Zebra Hunting: How Caring Is Lost When We Chase Diseases
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Division of Global Health Equity: Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA; 2Department of Medicine, Boston Children’s Hospital, Boston, MA, USA.
J Gen Intern Med DOI: 10.1007/s11606-020-06268-1 © Society of General Internal Medicine 2020
hen you hear hoofbeats, think horses not zebras—so the W old adage goes, but if you were an intern like me,
medicine was all about the zebras. For the most part, case presentations in the hospital start and end the same way: a vague one-liner, a few precious tidbits of data, and then our differential diagnosis. I have yet to be in a case conference where the first thing suggested is the most common cause of the complaint. Instead, we indulge in the opportunity to show just how esoteric we can be: it could be …—insert any plausible condition unlikely to be on the minds of those around you and you score points. And invariably, at the end, the diagnosis is some obscure and extremely rare creature with black-and-white stripes (Scimitar syndrome, Naegleria fowleri infection, etc.). On the wards, it’s not much different. My last differential was filled with conditions I secretly hoped it might be—the “interesting” cases. Sometimes, when the diagnosis is too obvious to ignore, I dive into the improbable causes of that “uninteresting” disease. Our elderly woman with two previous heart attacks who is now in heart failure might be so because of the cumulative effect of ischemia on her poor myocardium, or it could be an exceedingly rare invasion of the myocardium by a previously undiagnosed T cell acute lymphoblastic leukemia, because it could always be, but never really is. A part of that chase is driven by my own fear, my own selfdoubt: would I be able to summon that diagnosis when push comes to shove and I’m on my own? So, I look for them everywhere. But we’re also empowered to think that way. Despite the wise adages, we are constantly presented cases, lectures, and journal articles of the rare and atypical. It’s a part of our education system and how we practice medicine. If we don’t send the test, we may miss one of those zebras prancing around right under our noses. And so, in hyper-resourced institutions, as long as it doesn’t cause harm, we do. We send expensive work-ups and specialty blood tests literally across Received August 25, 2020 Accepted September 21, 2020
the country to the only laboratory where they can be run. It’s not for no reason either; thrillingly, every now and then one of those tests comes back positive. It never bothered me, that inspired chase for “interesting” cases, the hunt for zebras, until I was in Malawi. Rounding on the male medical ward—a room the size of a basketball court with high windows, spiders crawling on the off-white walls, and 20 beds—we met a somnolent elderly gentleman who had just been put on oxygen. He was frail, thin, and looked sick—the kind that catches your eye when you walk into a room. We were told he had presented the day before with what was diagnosed as a new psychotic episode, was given Seroquel, an
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