My Doctor Thought He Heard a Zebra In the Hoof Beats, And He Was Right. He’s Also Helped Me to Understand that All of Us Must Start Diagnosing Our Doctors’ Thinking Skills Even As They Are Diagnosing Our Ailments

The other day, a new doctor in my life—an otolaryngologist and a ENT man—told me, “You are the zebra.” He was defending the decision of my regular physician, a G.P., who had sent me to see the specialist.

I knew what he meant. You’ve probably heard this saying, too: “When you hear hoof beats, don’t think of zebras.” Supposedly, this is something they tell medical students on their first day, right after they explain what “primum non nocere”—first do no harm—means.

Distinguishing the hoof beats of zebras from those of regular horses means, for example, not prescribing a CAT scan for every infected hang nail you see. In my case, my G.P. had been correct to send me to see the specialist because I had something a specialist was needed to deal with.

What was perturbing about my zebra status was that what the specialist found has apparently been a condition that has been plaguing me for more than 40 years. My oft-reoccurring ear infections.

An unchanging, unchallenged pattern
I wear hearing aids in both ears because of congenital nerve deafness. First in one ear and then in the other, I have averaged a painful ear infection just about every couple of months since the mid-1960s. Each time, I’ve gone to my doctor and said something like, “I have another one of those pesky ear infections.” And gotten a prescription for antibiotics. And after a day or two, the pain from the infection has started to go away, only to return before very long, again and again.

My new otolaryngologist and ENT man took one look in my ears and told me that in effect it was like peering into Carlsbad Caverns. “The ecology of your ear canals and eardrum has been nearly destroyed by your infections,” he said. “We’ve got to rebuild it from the ground up.” And so we have begun to do.

I have confidence in this physician. And because he was the first to tell me I needed to do something different about my frequent ear infections, I have new confidence in my new general practitioner. (We moved to Florida last summer, leaving all our former physicians behind.)

Getting in the way of zebras
But these days I have less confidence generally in how medicine is practiced. And more concern than ever about how doctors think.

As the shock of knowing that my doctors had failed for more than 40 years to correctly assess and treat what has been going on in my ears has subsided, I thought a lot about all those times when I visited a doctor about ear infections. What I said. What I expected. What the doctor said. What the doctor must have thought. What the doctor did.

In retrospect, it’s pretty clear that not a single one of my physicians thought of zebras. And, in part, I now see that it was because I didn’t give them much of a chance to.

If at any time I had said to anyone of them, “Doc, we need to do something different about this. It’s happening too often. If we don’t stop these infections, I could end up losing what hearing ability I have,” I suspect I would have had a physician capable of recognizing zebras looking at my ears long before now.

But what I always did was march in and say something like this: “Doc, I’ve got another of those pesky ear infections. I need an antibiotic.” And the doctor would take a quick look in my ear and say something like this, “Yep, it’s infected all right.” And write me a prescription for the antibiotic. End of examination. End of discussion. End of treatment. And, end of any hope of getting to the root cause of this.

A physician’s thoughts
Jerome Groopman, in his best-selling book, How Doctors Think, suggests how for all these years, I was playing into two of the most common pitfalls that negatively affect how physicians think.

He calls one of these pitfalls “availability.” This is judging the likelihood of an event by how readily it comes to mind. The other he calls “confirmation bias.” This can cause doctors to assemble information so rapidly that they can misconstrue the evidence before them.

Every G.P. I’ve ever had was overworked and had only a limited time to spend on my complaint. And, for my part, when I’m convinced I’m right, I can be pretty insistent. I knew I had an ear infection. I knew wearing hearing aids during every waking hour in the heat and humidity of Texas and Florida has to breed fertile grounds in my ears for infections. I knew certain antibiotics seemed to knock down my infections quickly. And I was hurting. I wanted a prescription so I could rush to the pharmacy. Usually I even named the precise antibiotic I wanted. And for years and years, I got it. Quickly. From doctor after doctor. End of examination. End of discussion. End of treatment. And, end of any immediate hope of getting to the root cause of this.

I have great sympathy for physicians even as I have growing reservations for how they are trained. Dr. Groopman, a Harvard medical professor, made it clear in his book that medical schools haven’t solved the problem of how to teach a med student to think. Instead, in Groopman’s opinion, they have traded the devil for the deep blue sea.

This is because doctor-training faculties have been getting away from the traditional “catch as catch can” approach that teaches young physicians-to-be how to think about making diagnoses by having them watch experienced physicians try to figure things out. In its place, the med schools have been teaching future doctors to reason from flowcharts and algorithms—in other words, to think like computers.

An outcome with multiple costs
Neither approach seems to be curing this damning statistic: studies and autopsies show about 15 percent of patients are still getting inaccurate diagnoses.

A couple of years before Groopman’s book was published, another book with the exact same primary title was published by Oxford University Press. In How Doctors Think: Clinical Judgment and the Practice of Medicine, Kathryn Montgomery, Ph.D., a professor of medical humanities, argues that misunderstanding how best to train doctors to think is one of the medical profession’s biggest screw-ups.

She adds, “The costs are great. It has led to a harsh, often brutal, education, unnecessarily impersonal clinical practice, dissatisfied patients, and disheartened physicians.”

Failure to guide and nourish competent thinking skills in young physicians-to-be (she quotes a pediatrician’s description of first-year medical students as “looking like children who had been abused”) keeps future doctors from understanding, she says, that medicine is not a science. Instead, it is a science-using practice that operates with unusual proximity to death.

She adds, “The physician’s best clinical instrument—diagnostic or therapeutic—is the physician herself. How in the world is that capacity acquired?”

How indeed?

As I say, as my new otolaryngologist and ENT man and I have begun the task of rebuilding the ecology of my ear canals after nearly four decades of abuse, I’ve reflected a great deal on what I’ve observed about doctors over the years.

Mapping a doctor’s brain
Because it is a part of my own “availability” and “confirmation bias” history, my own “total brain” model as reflected in our BrainMap® assessment tool is never very far from my mind.

From watching the children of friends who have gone to medical school, I’m pretty confident that many young people choose medicine as a career for “right-brain” reasons, idealism being foremost. And that as they endure the mental and emotional “hazing” of medical school and hospital teaching methods, they are relentlessly driven toward left-brain functioning, demonstrated control of facts, methods and time being foremost.

It’s my experience that medical specialties themselves tend to select certain brain styles. Invariably, my surgeons have been primary I-Control (“I understand; therefore, I control”) thinkers. Whether in medicine or not, but especially in the surgical professions, these folks can tend to be gods with a small “g”. Absolutely certain of themselves, of their thinking outcomes. Because of the way they think, you always need to do your own thorough research into their previous performance and their methods before you let them cut on you.

On the other hand, most dermatologists I have known (and often loathed) are very I-Pursue (“I want; therefore, I act”) thinking oriented, and what they often seem to want most of all is money. These individuals tend to be impersonal and assembly-line-oriented, anxious to see your skin issue cut or frozen off and you long gone, leaving your payment or insurance number behind. Or at least this is the impression they leave with me.

Diagnosing the doctors

In my opinion, the very few psychiatrists I’ve personally encountered strongly reflected primary I-Explore thinking qualities (“I envision; therefore, I expect”). If you are watching closely, their treatment plans always, or so it has seemed to me, turn out to be more about them than about you. It can be this way for any primary I-Explore thinker. When your chief want in life is for the world to be different, it is almost impossible to see anyone other than yourself at the center of the new world you are seeking to create.

And the G.P.s? Two thinking styles seem to dominate. Either my personal physicians have been primary I-Direct (“I persevere; therefore, I complete”) thinkers. These have been competitive, task-oriented, outcome-focused and information-conscious individuals. Or they have radiated I-Preserve (”I respect; therefore, I defend”) thinking qualities. Very likeable people, willing to chew the fat, within reason, maybe not so mercenary, maybe not so professionally ambitious as doctors using other thinking styles but very clearly committed to deep-rooted personal (often religious) values.

It is clearer than ever to me that when we go to the doctor we are facing our own diagnostic challenge: More and more, we need to train our own thinking skills to decide very quickly how these physicians who suddenly appear in our lives and who may hold our very life in their hands think.

What are we hearing as we listen to the hoof beats in our physicians’ examining rooms? Do we hear horses? Or zebras? What are they telling us about themselves even as they encourage us to tell them about ourselves? What are their biases? What are their values? What are they most likely to miss and how can we help them avoid doing so?

How do our physicians think? And since their medical professors so often did such a poor job of it, how do we help them think better?

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