Our educational system rewards zebra finding more than conserving financial resources. Too many academicians think zebras first and then default back to the obvious diagnosis.
One problem stems from our educational process being haphazard. Rarely do we select attending physicians for teaching skills, or teaching philosophy. We get faculty generally from three buckets:
- Research future: Can they get grants funded and produce important research?
- Clinical expertise: Will they attract complex patients to the academic medical center because they are the expert for a zebra disease?
- Clinical need: Sometimes we just need another body to see patients in clinic, or do endoscopy, or do cardiac caths.
Only occasionally do we focus on teaching as a reason to hire someone.
When we hire any new faculty, we assume that they can teach, and that what they will teach will have worth to the students and residents. We do not really have department education goals. We have a written curriculum that everyone ignores.
Some attendings do not go zebra hunting. Some of us assume a horse (rather than a painted zebra), but will look for the zebra once the paint starts to crack.
I better write that concept more clearly. The diagnostic process works best when we try an obvious diagnosis, and see if the patient’s problem representation (a short synopsis of their presentation) fits our illness script for the obvious diagnosis. We should consider alternative diagnoses when the patient’s story does not really fit the illness script.
The key to zebra hunting is knowing when to hunt. We owe it to our learners to make that decision explicit. The onus of teaching this type of diagnostic decision making should fall on the entire faculty. But first we would have to teach them some teaching principles. And since teaching is, in my opinion, undervalued we will in the near future teaching students and residents that zebra hunting is a primary passion without regard to appropriateness.
Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.
