When You Hear the Sound of Hooves, Think Horses, Not Zebras

This is what medical students are taught about the diagnosis process. Start at the most common and work your way down to the rare diagnoses. It was first coined by Dr Theodore Woodward, a professor at the University of Maryland School of Medicine during the 1940’s and it is still used during medical teaching. Even I was taught this in the more medicine based parts of virology.

This isn’t always the case. Nor should it be the standard. As it can lead to people suffering for a long time and also is detrimental to their mental health. When people have to jump through hoops and essentially fight through all the common diagnoses till they land on the rarer ones.

This is much different in other cultures. A YouTuber I follow (Simon from Eatyourkimchi who lives in Japan (then Korea) had a really sore stomach and the first thing they diagnosed him with was appendicitis and after investigation, it turned out he had a stomach bug. This is good for him – as if he had, had appendicitis he would have been treated then and there. My experience here in the UK was the polar opposite.

I presented to the out of hours doctor and he said that I have viral gastroenteritis and sent me home to drink fluids and rest. No investigation, no treatment.

A week later at my GP appointment, she sent me to the hospital A&En with a note saying she suspected appendicitis. When I arrived they literally left me sitting in the waiting area for 3 hours and then took me through to the main area. Here I sat for 6 further hours, on a chair, on my own – getting moved every while for being in the way. No pain meds, no nurse, nothing. Then around the 10-hour mark, I was admitted to the acute ward – where you go till they find space for you or discharge you. Here I was given fluids and pain medication.

Over the next 4 days they done a contrast CT, they sent me to gynaecology, every day I had a blood test, they left me to “see how I go” at points. All the while my medical brain was screaming “I have appendicitis.” But every time I met with the consultant he talked about me not too me. Fair enough he has students but I am the patient. I would suggest it is my appendix and he disagreed. Everytime.

On day 4 I was finally scheduled for an exploratory laparoscopy. After which he said he had removed my appendix and sent it for histology. Turns out I had “parasitic granulomatous appendicitis.” This means that I have had many bouts of appendicitis that has scarred the tissue making it “granulomatous.” Which makes sense as I have presented with appendicitis-like symptoms a few times before and then discharged.

In total, I was in the hospital for 8 days. It could have been 4 – as the time from surgery to discharge was 4 days. But they spent 4 days poking and prodding and not looking for those zebras and hoping for horses.

In short, a qualified virologist was saying she suspected appendicitis but the consultant according to his training went with common to rare (horses to zebras). It took time and unneeded resources. I was a zebra in this case. Only 2% of appendectomies are granulomatous.

Are you a zebra? I’d love to meet you! Say hi below.


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