Portal de Periódicos da CAPES

Listening for horses

2021; Wiley; Volume: 28; Issue: 6 Linguagem: Inglês

10.1111/acem.14240

1553-2712

Gabriel Swenson,

Clinical Reasoning and Diagnostic Skills

They teach: “when you hear hoofbeats, think horses, not zebras.” It means that the likeliest diagnosis is often the most common one. Medical school requires learning about rare diseases that are hardly seen in clinical practice. When a patient walks into the exam room, they are more than a statistic and may just be a zebra. Right before graduating college, I began experiencing ascending paresthesias in the distal extremities after recovering from a cold. My medical student friend thought it seemed consistent with Guillain-Barré syndrome (GBS), so I went to a clinic. They seemed especially interested in the fact that I was stressed over not being accepted to medical school. They said to go to the emergency department (ED) if it got worse. It did. In the ED I was diagnosed with somatic symptom disorder from my stress over medical school. After following up with the clinic for a benzodiazepine prescription, I went home questioning my sanity. Was I even mentally stable enough to pursue medicine if my stress was causing me to go paralyzed? I knew something else was wrong. It had to be. I was weaker each day. I did feel stressed, but was it over medical school or the paralysis? I had to go back. Returning to the ED was one of the scariest things I have ever done, knowing that I was probably going to be dismissed once again. Maybe coming back would only confirm their suspicion that I was an anxious person. Having so many different physicians tell me that I was anxious was making me believe it. I stumbled through the ED as if intoxicated. While taking my vitals, they asked if I felt anxious. Firmly, I replied, “no.” I sensed hesitancy on the faces of the physicians examining me. It was as if they wanted to believe me but trusted the previous assessments of their colleagues more. The resident said that I could have a lumbar puncture done if I wanted. After the pinch of the lumbar puncture, there was finally relief. The results were consistent with GBS. Being bedridden allows a lot of time for contemplation. If someone had listened to me sooner, I would not have needed to relearn how to walk. Why was it that I suggested a diagnosis of GBS at three different visits, and not one person listened enough to investigate? Everything about the presentation seemed textbook. A resident told me that I knew too much for my own good. Knowing more led to my concerns being taken less seriously, but if I had not advocated so strongly, I may have needed respiratory support by the time they realized. At the same time, if I had not known as much, I would not have known to persist. Lying in bed, I received a call from an unknown number. I was shocked to hear the voice of the first physician I saw. Almost in a trance, I sat there speechless. What do you say? I sat there breathing through the nasal cannula that I would not have needed if someone had listened. I was staring at my legs that no longer worked but would have if someone had listened. That apology meant so much to me because finally it felt like someone cared about what I had to say. Ironically, I had nothing left to say. A week after being discharged from the hospital, I was accepted to medical school. I understand why attending physicians and residents would brush off the concerns of someone with far less training. It is easy to forget where you came from. I tell my story to my classmates in the hopes that they will not exclude rare diagnoses until after a thorough workup. I learned two important lessons: to stand up for yourself when you think you are right and to humbly concede when you are wrong. As much as I learned from my self-advocacy, nothing resonated with me more than that apology. The easier path would have been to shift blame onto the other physicians who missed it. The apology was genuine and courageous. I made a near complete recovery. The residual paresthesias in my toes remind me of my experience every morning. It will serve as a bitter reminder to take a patient-centered approach throughout my career. They will remind me to be open to feedback from other physicians in training, no matter their current status. Lastly, they will remind me that when I hear hoofbeats to check for zebras, too. The author has no potential conflicts to disclose.