In oncology, hoofbeats are nearly always from zebras

It happened again today.  A youngish man, age 59 (youth being relative these days) comes in for a consultation.  His history began eighteen months ago when he started to notice hoarseness.  Thinking he had laryngitis, he saw his primary care doctor.  He was indeed diagnosed with laryngitis despite the fact that he had not been shouting for his grandson at the local soccer playoffs, nor had he had upper respiratory symptoms such as a snotty nose or a cough or a fever. He was treated with antibiotics, and did not improve.

Three weeks later, he saw his doctor with the same complaint and was again given another course of antibiotics.  Again, he had no relief, but since he was feeling fine and had no other symptoms, he waited.  And waited.  Until July when he suddenly became short of breath, especially when lying down.  He heard himself wheezing in that position.  He was finally referred to an ear, nose and throat specialist who recognized the signs and symptoms of advanced laryngeal cancer and performed a tracheostomy to save his airway, and his life.

When we are young, and in medical school, we are taught an old saying:  “When you hear hoofbeats, don’t think of zebras.”  In other words, when a patient comes in with a cough, your first line in the differential diagnosis is infection or asthma, not lung cancer. Most breast lumps in young women are cysts, or fibroadenomas, not breast cancer.  And when a patient comes in with hoarseness, it’s likely laryngitis, not cancer of the vocal cords, causing airway obstruction and requiring an emergency trach.  As a radiation oncologist, I see things a little differently, as in “through a glass, darkly.”  When I hear hoofbeats, it’s nearly always a zebra, not a horse.  When a patient shows up in my office for a consultation, they’ve already been diagnosed with cancer, many times after being misdiagnosed for months or years with bronchitis, or laryngitis, or cysts, or hemorrhoids.

Today my patient was the fourth patient I have seen in as many years whose laryngeal cancer was misdiagnosed as a benign process, ultimately resulting in the need for an emergency tracheostomy.  This is because you cannot see laryngeal cancer with a wooden tongue depressor and a flashlight.  The Norman Rockwell image of the doctor with the bright light above the exam table, shining into the mirror strapped on to his head, which in turn reflects light on the tiny mirror held to the back of the throat—those are images from the past.  Primary care doctors simply do not have the fiberoptic equipment necessary to do a good laryngeal exam today.  It’s expensive, and used infrequently.  But there is no excuse for not referring a patient with persistent hoarseness to a qualified ENT doctor.  It could mean the difference between life and death, or life without a voice, which is no small disability.

As I was completing my internal medicine residency, before I decided to become a radiation oncologist, I had a brief notion to take the LSAT’s and apply to Harvard Law School.  Back in those days there were only five or so MD-JD’s in the country, and there was definitely a need for people who had a foot in both corners.  In the end, I decided that I didn’t want to give up patient care, as interesting as I found the law, due process, presumed innocence—the whole lot. I opted out and continued my pursuit of medicine.  Thirty years later, it occurs to me that I didn’t have the experience or the knowledge back then to have made a good attorney.  But now, knowing what I know about the consequences of missing a diagnosis of cancer, I’d make a helluva good malpractice lawyer for the plaintiff.  In the words of Marlon Brando, “I coulda been a contender.”

Miranda Fielding is a radiation oncologist who blogs at The Crab Diaries

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  • NewMexicoRam

    I understand your point. Get the best care to the patient and be aware of the history and possibilites. Makes sense.
    But other points of view also make sense. Place yourself in the place of the primary care doc. Year after year, he/she sees numerous folks with viral illnesses, bronchitis, sinusitis, etc. Maybe, just maybe, there will be one patient with laryngeal cancer causing those problems. 5000 patient visits per year, for 30-40 years—and one laryngeal cancer out of the group. And they delay the diagnosis because they thought “horse” and not “zebra.”
    Of course we as primary care docs need to use our smarts and training. But we also have to use our experience. And our experience doesn’t lend itself to order lots of laryngoscopes on patients.
    You sound angry about missed diagnoses. You say the diagnoses have already been made by the time you see the patient. How nice you have it. The insurance companies are always willing to approve the mega-workup when specialists order the mega-CT’s, mega-scopes, and mega-tests. When it’s the primary care doc, just maybe they will, and probably after lots of time on the phone trying to get the prior authorization. Then if the results are normal, boy, do we hear it.
    Maybe you should open up your practice to do the primary care. See lots of “horses” before you see any “zebras.” And if you don’t want to do that, then maybe you should thank your lucky stars that there are people out there willing to do that, the primary care providers.

    • Myrtle

      Agree with NewMexicoRam; common things occur commonly. When a patient has a new onset of hoarseness, infection is the most likely cause; voice over use, GERD and sinusitis are also possibilities. A good history can help sort it out somewhat. If a patient has hoarseness for 3 months, cancer becomes a more likely possibility, but GERD and sinusitis are still part of the differential. If the patient never comes back when his symptoms don’t improve, the primary care doctor can’t be blamed. Yes, it would be nice to call every patient back to make sure they are getting better, but that would be dozens of calls a day, in addition to calls for patient reminders, call backs for questions and test results, calls for prescription refills. Perhaps the patient could have been educated better on what to worry about and when to come back. Of course he may well have been told that; patients tend to remember only about 40% of what they are told. Still, it is the patient’s body, and he had responsibility for obtaining care and for using common sense, too. The idea that every doctor will make an instantaneous diagnosis at the first onset of every symptom is really unrealistic, and both this patient and his radiation oncologist seem to be operating under that fallacy. Medicine as magic or mind reading – you would think a radiation oncologist would know better.

      • southerndoc1

        “that would be dozens of calls a day”

        Careful: don’t get the OP started on phone calls. That’s another area in which she’s an expert.

        • Miranda Fielding

          Smile!

      • Miranda Fielding

        I completely agree with you that a patient needs to take responsibility for his/her own health. But it depends on your patient population–level of education and economic stability, English or non English speaking–whether or not they will do that.

        • Stephen706

          Bull crap!!!!

        • Stephen706

          It is the patient’s responsibility and duty. It is their health and their disease process. No one made this cancer appear. If they are/were engaged, this could have been a save.

          • http://www.facebook.com/Cheryl.A.Handy Cheryl Handy

            Are you really “blaming” the patient for not diagnosing his own cancer soon enough? That is whack. With more and more regularity, sick patients avoid physicians because there is a perception by patients that docs (1) dismiss patient concerns and (2) are irritated at a patient that is engaged and concerned about his/her health.

          • Stephen706

            No! I blame the patient for not showing up for 15 months for recheck on ongoing complaint and being WTF-shocked that it is cancer and advanced. Shocker!!!

            Docs aren’t irritated at patients who are engaged–they are irritated with the BS centered around taking care of the patient and all the steps and hoopla to do so. They are irritated with non-compliance. They are irritated with solving 20 problems in a 10 minute appointment slot. They are irritated that everyone thinks we do this for money.

          • http://www.facebook.com/Cheryl.A.Handy Cheryl Handy

            As a cancer patient, I don’t think all docs are “in it for the money.” There are much easier ways to make money. Some of us don’t keep appointments because we are scared, we hate the side effects, cancer upsets our friends and family, dying would be kinder.

            Some of us who have elderly parents with cancer have trouble getting them out of be to see you. We see the effects of chemo on their skin, we hear them cry at night. We wish that the cancer had come back to us because we are younger and could handle it better.

            The PCP heard the zebra two years before he called me and said dad needed a colonoscopy. Dad’s PCP knew I had cancer and dad was using it as an excuse for not getting tested. I was more “empowered” (hate that word) with dad’s cancer than my own.

            Cancer effects families in horrific ways. Please do not generalize all of us. We are scared. And if we don’t say it at each visit, we appreciate all of the doctors.

          • Stephen706

            And as a doctor thank you for appreciating the hard work we all do. Cancer sucks. So does stroke, diabetes, heart disease, sepsis, pneumonia, emphysema and on and on…
            If you cannot tell you doctor your fears and concerns and worries, get a different doctor. No one is a mind reader.
            My hell-bent ire with this post is the castigation and derision towards this patient’s original doctor for not diagnosing this. This wasn’t no friggin’ zebra—18 months of persistent hoarseness is a no-f-brainer. But who did the writer point the finger at???–wasn’t the patient, it was the doctor. Not a single word about the patient contributing to their own demise. Not one. Almost like she does the bs expert witness testimony for malpractice cases AGAINST doctors on the side.
            If she were in my area, I would not refer any of my patients to her. Period. Not until a public mea culpa apology. I don’t need holier than thou god-complex specialists. There are plenty of self-righteous and self-centered asshats out there. She may be nice and wonderful but her opine is way far skewed for my tastes, professionalism and practice. Dealt with enough friendly fire in my service career–don’t need another shooter at the back of my colleagues’ head.
            Hopefully this makes sense. She really struck a chord with many primary care docs!!!

          • http://www.facebook.com/Cheryl.A.Handy Cheryl Handy

            I see your point. My dad’s pcp couldn’t get dad to have a colonoscopy because dad made excuses. The pcp had the guts (and was probably tired of my dad making excuses) and gave dad a choice – he would talk to wife or daughter about the obvious blood loss and need for tests. Dad chose me.

            Sometimes the pcp who is concerned about cancer (or other serious disease) needs to contact family. That’s exactly what dad’s pcp did. Next appointment was with oncologist and dad beat colon cancer.

            Some people are so scared of bad results (or cancer dx) that they avoid the inevitability. It is the responsibility of the pcp to push the patient past that fear.

          • Homeless

            My spouse was SOB and his primary care doctor told him he was drinking too much coffee….not a great environment for follow up. Would you blame my spouse for any bad things that happened afterwards.

            Two rounds of unnecessary antibiotics…you really want to defend this doctor who probably belittled his patient as a complainer and told him it was not big deal.

          • http://www.facebook.com/Cheryl.A.Handy Cheryl Handy

            As a general rule, patients should not be blamed for anything when they go to doc. Patients are there bc they feel like crap or hurt. Patients are sick and scared. Who can blame the sick patient for being grumpy or a SOB.

            Physicians should be able to handle a grumpy, sick, scared patient without belittling or insulting the patient. Bedside manner 101.

          • Stephen706

            Actually two rounds of antibiotics (while not making sense unless treating a bacterial process–another vent–most cases are viral and this not responsive to antibiotics but patients or parents insist and most give in) is perfectly rationale and reasonable. 15-17 months of no follow-up is not on the doc.
            Don’t like your doctor find a different one!!!! I amazed that people will pay out the butt for their pets, out the butt for many things (clothes, cable, cell phones, meals out) but god forbid they pay for their own healthcare when it really matters (no insurance or extra copay or out of network or whatever).
            For your spouse got to know more to spread the blame game if you want to go there. Doc couldn’t been right but probably wasn’t.

          • Suzi Q 38

            isn’t that what you wanted to do, care for patients?
            So what if you do it for the money?
            You signed up for a job, I am sure other doctors described the downside of your profession before you completed your training.

            Is it all that much of a surprise?

          • Stephen706

            Exactly–care for patients, diagnose disease processes and help heal or comfort. But I cannot do what I do without the patient returning for follow-up. That is what didn’t happen here

          • Suzi Q 38

            Sometimes us patients are scared of a bad diagnosis.
            I think that in the end, I knew it might be bad, so I was happy that the insurance company gave me flack about getting a full MRI at the teaching hospital.
            I was able to get an appointment the day after I returned from my vacation, 2 1/2 weeks later. Ignorance is bliss.
            Before I left though, in fact 6 weeks before, I asked my doctor to help me with my troubling symptoms that were escalating in the last couple of months.
            He never answered my email, and I re sent it to his nurse, who wrote back that he had already received it.
            I was floored and hurt that he did not answer, was probably offended, and “blew me off.”
            I vowed to deal with him when I returned.
            I should have never left. I should have gone straight to the patient advocacy department immediately for medical help.

            Yes, he might have gotten in trouble, but I might have had more stability in my legs if I had done that.

            I don’t think I could have done more than that at that time. I was still walking fairly well, but my neuropathies were getting more pronounced.
            I listed all of my physical concerns in my letter.

            Oddly enough, since he has personally apologized in a long 1 1/2-2 hour conversation, that I hesitate to report him. He is an assistant professor, the “junior” doctor of his group of 3 at this cancer teaching hospital.

            If I told my story to the advocacy board, he may have to look elsewhere for a job, he would look that stupid and irresponsible. As it is, a few of his colleagues are aware of his stupidity and complacency. The neuro surgeon was livid and called him right away.

            On the other hand, I am the one that suffered as the result of his arrogance. He probably thought:
            “This letter is desperate and accusatory, I should not have to answer her. After all, I am the “expert.”"

            Right now I am focusing on getting well. As soon as I am better and stronger, I will figure out how to discipline the “junior” doctor.

            My daughter, who is a nurse, does not want me to do this. On the other hand, she was the one that told me that I should be more patient with my doctors about a year ago. I should have came down on them way back then like my instincts said to, but I didn’t want to be an annoying patient. I decided to trust my doctors, and look where it got me.
            They had no time to properly treat me, and when I tried to get them to take a closer look at me and my problems they got offended.

          • Stephen706

            I really have no idea where or what your point is beyond the fact than you emailed your doctor instead of making a follow up appt and somehow you think the two are equal? And instead if going in, you delayed things and then blame him cause you were glad to have delayed this and are worse off?
            Sorry don’t know your story

          • Suzi Q 38

            True You don’t know my story, as it is a long one.
            I had just visited with him on July 6, and I tried to go though my problems again (weak inner thighs, urinary stress incontinence, escalating leg weakness, nerve pulls under my arms when I bend over, numbness in hands and feet, etc.). He acted as if he didn’t want to hear it, and said, see you in 3 months. I was so shocked I didn’t know what to say. He had a medical student with him, so I didn’t want to be rude. That is why I wrote him the letter, sent to his email through his nurse.

            I waited and waited for a response, when none came, I emailed the nurse again to find out of he received my letter. She said he had.
            I even said that I was checking back because I was getting ready to go on a 2 1/2 week vacation to Europe soon (30th wedding anniversary, a year in the planning) so I needed to know if it was still O.K. to go.

            No answer. I finally got some good care from my gastroenterologist. He told me it was in my upper spine.
            I got the information a week before my trip.
            During my last week before the trip, I finally got in to see my neuro and he ordered my MRI (after waiting for 1 1/2 years) only at the insistance from the gastro.
            Once the gastro made a few waves (he was chief of staff), the neuro started doing his job). He still told me that it was o.K. to go, but I had to take an MRI when I returned.
            I was glad because I still wanted to go on my trip, but was frustrated with my medical team because I had sent a letter to one of the doctors a almost two months before my trip, when my symptoms started escalating.

            I knew that when I got back, if it was bad, I would deal with them all (the doctors) when I returned from my trip.
            Here I had been whining and complaining, asking for more tests and a full MRI, and the neuro told me it wasn’t needed. I pushed and pushed, hence the infamous letter. I almost drew a picture for him.

            The “lightbulb” finally came on with the neurologist only at the insistance of the gastroenterologist (chief of staff).
            There was definitely a senior vs/junior “call” here.
            This was days before my trip. He still told me that I could go.

            The time to do it all was when I wanted them to, 1 1/2 years and definitely the 4 weeks before when I wrote my doctor the letter due to my escalating symptoms. The letter came about because I was not happy with our office visit a couple of days before. I should have sent it registered mail, with a copy to the patient advocacy department. I just wanted care way back then. I didn’t want to be difficult.

          • Stephen706

            My hope and wish is things are going better. Your case is obviously different than what this post started about–bashing the primary care doctor for not picking up laryngeal cancer presenting as simple hoarseness that failed 2 rounds of abx and a lengthy gap. Kinda like blaming the GYN doc for modding cervical cancer because the last pap was minimally abnl but the patient didn’t return for 3 years.

          • Suzi Q 38

            Thank you Dr. Stephen 706,
            I am saying that a PCPor nurse navigator in charge of my overall plan may have helped me.

          • Suzi Q 38

            Mine irritated that I was engaged….old story. Read more below, like a bad novel.

          • Suzi Q 38

            I tried to tell my gyn/oncologist that there was a real problem after my hysterectomy. I was feeling leg weakness. He stormed out of the room, and came back to ask a few more questions. He was angry that I said that it was after his surgery.
            He did not write my complaints down…there was no reference to my complaints about my legs, and i had complained to him several times.
            He nurse knows, as she was with us.
            Now my legs are very weak, and I needed surgery to save the strength in my legs.
            My doctor was clearly offended and irritated that i was engaged.

    • Miranda Fielding

      Actually, I seem to do a lot of primary care in my practice, although I dont “advertise” it. I have the advantage of having originally trained in internal medicine.I do this mainly because my patients cannot get in to see their primary care doctors, which is most definitely NOT the primary care MD’s fault. I think we have already been over the fact that you are overbooked and overworked, It is definitely an advantage to be able to see a patient daily for treatment over 6-8 weeks if that patient needs to be seen. But this is not what I am talking about here. I am talking about the patient that comes in with laryngeal cancer growing through the skin of his neck having been diagnosed that late in the course of his disease. (Not the patient referred to above–that was a different patient). My point is that I see things differently, from a different perspective.And that after a couple of courses of treatment for benign disease, the PCP’s should consider cancer. And you are right about the fact that it is easier for me to order the “mega-work up” because it helps me with decision making (curative vs palliative, etc).

      • NewMexicoRam

        “…after a couple of courses of treatment…consider cancer.”
        Really?
        Even then, most causes will be benign. Does the incidence of cancer increase in that case? Yes, but not much. It’s still probably a horse.
        In your story, did the PCP document in their record that the patient should follow up if not improving? I know I do. You say the patient didn’t follow up because he was feeling fine. If that’s the case, how is the PCP supposed to get another opportunity to discover the difficult diagnosis?
        Did you know that there are a number of my hypertension patients who fail to follow up or take their medications because they “feel fine”–that is, until their stroke or MI? Then somehow I am at fault for not really letting them know how serious the situation was. How convenient they forgot my initial discussion with them about the risks of uncontrolled hypertension.
        You say you see things differently, from a different perspective. And that is supposed to negate the PCP perspective? You must think so, or you would not have added the paragraph about helping patients sue.
        So you do some primary care. That’s “some.” Watch your limitations, or you may be sued. I learned most of my primary care since residency, after doing it many, many times with many, many patients. What we learn in training doesn’t carry very far.

        • Miranda Fielding

          Please feel free to have the last word. But for the record, this blog piece was written tongue in cheek as part of a much larger blog mainly about other things including my kids and pets, not medicine. It was not submitted to KevinMD but picked up by Kevin all on his own. I thought about stopping him from “reblogging” because I knew it would be controversial but decided, no, if I cant take the heat I should get out of the kitchen. I stand by what I wrote–that I see horribly advanced cases of cancer which have been misdiagnosed or ignored and it is frustrating to me which pales beside the fact that it is life threatening for the patient. But for the record, I have NEVER helped a patient sue a physician, nor have I ever testified as an expert witness in a malpractice trial. Your turn now. So sue me.

          • NewMexicoRam

            Nice to see that you want to avoid nearly every point I brought up. So you see horribly advanced cases of cancer. I have seen advanced cases of cancer as well. The patient came to me when they couldn’t tolerate the symptoms anymore. Ignored by the patient. I’ve also seen patients ill-served by the “cancer” community–severely ill for the last several months of their lives from treatment, rather than in the care of hospice, creating comfort, not idealistic hope.
            Cancer is cancer. There really aren’t that many cancers that have a great longevity rate. And even if we could give every US citizen annual full body CT/PET/MRI, the cost would totally cripple our health care system.
            Again, you ignore the PCP perspective. And you are lumping the mistakes with the norm.

          • Miranda Fielding

            And you reveal your ignorance with the statement that “There really aren’t that many cancers that have a great longevity rate.” Common cancers such as breast, prostate, colo-rectal and even lung cancer are curable if detected early. Locally advanced head and neck cancers, stage IV, are 80% curable in the HPV+ population and 60% curable in the smoking/drinking population with chemotherapy and radiation. Even patients with advanced lung and colon cancers have significant disease free and symptom free survivals with targeted therapies such as Tarceva. Cancer is not “the big C”, that we dare not speak of anymore. Read up!

          • NewMexicoRam

            “If detected early.” Of course. Also include testicular and breast while you’re at it.. Again, it’s if detected early. What percentages are detected early? And what’s early enough? What do you mean by “curable?” My idea of great longevity rates must be different than yours.
            MY POINT ( if you forgot) was that PCP’s need to use their smarts and care for the patient appropriately. I agree with that. But you took one horrendioma and plastered PCP’s with it. And said you would like to help malpractice attorneys because of this. I’m sorry, but it’s you who said it. Evidently, you must think that PCP’s are the world’s worst diagnosticians. Now if you had said that you can understand that constraints we practice under and that we don’t see many zebras to recognize the zebra quick enough, that’s fine. But you also said the diagnosis has almost always been made when you first see the patient. You would be more receivable if it appeared you also were more understanding of the PCP point of view.

          • http://www.facebook.com/Cheryl.A.Handy Cheryl Handy

            WIth all due respect, it is “the big C” to patients. The only reason I was diagnosed with breast cancer is because I forced my gyn to get me a mammogram. My pcp was a boy at a major Chicago teaching hospital and didnt do breast exams. That’s whack.

            No history of cancer in my family before me. I felt the lump.

            Mammo didnt show it. Radiologist didnt feel it. I had to put her had on my breast and show it to her. By the time I could feel it, it was in lymph nodes.

            I’ve been through surgery, chemo, RT. It still is “the big C” and I will let cancer take me before I go through that horror again.

            I have family members who wont even go to a pcp or any doctor. After watching me and dad suffer with chemo, many patients refuse health care because they are scared of “the big C”

    • Homeless

      I was one of those patients that seemed to have viral illness, bronchitis, sinusitis, etc. I didn’t have laryngeal cancer but I did a lot of suffering before I referred myself to a specialist.

      All that information needed to make a diagnosis of a common illness is found at WebMD. Antibiotics need to treat that infection could have been obtained at a retain clinic staffed by nurses. GERD and sinusitis can be treated over the counter…at least a trial of medication to see if symptoms are relieved. And really, a virus just needs time. So why do I need to see a primary care doctor if they only consider common illnesses?

      Tests ordered by specialists exposed my problem…something very difficult…so maybe primary care’s failure could be forgiven. Armed with my chart that contained a very good description of my problem written by my specialist, I ventured back into primary care. Neither my words nor my chart convinced the doctor that I didn’t have a common illness. I didn’t get the right treatment and learned a valuable lesson about the value of primary care.

      • NewMexicoRam

        I believe most PCP’s do keep in mind the zebras. Maybe not as often as specialists, but specialists only concentrate on one area, not multiple ones. By the time a patient sees the specialist, it is time to consider zebras.
        I can’t tell you how many calls I’ve gotten from specialists like this, ” I’m seeing your patient for (……) and they mentioned they have also been having a problem with(….) that they admit they never told you about. That’s not my area, so can you see them again to evaluate?” As a matter of fact, it just happened again one hour ago.
        Remember that many times insurance companies will not approve more detailed tests unless it is ordered by a specialist.
        PCP’s are not trained to know the answer for everything. Neither are specialists. Try asking your ENT next time about vaginal bleeding. But PCP’s play an important role.

        • Homeless

          My problems were over multiple systems and it was not my experience that the specialists I saw had an advantage. But that is not my point. Sure zebras are hard to find, but my experiences were that possible zebras were not on the table. Instead of “I don’t know” I got “Here is a prescription for Prozac.”

          That specialist I referred myself to was the wrong one…and when that was clear, he sent me elsewhere.

          I had a Cadillac insurance plan at the time…no referrals needed which allowed me to self refer. My PCP didn’t have restraints in ordering tests. The bottom line is she refused to think outside the box…something I have found with all of the primary care providers I have seen. Before my ordeal, I may have made them my first line of information. Now it seems like a waste of time and money.

          I’ve had lot’s of experience with vaginal bleeding and even though it wasn’t a zebra, my PCP failed to effectively deal with the problem. I was so anemic when I finally got that referral. My GYN wondered why I hadn’t come in earlier. All better now.

          • NewMexicoRam

            I wasn’t trying to necessarily explain away your experience. I was trying to give general explanations that occur commonly. Do PCP’s miss the boat? Yes. Do specialists miss the boat? Yes. Does that mean they are bad docs? No. Could they be bad docs? Yes. I’m sorry you are in a community where PCP’s don’t think outside the box. I practice in Albuquerque, and with one exception, most of the PCP’s I know practice good medicine and do their best at keeping up and thinking outside the box.

          • Homeless

            RE…”Of course we as primary care docs need to use our smarts and training. But we also have to use our experience. And our experience doesn’t lend itself to order lots of laryngoscopes on patients.”

            We are not discussing good doc vs bad doc…we are discussing the statement you made that suggested it’s OK for primary care doctors to assign a common diagnosis for all patients even if the patient suffers from a zebra.

            So you think I have a bad doctor because she didn’t order a laryngoscope or I have a great doctor whose experience told her I didn’t need a laryngoscope?

            And if I cannot expect that great doctor to order that laryngoscope when needed, why can’t I just go to WebMD and get advice for all those common things that my great doctor’s experience would diagnose anyway?

          • NewMexicoRam

            That’s NOT what I said. I said that horses are common, essentially. Good doctors will use their experience and knowledge to guide them to do what is best for the patient, while also using resources wisely and carefully. Will some tests be used too liberally? Yes. Will some tests not be used enough? Yes. Will doctors make mistakes? Yes.
            Good doctors may decide not to order tests and bad doctors may decide to order the shotgun approach.
            There isn’t the perfect doctor. If you are expecting that, then find another universe.

  • southerndoc1

    Wow.

    “I’d make a helluva good malpractice lawyer for the plaintiff.” With your acutely tuned and always active retro-spectoscope, I’m sure you would.

    Combined with the overwhelming self-righteousness and joyful glee in condemning others shown here and in your other posts, you come across as a real piece of work.

    • Miranda Fielding

      My husband thinks so too!

    • N N

      She seems to live in an alternate universe essentially. She realizes how busy and overburdened PCPs are, but can’t understand why they are unable to make phone calls like she, a radiation oncologist, can. Just goes to show that one can be book smart, but lack complete common sense.

  • azmd

    Yikes! Another anti-primary care doc piece. Ever heard the saying “walk a mile in his moccasins?” I think that might apply here…

    • Miranda Fielding

      Maybe you should check out my blog. I spend a lot of time writing about my dogs, and no time writing about primary care doctors. Perhaps you’d like my dog and pony stories better!

      • Miranda Fielding

        That is, if you like dogs.

  • http://briarcroft.wordpress.com/ Emily Gibson

    No primary care doctor need react defensively about Dr. Fielding’s suggestions– we know from years of practice and experience that zebras are hiding in the middle of a herd of horses, often frequently. Part of our skill is to discern when to dig deeper, be more insistent, or act like Columbo the detective a little sooner. I wrote about this myself on this site last year at http://www.kevinmd.com/blog/2011/12/possibility-zebras-primary-care.html

    As for the patient that doesn’t feel triggered to return because of persistence of symptoms, I use the messaging feature on our secure patient web portal to not only send the patient a copy of their chart note saying “if not better by this date, needs to let me know or do a recheck in clinic” but I also send the patient a web message in x number of weeks reminding them to check back if they are not better. It is a reminder to them that I am concerned enough to check up on them. If they choose not to be rechecked, it is not because I didn’t ask.

    • Miranda Fielding

      Thanks Emily. What a great system, and good for documentation. I think Kaiser out here has something similar.

  • Miranda Fielding

    Perfect! I’ll have to work that one into one of my medical student lectures!

  • Marni

    Wow. The hubris. It’s unbelievable. Do your referring docs know what you think of them?

    Must be nice to be in a specialty where your patients come to you with their diagnosis all set. Just remember who wrapped it up into a nice little package for you.

  • drg

    i am a physician as well as a patient as of lately. Similar situation as the article, I was misdiagnosed. I had a space occupying lesion in my sacrum that was for whatever reason not taken seriously to be the cause of my pain. No one was accountable after seeing many specialists. Eventually could not move or stand it was so painful. Month after month went by without any doctor showing real concern about what was happening to me. In addition I was trying to answer to my practice. I eventually began to question the diagnosis myself but one specialist was particularly belittling that that could not possibly be the cause of my pain and he thought probably I was crazy. In the end I am lucky that it did not lead to paralysis and that I eventually got the required emergency surgery. I was told that ‘it might be too late’ by the neurosurgeon that recognized it. Although I’m not yet clear the physical toll taken I am able to weight bear. The psychological toll though has been the worst part about it. And there is no one to really go to. No apologies . i am not into suing but even if I was I have no case for multiple reasons not really having to do with medical ethics but with the law. Those 2 are different after all. I can understand the doctors outrage that he must feel from himself but his patients as well. And I also see and appreciate comments of PCP. My situation was different in that it was clear to me at least from the intense level of pain that this was not the common cold so to speak

    • Miranda Fielding

      And this is what I am talking about. If a physician cannot be taken seriously regarding his complaints, then what hope does an ordinary person have? Thank you for telling your story.

      • southerndoc1

        “And this is what I am talking about.”

        No, it’s not.

        Your post was specifically aimed at slamming PCPs. drg was misdiagnosed by various specialists.

        Every PCP I know can give you a long lists of zebras they diagnosed after multiple specialists couldn’t see the big picture. But, unlike you, we consider retroactively pointing out other doc’s mistakes an intellectually bankrupt exercise.

        • Miranda Fielding

          You certainly have a point there! I probably engage in more than one intellectually bankrupt exercise. But eBay got too expensive.

          • Stephen706

            There is a reason what we do is called a practice and an art–it is not perfection and never will be. We take histories, do exams, order appropriate studies, offer our opinions in assessment from a differential diagnosis and design a plan which (at least for me ALWAYS) includes follow-up instructions.

            We use science, we use our training. We are not nor ever will be right every time, all the time. Just as long as we try and stay open to other ideas is what is most important.

          • Miranda Fielding

            Exactly my point! Try to stay open to other ideas. And in my essay (if you actually read it) and many of my replies, I admit repeatedly that from my perspective, it’s ALWAYS cancer. And the other point, since you focused on the one case I mentioned, was that seeing disease that was picked up far too late after repeated doctor visits is just sadly not uncommon. But again, if you read my actual blog, you will see that I’ve been dealing with cancer in my family since I was 10 years old (“Nana”) so I clearly have a different perspective. It is my life’s vocation, after all.

        • NewMexicoRam

          Exactly.
          I remember as a second year resident a patient came in with a hypertensive stroke–he was a PCP no less. The story from the family, along with the patient’s lack of response to treatment, made me think this could be renovascular HTN. My attending, a very good and well respected renal doc, disagreed. I ordered the renal arterial scan against his opinion–and need I say more?
          10 years ago I had a patient come into my office with complaints of muscle pain. After a careful exam, I noticed firm subcutaneous plaques and thought of dermatomyositis. I did the tests and sent her to the rheumatologist immediately. He called me back, flabbergasted, and asked how I was able to make the diagnosis that quickly. I had never seen that disease before.
          I’m not pumping iron here but making a point that PCP’s can make a difference. Not every time, but often. I’m preaching to the chior responding to you this way, southerndoc1, but I just wanted to expand on your point for others.

      • N N

        That’s because your complaints show a total lack of understanding of the current environment for PCPs.

      • LastoftheZucchiniFlowers

        have you read “My Voice – A Physician’s Personal Experience With Throat Cancer” which was written by Dr. Itzhak Brook? It’s an indictment of our profession(s) vigorously earned by Brook’s surgeons. That he lived is a testament to his own fortitude and certainly NOT due to his surgical/medical care. Incredible story and likely not uncommon.

        • Miranda Fielding

          I have not, but I will! I wonder if this is the book that the movie “The Doctor” was made from–where William Hurt plays a surgeon who gets laryngeal cancer. The movie painted an extremely unflattering picture of his doctors.

      • Suzi Q 38

        Amen Dr. Fielding.
        I can be on this message board because I am recovering from my C spine discectomy from 1/18.

        My story is a long one.
        Started with a hysterectomy and subsequent nerves weakening in my legs. Tingling in hands and feet.
        Sent to neuro, only after 4-5 months of bugging my gyn/oncologist for the referral. He didn’t want to refer because he was hoping it was NOT his surgery and it would go away on its own. It didn’t.
        I could barely walk. The chief of staff (who was my gastroenterologist) told me to tell him (the neuro) that the problem was in my upper spine.

        Finally all the tests that I wanted a year prior was being ordered, at the demand from the chief of staff. I told him that he was so foolish to let this go on this long, that I don’t know where his mind was at when he was treating for the last year and a half. He asked me to have the surgery done at their cancer hospital.
        I left for a second opinion at another teaching hospital.
        I was told before my surgery at a different teaching hospital that I may not get my strength back in my legs.

        I realized that the first physician (gyn/oncologist)wanted to stall because it is a one year time period to sue in the state of California.
        He succeeded is stalling me, but by doing so allowed my paralysis to continue without treatment.

        My family does not want me to complain, as it will only take more time and effort away from my healing.

        On the other hand, I don’t want him to get away with this so easily. He needs to be held accountable, at least by his peers, the California Medical Board, and the joint commission. I have decided that I am at least going to complain to his superiors, and let them know what has gone on the last 2 years.
        Maybe they have some suggestions to stop this from happening again. Fire the gyn???Reprimand, his college buddy, the neurologist?

        If I knew that I was in danger, I would have left sooner.
        i can relate to “DRGG” as I am not a doctor, but fairly educated. It is just that I did not know much about neuro.

        We trust our health and lives to doctors, and they choose to do act as if not much is really going on.

        Doctors: At least listen to what I have to say.
        If I write you a letter of concern, get me the proper care, do not be offended.
        If you don’t know, get the proper tests, or think my situation out. If you really don’t know, tell me so I can go to someone else. Or better yet, get me to someone else.

        My predicament came as the result of specialists, not my PCP.
        My PCP thought the numbness was diabetes (my A1c was 5.8). I knew the weakness in my thighs after my hysterectomy was not normal.

        I relied on specialists that had an average of 15 years of medical school and specialized training to treat me.
        Several of them failed miserably.

        When I get well, I don’t particularly want to sue them, but a few may be very embarrassed or in a little trouble with their hospitals and fellow doctors.

        Two doctors were my heros. They “called out” the other two in order to save my leg strength rather than anger the others.

  • drgg

    thank you for saying that Dr. Fielding. i know my situation was different than what you describe in your article, but I thought the same. If I’m having this much trouble then how does the average person deal with it?

  • Noel Graham

    I guess I don’t understand the point of this article. Is it that a zebra doctor sees a lot of zebras? Did you speak to the physician who saw this patient or are you just going off what the patient told you? When I send a patient to a specialist they often get a history that is distinctly different from the one I got and I don’t know why there is such a difference. I don’t bad mouth other physicians because I don’t know what the truth is. You were not there for the visits and I doubt you got a copy of the visit notes to review them. For all you know this patient is going back to his doctor and saying you advised he sue him as you obviously think that should be the case.

    • Miranda Fielding

      Actually, the point of the article is NOT that I think that primary care doctors are bad doctors–it is as I said if you read closely–I have a different perspective BECAUSE when I see the patient, it is always cancer. I try to keep that in mind–my different perspective–I called it “through a glass, darkly” (Corinthians 13:12). But sometimes mistakes are egregious. By the way, I DO ALWAYS get the other physicians’ office notes.

      • southerndoc1

        I’m also confused about what point you’re trying to make.

        It seems to be something along the lines that since you see nothing but zebras who come in with their name tags in large letters hanging from their necks, any other doctor who ever misses a diagnosis is guilty of malpractice.

        Is that it?

        • N N

          Pretty much. How could that Primary Care physician with no laryngoscope have missed this throat cancer that I can easily see?

        • http://www.facebook.com/profile.php?id=662132748 Lata Potturi Schaedler

          There is something very critical in her posts, and it’s usually aimed at PCPs who have “missed” something or aren’t living up to some impossible standard in her eyes. She seems to have no insight into her own patronizing tone, which is unfortunate. I am a specialist, and I speak for most specialists I know who not only value PCPs but also appreciate them for making our jobs easier.

      • Stephen706

        As an oncologist, all your patients have cancer!!!

  • Stephen706

    I read this, and as a primary doc and really annoyed with the hubris and arrogance. Sorry if you don’t agree. But read below and tell me where I am wrong!!!

    The only reason, and I repeat, the only reason, this went on 18 months and became advanced is because the patient did not return to follow-up the persisting complaint. Don’t blame his primary care doc–unless his doc said, “don’t ever come back and see me again!!!” I nor any one else can diagnose crap if the patient doesn’t show up. The only reason he was not referred is because he DID NOT SHOW UP OR RETURN. Understand the difference yet!!!

    So get off your bloody horse. He wasn’t mismanaged–the patient on his own volition did not return. He wasn’t misdiagnosed either–I will bet you the record diagnosis was pharyngitis, laryngitis, croup, laryngotrachael bronchiolitis or tracheitis. All are accurate–he did have inflammation of the pharynx, larynx and trachael areas. That is what these words mean.

    By the time most patients get to you, the hard work has been done. Instead of cherry picking and arm-chair quarterbacking, come down to the clinic and see patients. Saw 31 patients in the ER with sore throats–not a single one will be laryngeal cancer today. It is strep or viral. And yes, you left out of your differential paillomatous disease, polyps and even a small CVA (yes, had one of them 2 years ago–presenting complaint was hoarseness, laryngitis but my patient followed-up as instructed the next day with his primary doc)

  • Homeless

    Clinical practice guideline: Hoarseness (Dysphonia)

    The panel made strong recommendations that 1) the clinician should not routinely prescribe antibiotics to treat hoarseness

    The panel made recommendations that…3) the clinician should visualize the patient’s larynx, or refer the patient to a clinician who can visualize the larynx, when hoarseness fails to resolve by a maximum of three months after onset, or irrespective of duration if a serious underlying cause is suspected;…; 5) the clinician should not prescribe antireflux medications for patients with hoarseness without signs or symptoms of gastroesophageal reflux disease;


    So…wrong treatment first thing. WebMD calls infection rare with hoarseness. No prior illness and no overuse of voice. Let’s assume the patient waited three weeks before consulting PCP. Six weeks in and more unnecessary antibiotics? Shouldn’t there have been a discussion of possible cancer if not better?

  • LastoftheZucchiniFlowers

    I was persistently hoarse some years ago (I Was yelling at my kids a Lot back then!) so I snagged an after hours larygoscopy with a nice ENT who dxd reflux (part of the ddx for painless, persistent hoarseness). Not too many PCPs can use relatively cheap hand-held dermoscopy units on their patient’s skin lesions and make accurate assessments of b9 v. malignant lesions. That’s MY job. Cancer is ubiquitous. Always has been.