A couple years ago I fell very ill.  It was a Sunday night after a stressful week of work, with part of the day spent playing with a friend’s rambunctious six-year old boy followed by a frozen “healthy” dinner that I had never eaten before.  I tried to sleep but I couldn’t lie still.  I sweated through my t-shirt, I projectile vomited, my chest hurt.  At first, I blamed the funky butternut squash souffle I ate combined with my sheer exhaustion.  The next day my wife took me to urgent care, where they confirmed I hadn’t had a heart attack and they didn’t think I had angina either.

I stayed home and rested for a couple days and then Mr. Tough Guy journeyed 50 miles up the New Jersey Turnpike to my office.  What a shmuck I was as my wife made amply clear to me.  The pains in my chest got worse and now I was short of breath even during small walks.  And my heaving, body-wracking cough was a beaut.  The next morning I went to my internist.  He wasn’t sure exactly what was going on but my ghastly pale face scared the crap out of him and he told me to go to the ER at once.  

The off-kilter inpatient

I spent 14 hours in the ER because I was a medical enigma.  I was diagnosed with pneumonia and an infected gall bladder, quite an unusual combination I believe.  My care providers said the gall bladder had to come out and I was promptly started on a powerful IV antibiotic for the pneumonia once I was admitted as an inpatient.  Oddly enough, my pneumonia ending up sparing my gall bladder.  An anesthesiologist put the kibosh on my surgery because she said it was too risky to operate on someone with pneumonia. She feared that my pneumonia might make it impossible for her to remove the breathing tube used during surgery, which could be fatal.

Eventually my dual infections calmed down and I was discharged from the hospital after several days there.  The surgeon asked me to set up an appointment in a few weeks to discuss having my gall bladder out, which he said was still needed.  After a hospital experience during which no one had figured out the connection between the twin infections in my lungs and my gall bladder and my almost having had surgery that could have cost me my life, I didn’t trust anybody involved in my care there.  So I told the surgeon I wanted to get a second opinion from my super-brilliant gastroenterologist.  He said, “great idea.”  And boy was he right.

This Einstein of the GI tract heard my story, looked at my hospital records, and said the way I had suddenly developed a gall bladder infection was very strange.  She then hypothesized a diagnosis that sounded truly bizarre, Legionnaire’s Disease – you know, the condition that those Legionnaires meeting at Philly’s Bellevue Stratford hotel in 1976 got from the HVAC vents.  I asked my wife, who also sees this gastro, if the good doctor was nutters and she said “no, she’s a genius and you should go for the blood test.”  And damn if Dr S wasn’t right.  She was surprised no one in the hospital had figured it out and she dismissed my comments about her superhuman diagnostic acumen.

Hoofbeats

You may have heard the adage taught to new doctors that when they hear hoofbeats, look for horses not zebras. In other words, focus on what’s most likely when making a diagnosis rather than rooting around in the esoteric.  That saying may have been around since the dawn of time but it’s still widely followed as my experience attests.  I had two seeming horses going on – one in my lungs and one in my gall bladder – but due in part to the uncoordinated state of care in the hospital (see my blog post on the topic) each specialty managing my care focused on their respective horse while missing the 800-pound zebra in the room.  Alright, I think I’ve pushed the animal analogies as far as they will go. 

I get why doctors are taught to first look for horses.  When the clock is ticking – both in terms of illness progression and the limited amount of time doctors can often spend with patients – there’s pressure to make a quick diagnosis and get treatment started. Also, insurance companies often make physicians and patients jump through hoops to get the tests sometimes needed to diagnose rare conditions.  So, I don’t want to put this all on doctors but in my case, the doctors who treated me in the hospital could have done better despite the fact that they may have saved my life.  (I know I sound like a world-class ingrate😊) It could have gone the other way, though, if the antibiotics used to treat the supposedly more garden-variety form of pneumonia they thought I had weren’t able to also treat the rare form I actually had.

In defense of the hospital docs, you could say that my gastroenterologist had the luxury of being able to take a more carefully reasoned approach to my situation since by the time I met up with her the crisis had passed and there was no pressure to treat.  However, I’d bet the Dr. House that she would have gotten the diagnosis right even if she had been the attending physician in the hospital.  Something was off in her eyes and she needed to figure out what it was.  And I think it’s important to mention that the medical group in town for which she works has pretty aggressive productivity goals, which translated into a fairly brief appointment with the good doctor.

The keys to being a great diagnostician

What makes Dr. S a diagnostic wizard?  First, she knows an enormous amount about medical matters beyond the gut.  She is the rare holistic thinker in this era of specialization.  Also, I’m going to guess that she possesses the humility needed to continually question her hypothesized diagnoses.  Humility without brainpower is a nonstarter though.  If you’re going to quickly generate hypotheses and discard them until you come up with the one that makes the most sense, a first-rate mind is essential.

I say doctors should forget about the horse/zebra dichotomy in making diagnoses and put all options on the table if the facts don’t strongly support the more common condition.  While each rare condition has a small prevalence, the collective number of people in the US that have one of the 7,000 diseases considered rare is very large, almost 30 million.  Thus, the average doctor is going to encounter many zebras in their career. And to paraphrase the wise philosopher Ferris Bueller, if you don’t stop and look around you may miss them.