The classic metaphor of the zebra in medicine harkens back to either Maryland in the 1940's or Arkansas in the 1960's when medical students were advised: "When you hear hoofbeats in the night, look for horses - not zebras." (1) With this simple instruction, the concepts of clinical acumen and outlier awareness have permeated our healthcare culture so we are ironically looking for and sometimes celebrating the zebras we find.
Although common things happen commonly, we are on a safari
for a good pick-up, as they are called, when we proactively discover an uncommon disorder that a more casual observer may have overlooked. Those rarities sometimes
occur in a Pareto (2) distribution to the extreme or push the bell curve (3)
and our diagnostic curiosity to the narrow and more remote heads or tails of a
Gaussian function.
Even if there is the chance of a problem being that one out
of a million occurrence, we need to construct what is called a differential
diagnosis (or differential, for short), a laundry list of the entire
constellation of possibilities, sometimes even organized in the order of the
complex and interrelated systems of the human body. In turn, a Bayesian
approach guides a thorough history taking, a targeted physical examination, and
appropriate testing to gravitate toward a solution so we find the solid ground
of evidence and stick the landing with more sure footing.
Teenage well-child checks can be the most challenging visits
on our schedules in primary care. These creatures' social awkwardness, changing parent
dynamics, and reticence to the required counseling topics of “sex, drugs and
rock ‘n roll” are daunting, especially since the entire task is usually inserted into a
meager 15 to 20-minute timeslot. A positive review of systems for mental
health, attention issues or school performance will wreck your timeliness
metric for the rest of the morning or afternoon.
One of my most memorable visits in private practice was with
a high school sophomore who had the typical disheveled look on the exam table
with tossed hair, torn jeans, and mismatched clothes. Her low level of
engagement and lack of eye contact were predictable components of the standard
presentation. Once the birds and the bees and requisite substance use topics
were covered, rock ‘n roll was the prompt for me to engage a bit more with my
patients and ask about broader social-related items: favorite music, interesting hobbies, creative
endeavors, or athletic outlets such as school clubs, community groups, church
activities, the arts or sports. Everything is fair game to make a connection.
She sheepishly muttered under her floppy hair, “I paint.”
“Really, that’s awesome!” I said. “What medium do you use?
Oils? Watercolors? Acrylics?”
“All of them. I just like to paint and draw.” was the answer
in a non-descript adolescent way.
I had encountered some amazing stories over the years by
showing curiosity in these growing human beings, expressing interest in them as
a person and their unique attributes. Kids from the farms told me about their
most recent rabbit or chicken they had shown at the fair. Athletes told me
about their most recent games or travels. Anime fans related what they had
discovered at the most recent convention they had attended. Budding young
artists or their parents often snapped pictures on their phones so I could view
samples of their work which is what I was hoping to find in this case.
“Well, what do you typically paint as your subjects?” was my
volley back to her.
Once again, she was evasive. “Different things.” was her
reply followed by a slight pause. Then she looked up at me with a focus and
zeal I had not seen until that point, “I painted a zebra last week.”
I now had my in. “That's awesome!" I exclaimed. "Zebras are famous in
medicine!” I gave a summary of the fabled history and how applicable these
animals are to my role as a family physician and the charge to herd the common horses
while scanning for the unusual zebras.
Almost apologetically, she then admitted to me “It’s a
rainbow-striped zebra.” as if I would be disappointed in her more abstract interpretation
of the black and white version. My response was even more excitable since that
metaphor is what my wife had always talked about as the rare findings in her
own clinical experiences as an occupational therapist: a rainbow-striped zebra,
the combination of a naturally occurring animal with fantastical magic, unanticipated
wonder, and significant promise from its outward expression of graceful form and unique content. She had witnessed
patients present to her hospital rehabilitation unit under the strangest and most dire of
circumstances from strokes, multi-trauma car crashes, surgical complications,
spinal cord injuries, or traumatic brain injuries. Nonetheless, these patients
conjured up unseen powers to walk again, talk again, or express their unbound
love in other explicit ways when no one had believed such activities would ever happen again.
Her mother then piped up with pride: “She has a whole portfolio
if you want to see it.”
“Of course!” I said. “Come by any time so I can see what you
have painted.” was my simple but earnest ask. We ended the rest of the visit
with the standard review of the shot record and additional health and safety counseling
related to diet, exercise, seat belts, helmets, and firearms. I said goodbye
and they checked out of the clinic.
A few days later, I was seeing a full schedule of patients
and my reception staff sent an instant message to me over our computer system. “There’s
a family here at the front desk who wants to show you some art.”
“Send them to the second waiting area please” was my
response.
After the patient on hand was checked out, I went to find
the girl, her mother, and the little brother who was bouncing on the nearby
cushy chair. Using the side table as a display stand, they proceeded to show me each of
her paintings, drawings, or sketches with great care but at a deliberate pace.
They stopped at the zebra. She was gorgeous. Vibrant streaks
and esoteric dots emanated from each of the stripes with radiant leaves and
flowers showering this majestic creature in a variegated stream of color and
energy. A dark red rose was perched behind her right ear as a stroke of beauty and
grace.
“It’s beautiful!” was all I could say. This artist
had found and captured the elusive rainbow-striped zebra in perfect form and
detail. I was in awe.
“You can have it.” she said.
I denied such a privilege. “I can’t just take this.” I
replied. It was too much for even me who had received many patient gifts in my
rural practice over the years: fresh eggs, fruit, smoked fish, books, a knit
scarf, a crocheted pillow, crazy socks and even a baseball signed by a
patient’s grandfather, a former Detroit Tiger now confined to a wheelchair
after a stroke. I was still mesmerized by the sight in front of me.
“Paint and brushes aren’t cheap.” was her mother’s response.
I awoke from my gaze and caught her signal. Purely out of dumb luck, I had a
substantial amount of cash in my wallet. I completed a more reasonable exchange
of goods for money to subsidize the healthy habit of art for my patient and
gain a newfound prize for our practice.
Several weeks later, I received the phone call from the
local frame shop for pick-up where I had a simple black mat and border placed
around my new wall decoration. I hung it in the hallway between my two
designated patient rooms for the next three years before management did a
clinic renovation with new carpet and paint on the walls. At the time, I was taking
up a new position at a teaching program in family medicine at a different
location, so the timing was right for me to move out anyway. I brought the
painting home thinking this may be another piece of swag that would not make
the cut for my next office and be set to the side with other relics of my
career.
Around this same transition time, I was preparing for other milestones,
turning 50 on April 22nd and celebrating a military retirement
ceremony on May 7th. Following my own well-adult health check, I
learned the worsening vision, unintended weight loss, and frequent urination over
the prior three months had a cause that would be one more milestone of sorts.
On May 17th, 2022, I was formally diagnosed with Type 1 diabetes.
Although I had run one of my routine 5K routes around the neighborhood a few
days prior and our family ate relatively healthy, my immune system had been
triggered by a mechanism we will never know and was slowly attacking the
insulin-producing islet cells in my pancreas. Close friends, coworkers, and
relatives were surprised to hear a relatively healthy guy, out of the blue,
could be diagnosed so dramatically with a lifelong chronic disease. Due to a
family history of prostate cancer and the urinary symptoms, we had been more
concerned with the possibility of cancer so the odd diagnosis of diabetes at my
age was, in fact, a welcome finding from much worse diagnoses that were sitting
on the differential. The negative CT scan to rule out a malignancy in my belly
was a welcome datapoint when that result showed up in the patient portal within 18 hours of leaving the radiology suite.
As our family was setting up the home office for my new
administrative job with the health system, we considered the various
options we had as a background for teleconferences or remote
meetings. There was no question about what came out of the collection of
artwork, photographs, and certificates in the nearby closet. My wife insisted
the rainbow-striped zebra be the centerpiece to the newly painted wall opposite
my colorful military shadowbox of patches and badges along with other memorabilia hanging nearby. They all formed complementary colors and images with symbolic messages of hope,
peace, and joy from expected and unexpected sources.
I am a rainbow-striped zebra. So are you. Start painting.
1 https://quoteinvestigator.com/2017/11/26/zebras/
2 https://en.wikipedia.org/wiki/Pareto_distribution
3 https://en.wikipedia.org/wiki/Normal_distribution
