Recent fever, occasional cough and night sweats made me instantaneously think of tuberculosis as it classically presents with these three symptoms. Looking at the patient however, a healthy appearing 16 year-old female with no recent travel history, a diagnosis of seasonal allergies with a recent cold was much higher on the differential. It was then that I remembered someone saying to me on my first day of medical school: “When you hear hoofbeats, think of horses not zebras.”
I had the opportunity to work with Dr. Sahmon Fallahian at Colchester Family Practice for my year of Doctoring in Vermont (DIV). The spring sessions started with shadowing where I learned how to apply my scientific knowledge, history taking techniques, and physical exam skills in the clinic. For example, in the Attacks and Defenses course, I learned how fungi form hyphae that can be seen under the microscope. When we saw a patient who had symptomology consistent with a cutaneous fungal infection, Dr. Fallahian taught me how to do a simple KOH prep in the office. Upon examination of the scrapings of the lesions, we did indeed see hyphae, supporting our primary diagnosis. I also worked closely with a clinical care associate, Zac Brown, who showed me how to prepare patients for their visit. Everyone at Colchester Family Practice taught me the importance of team work, how to build a good rapport with patients, draw blood, remove stitches, give flu shots, and much more.
The shadowing gradually turned into more of a clinical rotation by the fall, where I saw patients independently, and presented my findings to Dr. Fallahian. One of the more important lessons I learned was what to do with a patient who comes in with a laundry list of medical problems. Many of these patients came to the physician once every few years when symptoms begin to interfere with their everyday lives. On one occasion, I saw a 40 year-old carpenter who had a multitude of medical concerns including arm pain exacerbated by his work, pitting edema of the legs, and concerns about his smoking habits, obesity, and nutrition. Dr. Fallahian taught me that when patients come in with many health concerns, we need to create a problem list and treat imminent issues immediately. In this case we treated his arm pain, because it was preventing him from working, and his pitting edema, for fear of damage to vital organs. The rest of the medical concerns were to be addressed in a follow up visit. A good patient-physician relationship was crucial in maintaining continuous patient care.
As I transition from the classroom to the hospital wards, I will take these lessons I have learned from DIV with me. In the case of any patient, it is important to create differentials and problem lists that will allow for continuous and proper care of the patient now and in the future. I enjoyed seeing patients return in an improved medical state, and my DIV experience has made me consider Family Medicine as a career path. When caring for my patients, when I hear hoofbeats, I will think horses first. But I will not forget about the rare zebras that I may also encounter in the wild.