Thinking outside the box

There were many lessons to learn at Charity Hospital as a medical student. One such lesson was that as a physician one should avoid “tunnel vision” in diagnosing and treating patients.

In 1969, as a third year medical student, Ms. Zapata taught me this valuable lesson. My first clinical rotation was on the Charity psych unit. I was very interested and excited about the rotation because I was contemplating going into psychiatry. Ms. Zapata was my first assigned patient. She was a lady in her 30’s who had been hospitalized for several weeks with severe depression. She was recalcitrant to current treatments. I do not recall all her past history but do remember a recent history of “pseudocyesis”.

The physical exam revealed an obese lady who was essentially non-communicative. She also exhibited slow speech, dull facial expression, coarse hair texture, dry skin, and hyporeflexia.

To a medical student fresh from clinical pathology, the findings appeared to be consistent with myxedema(severe hypothyroidism). I asked the resident in charge if she might have hypothyroidism as a source of her depression and if I could order a PBI(which was the lab of choice for thyroid dysfunction in those days). The resident was a bit dismissive but consented. The result was a PBI less than 1.

She was subsequently transferred to medicine for thyroid replacement which “cured” her of her myxedema and depression. A “coup” for a wet behind the ears junior medical student.

The episode taught me to avoid tunnel vision and consider “out of the box” scenarios when caring for my patients when the facts are not consistent with my preconceived ideas.

By the way, there were no more “cures” for me on that rotation. In addition, I eventually decided not to persue psychiatry and now have been an orthopedic surgeon for over 40 years.

R Edward Roybal MD

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