Hoofbeats

"Don't fill your photo with more than necessary," I told my younger sister during our recent photography trip. "Life is never rosy," I continued, "We'd better crop out the thorn and leave behind the roses that will stay etched in the picture, and our memory."

The trick with selective memory is especially germane to our work in the hospital. The medical encounter, it turns out, has been replete with less-than-exciting patients of all sorts. "Good clinicians think of horses when they hear hoofbeats," I taught my students last night, "but we never forget that the hoofbeats are once in a while made by zebras." There can be no gainsaying the fact that medical doctors are often bored by the frail elderly patients who come in with pneumonia, twenty-four hours a day, seven days a week. Fortunately they seldom stay in our memory; we would rather marvel at our ever making a zebra-diagnosis, which is to stay in our memory forever.

A clinician might not be able to pull a diagnostic rabbit (or zebra) out of a hat at the end of each morning round, as what Dr. Gregory House did. Don't worry. Few of us remember the number of times we hear the hoofbeats, but I will never forget the once-in-a-lifetime chance to make a diagnosis of Wilson’s disease or acute porphyria masquerading the hoofbeats of the horses.