Friday, April 6, 2012


It's plausible and popular to conclude that unnecessary testing and treatment comes largely from "defensive medicine," but that's not the whole story. Much of it comes from physicians' almost exclusive loyalty to medical science.

This came home to me recently when a friend told me her story. She'd been caring for her frail and aged mom, two hours from her own home, for weeks. At last things settled down. Driving home, she noticed pain in her back. She realized she might have expected something like that, "…as I'd been carrying a heavy burden." By the time she reached home, the pain was severe enough that she called her physician and requested strong pain medication. He suggested he see her first.

He examined her, agreed that her pain was probably secondary to stress, but--just to be sure--recommended a CT scan. When she took the order slip to radiology, the receptionist said, "Fine, but are you aware this will cost you about a thousand dollars?" My friend hit the ceiling. She tore up the note, called her physician, and said, "We both know I don't need a scan. How about just giving me a prescription?" The doc said, "Fine."

Okay, we can say that was an example of defensive medicine. When I related it to another doctor friend, though, he had a different take. "How old is she?" he asked. "Has she had a bone density test? How do we know this isn't a pathologic fracture, or a bony cancer metastasis?"

"My God," I answered, "those are such zebras." That's actually a medical term, deriving from a time-honored axiom in this biz, "When you hear hoofbeats outside, think of a horse before a zebra."

"Sure," my friend said, "but zebras do show up sometimes."

Thinking about that, I realized that's a standard medical rejoinder. Mention zebras and horses to doctors, and they'll focus on zebras because pulling the strange and rare diagnosis out of the hat is one of medicine's holy grails. We all want to be the diagnostic hero. With no connection to the woman with back pain, my doctor friend wasn't practicing defensive medicine. He was on rounds, demonstrating his allegiance to exhaustive science.

The doc who finally wrote the painkiller prescription (the pain, by the way, is now history) was jarred from his scientific perch by his patient simply reminding him of common sense. Of course, both approaches are valid, and precise circumstances ought to dictate the eventual strategy. That must depend, then, on a full conversation between doctor and patient. I'm gratified that an increasing number of studies are concluding that this crucial relationship--which our obsession with high-tech interventions has steadily eroded--seems to be reviving.


  1. My take on this is that the doctors are attempting to resolve their fear of missing something and being dragged into court.

    I am convinced that this syndrome is actually dragging our society into a sort of dark ages where the unknown looms larger than life and the known is trivialized. The irony is that this unbalanced bias is materializing the demons it purports to be fighting.

    If we -we includes me- could just relax a little, that would be the best.

  2. The diagnostic column the NY Times runs every week or so focuses on the zebras and not the horses. Readers are informed of a strange medical situation and told about all the inconclusive tests, even given links to the xrays and scans. All the symptoms are described. Then readers are invited to take a guess as to the diagnosis. I think it feeds our fears, patients and doctors alike, that we will get some awful disease and die because our doctor missed some tiny crucial detail. If I was a doctor I would shudder and order more tests, more tests!

    1. Thanks for pointing that out, Anne. I read that diagnostic column, too. Never connected it with zebras, but of course, you're right. I rest my case, then: bag a zebra, be a medical hero!

      I think you're also right about this tendency feeding fears. Believing we're invaded by zebras can leave us feeling mystified and helpless, and in real life that's very, very seldom the case. We're actually in the midst of horses--friendly, pretty ones at that.

  3. A colleague of mine was asked to evaluate a dental patient who had three wisdom teeth removed with one socket bleeding extensively! He ran a full battery or tests for bleeding dyscrasias. I told him that the other two didn't bleed so it must have been a local factor. He didn't care. The test results? You know :-)