Horses and Zebras and Fears, Oh My!
It is actually remarkable how much we test patients. We test their blood, their brains, their bones, and their hearts. If a bodily fluid exists, we test the crap out of it. What do we do with all that information? We file it. Why? Because you never know.
When I was a medical student in the Renaissance, under my Chief Resident Leonardo, I began to learn the fine art of making a diagnosis. Here it is - the great secret of medicine. If you learn this then you too can become a doctor (by the way, you do have to send me $75,000 to cover your first malpractice insurance payment - a slight detail I may have overlooked):
"When you are on the prairie and you hear hoofs, don't look for zebras, look for horses."
Actually I thought you had to look for Weapons of Mass Destruction. That is only in Texas, I guess.
In reality, what does this old medical adage mean? It basically means that common things happen commonly. If someone comes to you with a cough, don't think they have end stage lung cancer- look for a chest cold. In fact, it is pretty good advice. The problem is that in the Renaissance they also actually listened to the advice of intelligent people and as Shakespeare told them- "The first thing we do, let's kill all the lawyers". (King Henry the Sixth, Part II). (Unfortunately, they did not kill them fast enough.)
If you diagnose every horse that comes around and a zebra walks into your office with a martini and a grin and you miss him- you are going down. Fast and hard. The lawyers will descend on you faster than a pack of 3 year olds around a plate of Mrs. Fields cookies. Therefore, most doctors spend their time and the money in medicine looking for zebras. We look for them in the knee with MRIs. We look for them in the chest with CAT scans, and we even look for them up the butt with colonoscopy (every two years for that matter).
It is not entirely the lawyers' fault. Mostly everything else in society is the fault of lawyers but this one gets shared by the doctors. In general we are a fearful, low risk lot. Medical schools, which I refer to as Internal Medicine School, teach us to be. In medical school you are taught a deadly expression. In all the English language I know no other field but medicine that uses this term. The term is "rule-out."
How is it used? It goes like this- if someone has belly pain (oops- I should say abdominal discomfort since I am a doctor- sorry) and you suspect the cause is mainly due to a particular reason, our medical school professors have taught us to list all the possible diagnoses it could be and sequentially "rule-them out." In other words, prove they are not the cause so we can cross them off our list. Rule out this, rule-out that. Young medical doctors have a lot of lists. Actually the young surgeons didn't. We had a single list. More of a multiple choice:
Question: Should you operate on this patient?
Possible answers
a. Yes
b. Who wants to know?
c. What's it to ya?
d. Who do you think you are talking to?
e. Get out of my face
I trained in a trauma center in the Bronx (that's New York for those of you who live South of New Jersey and have yet to return back to Earth after the last election).
Lists can be a problem, though. We had lists of causes of pimples written on clipboards and our friends who graduated college with us and went to work in business had lists of dates written in black books. Guess who the real smart ones were...
Back to ruling out.
Let's take a real life example. In the Emergency Room a man is rolled in by three paramedics who resemble championship Sumo wrestlers. They actually each weigh no more than Calista Flockhart when wet but with 1,861 various black and matte gray devices of high technology like 21 inch flashlights (you don't need to be Freud to figure this one out) and key rings that can open every room and cabinet in the NY Public Library hanging from their belt, it adds to their mystique and shear physical mass. Also, Einstein noted that e=mc2. The e stands for action. You would think that "a" would stand for action but as a surgeon I choose the first letter I came across and figured I could make it work. Also I don't have the time to rule out the other 25 letters to make the real diagnosis (actually it is 22 possible letters if you believe as I do that LMNO is one letter).
This man is properly braced on the stretcher with a neck brace, 1,215 puncture holes from failed IV attempts and a single 27 gauge butterfly IV in his left eyeball (the only vein left). There is a machete through the center of his chest wall starting in the back and exiting out the front. Sort of an extra-cardiac stonehenge (see image to the left). The surgical team made their initial and final diagnosis - to quote the Chief Resident who was going on to the Mayo Clinic the next year after his training - "This guy is really messed up. Let's go to breakfast." The chap who was the Emergency Room resident had a few "other ideas." What was the real cause of death? He furiously wrote down the list of possibilities of diagnoses and/or the cause of the situation at hand:
He eventually got it right but of course he got sued because he missed a long-standing gallbladder cancer that was eventually picked up on autopsy when the city medical examiner finally got to him 2 years and 7 months later (one month before the statute of limitation on malpractice suits). It was interesting that the surgeons were named in the suit as well even though the resident wrote a single note that was about as legible as a smudged paw print from an old Lassie episode.
Which brings us back to horses, zebras, and fears. The training of physicians stimulates the push to look for every diagnosis possible. This noble approach unfortunately is then exponentially exaggerated by the fear of lawsuits. Physicians are caught between the proverbial "rock and a hard place." If the doctor orders too many tests he is wasting the few valuable resources in medicine. If he orders one too few, that will be the test that the medical malpractice lawyer (read that as SHPOS) will seize on and sue him for missing.
Concerning wasting resources in medicine- forget that criticism- the resources in medicine are going into the pockets of insurance and pharmaceutical executives and shareholders. The private jet fuel bills from the CEO of Pfizer can pay for all of Medicare for the number of years equal to the half life of plutonium (~5700 years give or take a week or so). The second part about the lawyers is sad but true.
To quote the warden (played by Strother Martin) in Cool Hand Luke: "What we have here is a failure to communicate." That failure is because everyone and their mother think they are doctors or nurses and knows better. Sometimes they do but most of the time they do not. Left to our own devices, doctors and nurses will do their best to help you. Diagnosing disease and treating patients with terrible, complex problems is hard enough than to have a politician devil (with his hand in the pocket of an insurance company) on one shoulder and a lawyer devil on the other. At least Paul Muni in "An Angel on my Shoulder" did get the benefit of the angel.
Barring any miracle of insurance reform or tort reform our journey into the apocalypse of medical hell will be led by the four horsemen:
Maybe a knight in shining armor will appear on the horizon to take on this onslaught. For now, it is time for this cowboy to ride into the sunset...
Dr. K.
Glossary of numbers and terms:
When I was a medical student in the Renaissance, under my Chief Resident Leonardo, I began to learn the fine art of making a diagnosis. Here it is - the great secret of medicine. If you learn this then you too can become a doctor (by the way, you do have to send me $75,000 to cover your first malpractice insurance payment - a slight detail I may have overlooked):
"When you are on the prairie and you hear hoofs, don't look for zebras, look for horses."
Actually I thought you had to look for Weapons of Mass Destruction. That is only in Texas, I guess.
In reality, what does this old medical adage mean? It basically means that common things happen commonly. If someone comes to you with a cough, don't think they have end stage lung cancer- look for a chest cold. In fact, it is pretty good advice. The problem is that in the Renaissance they also actually listened to the advice of intelligent people and as Shakespeare told them- "The first thing we do, let's kill all the lawyers". (King Henry the Sixth, Part II). (Unfortunately, they did not kill them fast enough.)
If you diagnose every horse that comes around and a zebra walks into your office with a martini and a grin and you miss him- you are going down. Fast and hard. The lawyers will descend on you faster than a pack of 3 year olds around a plate of Mrs. Fields cookies. Therefore, most doctors spend their time and the money in medicine looking for zebras. We look for them in the knee with MRIs. We look for them in the chest with CAT scans, and we even look for them up the butt with colonoscopy (every two years for that matter).
It is not entirely the lawyers' fault. Mostly everything else in society is the fault of lawyers but this one gets shared by the doctors. In general we are a fearful, low risk lot. Medical schools, which I refer to as Internal Medicine School, teach us to be. In medical school you are taught a deadly expression. In all the English language I know no other field but medicine that uses this term. The term is "rule-out."
How is it used? It goes like this- if someone has belly pain (oops- I should say abdominal discomfort since I am a doctor- sorry) and you suspect the cause is mainly due to a particular reason, our medical school professors have taught us to list all the possible diagnoses it could be and sequentially "rule-them out." In other words, prove they are not the cause so we can cross them off our list. Rule out this, rule-out that. Young medical doctors have a lot of lists. Actually the young surgeons didn't. We had a single list. More of a multiple choice:
Question: Should you operate on this patient?
Possible answers
a. Yes
b. Who wants to know?
c. What's it to ya?
d. Who do you think you are talking to?
e. Get out of my face
I trained in a trauma center in the Bronx (that's New York for those of you who live South of New Jersey and have yet to return back to Earth after the last election).
Lists can be a problem, though. We had lists of causes of pimples written on clipboards and our friends who graduated college with us and went to work in business had lists of dates written in black books. Guess who the real smart ones were...
Back to ruling out.
Let's take a real life example. In the Emergency Room a man is rolled in by three paramedics who resemble championship Sumo wrestlers. They actually each weigh no more than Calista Flockhart when wet but with 1,861 various black and matte gray devices of high technology like 21 inch flashlights (you don't need to be Freud to figure this one out) and key rings that can open every room and cabinet in the NY Public Library hanging from their belt, it adds to their mystique and shear physical mass. Also, Einstein noted that e=mc2. The e stands for action. You would think that "a" would stand for action but as a surgeon I choose the first letter I came across and figured I could make it work. Also I don't have the time to rule out the other 25 letters to make the real diagnosis (actually it is 22 possible letters if you believe as I do that LMNO is one letter).
This man is properly braced on the stretcher with a neck brace, 1,215 puncture holes from failed IV attempts and a single 27 gauge butterfly IV in his left eyeball (the only vein left). There is a machete through the center of his chest wall starting in the back and exiting out the front. Sort of an extra-cardiac stonehenge (see image to the left). The surgical team made their initial and final diagnosis - to quote the Chief Resident who was going on to the Mayo Clinic the next year after his training - "This guy is really messed up. Let's go to breakfast." The chap who was the Emergency Room resident had a few "other ideas." What was the real cause of death? He furiously wrote down the list of possibilities of diagnoses and/or the cause of the situation at hand:- Lead toxicity
- Infection- he was able to note, by analyzing that the only 3 mm section of his body not covered by tattoos showed that he did not shower that morning with antibacterial soap
- The patient was actually an active and alive member of Congress needing no medical attention at all and only a visit from a lobbyist
- The cause of the situation was Karl Rove (eliminating any potential Supreme Court nominees so as not to repeat the Harriet Miers debacle)
- The patient was dead due to complete shredding of the heart, aorta and 5 other major organ systems like an attack from Sigourney Weaver's Alien movie.
He eventually got it right but of course he got sued because he missed a long-standing gallbladder cancer that was eventually picked up on autopsy when the city medical examiner finally got to him 2 years and 7 months later (one month before the statute of limitation on malpractice suits). It was interesting that the surgeons were named in the suit as well even though the resident wrote a single note that was about as legible as a smudged paw print from an old Lassie episode.
Which brings us back to horses, zebras, and fears. The training of physicians stimulates the push to look for every diagnosis possible. This noble approach unfortunately is then exponentially exaggerated by the fear of lawsuits. Physicians are caught between the proverbial "rock and a hard place." If the doctor orders too many tests he is wasting the few valuable resources in medicine. If he orders one too few, that will be the test that the medical malpractice lawyer (read that as SHPOS) will seize on and sue him for missing.
Concerning wasting resources in medicine- forget that criticism- the resources in medicine are going into the pockets of insurance and pharmaceutical executives and shareholders. The private jet fuel bills from the CEO of Pfizer can pay for all of Medicare for the number of years equal to the half life of plutonium (~5700 years give or take a week or so). The second part about the lawyers is sad but true.
To quote the warden (played by Strother Martin) in Cool Hand Luke: "What we have here is a failure to communicate." That failure is because everyone and their mother think they are doctors or nurses and knows better. Sometimes they do but most of the time they do not. Left to our own devices, doctors and nurses will do their best to help you. Diagnosing disease and treating patients with terrible, complex problems is hard enough than to have a politician devil (with his hand in the pocket of an insurance company) on one shoulder and a lawyer devil on the other. At least Paul Muni in "An Angel on my Shoulder" did get the benefit of the angel.
Barring any miracle of insurance reform or tort reform our journey into the apocalypse of medical hell will be led by the four horsemen:
- War (the war between the haves and have nots in healthcare insurance),
- Famine (the removal of so many resources by the insurance companies and pharmaceuticals that we will be starving with what is left),
- Pestilence (Congress), and
- Death (disease- the real enemy here).
Maybe a knight in shining armor will appear on the horizon to take on this onslaught. For now, it is time for this cowboy to ride into the sunset...
Dr. K.
Glossary of numbers and terms:
- 75,000. The real cost of medical malpractice insurance in NY for an Orthopaedic Surgeon. For the record that equals 15,000 $5.00 co-pays from patient office visits. A typical Monday in my office.
- 1,861. The year the serfs were freed in Russia. Doctors' freedom from insurance companies lags behind obviously.
- 21. The legal drinking age in NY. Note that the legal voting age is 18. This leaves on 3 years of sober voters. Now we can understand why Congress is in the state it is in.
- 1,215. The year the Magna Carta was signed. The major significance of this is that I remember when I got this question right on an exam in 7th grade leading me to the conclusion that there was hope that I would get into medical school.
- SHPOS- due to editorial constraints I can't print this.
- The compensation, not including stock options, for a single year of salary for the current CEO of Pfizer is $17,188,437. That pays for a ton of flu shots for people who can't afford them.
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7 Comments:
I LOVE IT
I agree sometimes the doctors and nurses don't and should not be expected to know everything. What get's me is when I run into the doctors who act like it. I was told recently to my face "I don't have to ablige or talk to you or discuss with you anything I do with my patient. Well that patient was my Mother, and an open heart patient with complications. I happen to be an Occupational Therapist; with some however trivual to compared to his medcinal ego; all I wanted to know was her status. This Doctor had performed a bedside emergency procedure on her, of which I was not notified or told about until I arrived at the hospital during visiting hours. The staff commented afterward that this Doctor has frequently had outburst like this. The apologizies went on and on. My concern is should someone this volitile be performing heart surgery? What recourse does a patient or family member have when you have been wronged by a doctor? I agree, sewing and money isn't always the answer.
I am a Zebra. I have Ehlers-Danlos Syndrome, one of the most common disorders of collagen production found in one of every 4,000 people.
I diagnosed myself at age 55. Not one doctor had ever followed the dots. When I asked my wonderful rheumatologist about it, he told me if I had EDS, I would have been diagnosed as a child. Diagnosed by whom?
as I head toward my 36 th surgery as a result of EDS, I wonder how much of this could have been avoided if I knew then what I know now about what activities I should engage in and treatments I should have avoided.
All doctors need to realize that zebras do exist, and because we don't fit the profile that is expected of a horse, not to assume we are hypochondriacs or crazy. Since most EDS does not show up on tests, how about physicians using their skills as listenters instead of relying only on test results.
Speaking for the many Zebras I personally know, I would like to know how to publicize EDS so it becomes as recognizable and Fibro or CFS. Any ideas on how to remove the stripes from a zebra and turn it into a horse?
Looselinks
Hey I have EDS too. They've been only diagnosing it since the turn of the 20th century, so give it some time. I went around to doctors for five years until a geneticist diagnosed me. It's just not very popular yet, but soon people will begin to recognize it.
I have now been diagnosed by one doctor as having ehlers-danlos syndrome, and by another doctor with lupus anticoagulant. The treatment for EDS is no aspirin or blood thinners, and the treatment for LA is aspirin and blood thinners. I am one very confused zebra.
Thanks Dr. K. Very amusing. And true. I,too, trained in a NYC Emergency Department (NYU and Bellevue Hospital) ...yep, those DDx lists are really long...partly to save our rear ends but also to save our patients' rear ends. As an Emergency Doc, I am pretty glad I have long mental lists of differentials (pounded into me by the fantastic attendings at Bellevue /NYU and my stellar senior residents). So even if in the end, I conclude that the GSW through the left chest is the cause of death, (but as a good ER doc trained by the best toxicologists -NYC poison control- lead poisoning would still be on my list ;-).
Regarding treatment for Ehler's- Danlos Syndrome: it depends on the type of EDS. Vascular type EDS or Classical EDS , (which can be diganosed accurately by genetic testing or by skin biopsy), should avoid aspirin and other anticoagulants. Ehlers-Danlos Hypermobile type, the most common type of EDS, has no vascular or hemorrhagic complications, therefore aspirin is not contraindicated. Unfortunately, there are no known genetic markers for Hypermobile EDS. The diagnosis is a clinical diagnosis as well as looking at family history (as it is an Autosomal Dominant disease). Find a rheumatologist or genetist who can accurately determine if you have EDS. Visit www.ednf.org for more information about EDS. Good Luck!
In the end, I know common things are common, but I actually give a damn about those Zebras, too. And, they are often a little more common than we docs have been traditionally trained to think.
Dawn C. Leighton, MD
Emergency Physician
Zebra: EDS Hepermobile Type
Lostinmissouri,
I was a Nurse for 18yrs, yes I have a history of bad health but now after another 18yrs I have been told the I have EDS Arterial Ecchymotic typeIV.. And I think half the Dr's in this Country worry more about other things then the people they take care of. Now am I worng to think that way.
In alot of pain everyday
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