Wisdom Wednesday: When You Hear Hoof Beats, Don’t Look for Zebras

Many years ago an MD I worked with gave me this answer when I inquired about the possibility of some exotic disease in a common patient. The exact quote was “Oh Bill, when you hear hoof beats, don’t look for zebras, it’s usually horses.”

My response was that during college I lived along the Hillsborough River in Tampa. Every morning, driving to class at USF, I passed Bush Gardens and saw lots of zebras.

Zebras do occur in everyday practice. They just don’t occur every day. However, as a primary care physician, it is my responsibility to see the tell-tale ‘stripes’ and act accordingly.

The patient that comes in with acute low back pain is almost always a horse. But if she has a history of breast cancer or he has a history of prostate cancer, they might be a zebra. Metastasis from breast or prostate loves bone, especially the low back. I am responsible for picking up on that stripe even if the patient doesn’t give me the history. That’s because it’s my responsibility to ask.

I don’t have to diagnose the cancer or treat it, but I have to make the appropriate referral. I may decide to run further testing to make a more educated referral or even co-treat. What I cannot do is delay proper diagnosis or medical treatment.

Diagnosing zebras is also an issue. If I, or any other physician, suspect a particular disease, you cannot tell the patient they have that disease without running the appropriate diagnostic testing. You tell them that you suspect a possible pathology. If pressed, you give them a differential that includes a few possible disease processes.

Wisdom Wednesday: The Patient Always Knows

I frequently reiterate this statement to my patients, “on some level, the patient always knows.” As a physician it is my obligation to listen to what my patient is trying to tell me.

Many years ago, during an initial consult, I had a new patient who confided to me, “I don’t know what it is, but I just feel like something is living inside of me.” Initially, I discounted her statement. I continued the history learning that she and her husband had been separated for six months and that her stress levels were quite high.

I ordered some routine lab work on her and scheduled a follow up visit. The lab work include a urine analysis which came back showing Chlamydia, an STD (sexually transmitted disease). Typically, Chlamydia doesn’t show on a UA but will on a vaginal smear. However, her infestation was so high that hundreds of thousands of these microscopic organisms spilled over into the urine. I was very fortunate to have stumbled across the correct diagnosis. Chlamydia looks like sperm, with a head and a tail swimming about. They are too small to feel yet she knew on some level, “something was living inside” of her. When I shared my findings with her she admitted that she had separated from her husband because he had a thing for prostitutes.

Patients live in their bodies 24/7. They know on some level what is going on. However, they often cannot express that information in a way that the physician will understand. Many times, the patient doesn’t really understand what they are trying to say either. That new patient taught me “the patient always knows.”