Zebra is the American medical slang for arriving at an exotic medical diagnosis when a more commonplace explanation is more likely. It is shorthand for the aphorism coined in the late 1940s by Dr. Theodore Woodward, professor at the University of Maryland School of Medicine, who instructed his medical interns: "When you hear hoofbeats, think of horses not zebras". Since horses are common in Maryland while zebras are relatively rare, logically one could confidently guess that an animal making hoofbeats is probably a horse. By 1960, the aphorism was widely known in medical circles.
As explained by Sotos, medical novices are predisposed to make rare diagnoses because of (a) the availability heuristic ("events more easily remembered are judged more probable") and (b) the phenomenon first enunciated in Rhetorica ad Herennium (circa 85 BC), "the striking and the novel stay longer in the mind." Thus, the aphorism is an important caution against these biases when teaching medical students to weigh medical evidence.
Diagnosticians have noted, however, that "zebra"-type diagnoses must nonetheless be held in mind until the evidence conclusively rules them out:
In making the diagnosis of the cause of illness in an individual case, calculations of probability have no meaning. The pertinent question is whether the disease is present or not. Whether it is rare or common does not change the odds in a single patient. ... If the diagnosis can be made on the basis of specific criteria, then these criteria are either fulfilled or not fulfilled. — A. McGehee Harvey, James Bordley II, Jeremiah Barondess
The term for an obscure and rare diagnosis in medicine is fascinoma.
Necrotic skin lesions in the United States are often diagnosed as loxoscelism (recluse spider bites), even in areas where Loxosceles species are rare or not present. This is a matter of concern because such misdiagnoses can delay correct diagnosis and treatment.
Ehlers–Danlos syndrome and hypermobility syndrome are both medical zebras and yet are commonly under diagnosed and misdiagnosed. The EDS and hypermobility syndrome awareness movements have adopted the zebra as the mascot for their campaigning.
Patients with other under diagnosed illnesses have also pointed out the aphorism's failure in logic. Since zebras make up a percentage of the medical patients a doctor will see in their practice, these patients must be also be "thought of." Otherwise, a percentage of the national population will go undiagnosed simply for being "less likely."
In popular culture
The television series Scrubs episode "My Balancing Act", focuses on this theme, and the medical veteran Dr. Cox uses the metaphor to explain to intern John "J. D." Dorian why he should first consider a simple diagnosis.
The television series House had the working title Chasing Zebras, Circling the Drain, a reference to the show's recurring theme of hunting for obscure diagnoses while a patient is in a critical condition. The title character, diagnostic expert Dr. Gregory House rejects the aphorism, arguing that any cases with simple solutions would have been successfully diagnosed by someone else before reaching him.
Harvard Medical School and Harvard School of Dental Medicine's 2017 music video "IT'S NOT A ZEBRA!" depicts a group of first-year medical students erroneously trying to diagnose a patient with a rare and unlikely disease, when in fact she has the flu.
Other medical aphorisms
- Sutton's law – perform first the diagnostic test expected to be most useful
- Occam's razor – select from among competing hypotheses the one that makes the fewest new assumptions
- Leonard's Law of Physical Findings – it's obvious or it's not there
- Hickam's dictum – "Patients can have as many diseases as they damn well please"
- Samuel Gee — author of Medical lectures and aphorisms (1902)
- James Alexander Lindsay — author of Medical axioms, aphorisms, and clinical memoranda (1924)
- Maimonides — Commentary on the Aphorisms of Hippocrates and Medical Aphorisms of Moses
- Sotos (2006) page 1.
- Sotos (2006) page 1.
- Imperato (1979) pages 13, 18.
- Sotos (2006) page 7.
- Harvey (1979) page 15.
- Vetter, Richard S. (2008). "Spiders of the genus Loxosceles (Araneae, Sicariidae): a review of biological, medical and psychological aspects regarding envenomations" (PDF). Journal of Arachnology. 36: 150–163. doi:10.1636/rst08-06.1.
- Why the Zebra|url=http://www.ehlers-danlos.org/about-eds-uk/why-the-zebra
- "House... and Holmes". Radio Times. BBC Magazines Ltd. January 2006. p. 57. Archived from the original on January 18, 2010.
- Price, Mirissa D. (2017-04-27). "10 Best Moments from the Class of 2020 Harvard Medical School/Harvard School of Dental Medicine Music Video". Huffington Post. Retrieved 2018-11-28.
- Sotos (2006) page 15.
- Harvey, A. M.; et al. (1979). Differential Diagnosis (3rd ed.). Philadelphia: W.B. Saunders.
- Imperato, Pascal James (1979). Medical Detective. New York: Richard Marek. ISBN 0-399-90058-6.
- Sotos, John G. (2006) . Zebra Cards: An Aid to Obscure Diagnoses. Mt. Vernon, VA: Mt. Vernon Book Systems. ISBN 978-0-9818193-0-3.