you have to forget about this sort of control. I have 

to sift and rationalise the histories, opinions, perceptions and 

previous interactions of the family members otherwise my 

mind becomes discombobulated.

We spend a lot of our day like this, trying to marry the 

paradoxes and ambiguities of everyday life into some form 

of order so that we can have a management plan.

The Greek poet, Archilocus, said “the fox knows many things 

but the hedgehog knows one big thing”. This is because the 

fox is cunning and thinks up many schemes for attack and 

defence, whereas the hedgehog has only one mechanism 

to defend itself against any attack and that is to curl up into 

a ball.  This survival solution of the hedgehog copes with 

most problems. This fits in with much of our reasoning in 

medicine in line with the aphorism “common diseases occur 

commonly”.

We spent a lot of time, like the fox, doing multiple 

investigations, scans and X rays that turn out to be negative 

whereas our first assessments or our common sense, like the 

hedgehog, are found to be correct. In the distant past, when 

there was less information around, I used to have a few big 

ideas and alternatives but now, because of the information 

explosion, the field is strewn with many small “what ifs” as 

well.

We have to try and blend the personal stories and situations 

of patients into the medical facts that we have obtained from 

the formal history, examination and investigations as well as 

all the epiphenomena.

In the past I always used to want to treat everything; that is all 

the patients presenting problems along with the collapsing 

health system and world poverty (well, maybe not in one 

consultation but at least by the end of the week). But family 

medicine is a messy business and I have learnt over the years 

to try and select the information I consider useful but then 

along comes another interloper: the outlier.

An outlier is that recording that is way off the nice linear rising 

or falling of the curve of the graph. It is almost as frustrating 

as the peripheralia. You cannot squeeze either of them into 

the box.

In a busy day we usually need to focus on a few big 

alternatives or diagnoses that initially crop up in our minds. 

We then go on a heuristic journey to narrow them down and 

try and reduce the complexities of our clinical judgments 

and investigations into some form of assessment and then: 

the patient produces the computer printout from Dr Google 

that tells us the diagnosis.

Chris Ellis, Family Physician, Pietermaritzburg, KwaZulu-Natal 

e-mail: cristobalellis@gmail.com

Non-obtrusive sources  
and secondary actors