Looking for zebras as a locum GP on safari
Dr Burnt Out espouses the values of GP locums in identifying and treating zebras – the patients with rare and unheard of symptoms
‘When you hear hoofbeats, think of horses not zebras.’ It’s an old and well known adage for GPs, but what should you do on the rare occasion that you’re actually faced with a zebra?
Most of the time as GPs, we are dealing with routine and familiar cases: infections, cancer, cardiovascular disease, respiratory disease, arthritis etc. But occasionally a zebra gallops into the consultation room – a patient with symptoms that turn out to be a rare, or sometimes almost unheard of disease
Have you heard of Mal de Débarquement Syndrome (MdDS)? I hadn’t either until I saw a patient a few months ago who turned out to have it – and hadn’t even been on a nice cruise to blame it on.
If you were to look up a list of all the rare diseases that exist, you would not believe the variety and number of them out there. There are a hell of a lot of zebras (a whole dazzle) out there that may come and see us in their early, middling or late stages.
I can hear you already: what’s the point knowing that much about them? Can’t I just refer them to a specialist anyway who can make the diagnosis? This may be true, but I think it is slightly overplaying the skills of specialists – some of whom nowadays just send us long lists of tests to do, asking to forward them the results at a later date.
In my role as a locum GP I am interested in how these zebra illnesses can present; often with subtle or non-specific symptoms – slightly raised blood test results, a funny rash, chronic pains, other non- resolved symptoms etc. As a locum GP, it is especially important to have your clinical antennae tuned up to 11 because you may well not see the patient again. You want to do what is clinically right by them on that one occasion that you are likely to see them, where decisions can be singular, acute and crucial.
Patients are now commonly trying to diagnose themselves using AI and routinely Accurxing into practices with long, AI-generated lists of conditions and tests they think they need. While this can sometimes muddy the waters, it does highlight that persistent unexplained problems or abnormalities that don’t quite fit a familiar pattern should always give us pause. When symptoms don’t follow the expected trajectory, don’t respond to standard treatments, or span multiple systems, that’s often where the zebra quietly grazes.
I would also add to this trust your experience and judgement on whether you think something more may be going on; usually your intuition is spot on and you should always trust it. Gut feelings are hugely important for GPs and can be more accurate than ‘traditional’ tests and assessments as shown by research. If in doubt, seek help, advice and/or refer. Use the ‘can you go to sleep at night’ test when it comes to decision making ie. you should be able to go to sleep at night without anxiety about the clinical decisions you have made that day; as with everything it is not always foolproof, and you may only find out you have anxiety or a new intuition about your day at work when you actually try to go to sleep…)
Continuity of care has been the general practice mantra for so long, but I want to argue that as a patient (and to be honest also as a GP) sometimes it is good not to have continuity of care. Maybe a fresh set of clinical eyes can read between the lines where a patient’s regular GP has glossed over. The fresh set of eyes might be able to be more accurate in terms of diagnosis and appropriate management. There has been previous research into this with cases of cancer diagnosis.
For their ‘normal’ GP, the patient’s symptoms may just be to them a flare up of the ‘normal’ symptoms. But a locum may spot something unusual, or a pattern of symptoms that the regular GP does not. They may refer more freely; they may order some different tests that the ‘continuity’ GP does not, and they may have specialist knowledge of this particular condition or set of symptoms.
So if I had to give you a take home message – both as GP and patient – it is this: If you think you are ill but haven’t got anywhere with your normal GP, perhaps the best thing to do is to see a locum GP.
That is of course, if any locums are actually employed by practices anymore. But that’s an issue for another day…
Dr Burnt Out is a GP locum in London
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READERS' COMMENTS [5]
Please note, only GPs are permitted to add comments to articles
I once locummed for an elderly single-hander apparently beloved by his patients but who appeared to only ever see Horses everywhere. Zebras never occurred to him. He was as stubborn as a Mule. In the end, as a fresh pair of eyes, I got fed up catching the few Zebras for him so cancelled my further locums for this Ass.
We all know zebras exist. A bigger problem nowadays seems to be getting on with the business of addressing the presenting concern without pursuing unknown unknowns ‘just in case’.
Such unknown unknowns can be leaned upon to a questionable degree by way of justification for locums for ordering a raft of tests with advice to see own GP for another examination a week later, ‘just in case’. Entirely passing the buck for owning a clinical decision or offering any differential diagnoses at presentation while shouldering no responsibility for the results or ultimate resolution of the patients dis-ease at their symptoms, indeed perhaps worsening their concerns via this approach.
And don’t get me started on the merits or otherwise of the M.O of remote clinicians via a company that rhymes with privy
I have been involved in three patients care in the last 5 years who were diagnosed with Addison’s disease, 5MND patient in surgery of 8000 patients (way too high), Cowned Dens Syndrome, Stiff Persons Syndrome with + DMI AB, Myasthenia Gravis, Petechial Cimicosis etc etc. We forget how many rare and wonderful things we see. Especially with signposting being a thing now our a priori chance of weird and wonderful is much higher. With higher pressure on secondary care the onus is more on us to watch out for the Zebra’s. I like the sound of hooves either way.
Whilst I have never seen this in a patient, I was brought up at the coast, and worked near the coast, and familiar with the borad-based gait of sailors once on land – indeed many of us experienced it for short periods after crossing the Channel.
My most dramatic acute case was of a young sportsman, who, during a week of other activities, spent one half-day on the sea in small boats. That night he was unsteady walking, and then proceeded to roll out of a top bunk with rails, and break a leg, showing just how significant it can be.
MDT for patients who have difficult to diagnose symptoms or persistent symptoms is a good idea. Hospital specialist always do that once in a week.