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Dr. Moore: INTERVIEW: WHEN I GROW UP: BECOMING A PATHOLOGIST.
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INTERVIEW: WHEN I GROW UP: BECOMING A PATHOLOGIST.

(DRAFT COPY ONLY)

G. William Moore, MD, PhD.

http://www.netautopsy.org/billgrow.htm


United States Government Work, uncopyrighted, public-domain, DRAFT COPY ONLY. This document does not necessarily represent the views or policies of any United States Government agency. This document is provided "as is", without warranty of any kind, express or implied, including but not limited to the warranties of merchantability, fitness for a particular purpose and non-infringement. In no event shall the authors be liable for any claim, damages or other liability, whether in an action of contract, tort or otherwise, arising from, out of, or in connection with the document or the use or other dealings made with the document.


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The following discussion is adapted from an email correspondence exchange between myself and the students of Johnston Middle School, Johnston, Iowa, in February, 1999.

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What is Pathology?

Pathology is the study of diseases that occur in humans (human pathology) or in non-human animals (veterinary pathology).

Many questions about pathology are answered in more detail if you go to the internet, and enter a few keywords, including PATHOLOGY or HUMAN PATHOLOGY:
http://www.google.com/


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What education is required to be a pathologist?

Human pathologists must have a bachelor's degee (four years of college) a Doctor of Medicine (M.D.) or Doctor or Osteopathy (D.O.) (four years), plus five years of additional training in a pathology residency program.

Veterinary pathologists must have a Doctor of Veterinary Medicine (D.V.M.) and additional specialty training. Admission to U. S. medical schools and veterinary schools is highly competitive, and requires good undergraduate college preparation and grades.

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How did I become interested in Pathology?

I became interested in biology and medicine research when I was a middle school student. I participated in Science Fairs, which were an opportunity for young scientists to show their work to their peers (that is, among other young scientists), as well as to adult judges.

I chose to go into medicine, because this is a practical area, where you can immediately help other people. I chose pathology because it is one of the most scientific branches of medicine, and because it is one of the few branches of medicine, along with general family practice and radiology, where you can work with diseases of the entire body. Most other medical specialists work with a particular area of the body, like the brain, the eyes, the skin, the chest, the abdomen, etc.

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What electronic tools are used in pathology?

At this moment in history, there are not many electronic tools in the routine pathology laboratory, outside of computers to perform ordinary office functions, like email and fax. There has been a lot of discussion about an emerging area, namely, TELEPATHOLOGY, in which a pathologist in one location looks at specimens under a microscope which is physically located hundreds of miles away. This has been suggested especially for remote, sparsely populated areas, which do not have enough work to employ a full-time pathologist. Right now, telepathology is still very experimental, and many of the problems have not yet been worked out.

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How important are autopsies?

Autopsies have always been very important in societies with a sophisticated medical culture, like the United States. There are many medical questions that you can determine from autopsy studies that cannot be answered any other way.

There are two basic types of autopsy: MEDICAL (asking why a patient died in a hospital); and FORENSIC (asking why a patient died under suspicious circumstances). You might wish to enter FORENSIC PATHOLOGY as a keyword on google.com.

In my job, I perform medical-type autopsies. Medical-type autopsies are important in studying the progress of diseases, like heart-disease and cancer, and determining whether certain treatments have helped the patients. There is a Latin saying that every pathologist knows: Mortuí vivós docent. The dead teach the living.

Most states have a MEDICAL EXAMINER, a group of pathologists who have additional training in forensic-type autopsies, and who perform autopsies on persons who died under suspicious circumstances. Every pathologist, of course, has some training in forensic pathology. In my job, if I think that a crime has been committed, I consult with the medical examiner. In recent years, the number of medical-type autopsies performed in this country has decreased greatly, but the number of forensic-type autopsies has remained steady. I think that the decrease in medical-type autopsies is a mistake, but I am not allowed to decide whether to request an autopsy.

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Does it hurt the family to have and autopsy?

In my opinion, it never hurts the family to have an autopsy, unless the family objects to an autopsy for religious or other personal reasons, or the family is informed of the autopsy results in an insensitive way. For example, in Muslim cultures, autopsies are almost never performed. In my opinion, the doctor who has cared for the patient during life should always interpret the autopsy report for the family. The autopsy report is written in very technical language, and non-medical people might be offended or confused by what they read in an autopsy report.

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How do I feel when I do an autopsy?

Pathologists are usually thinking about the technical parts of an autopsy when they perform an autopsy. Why did the patient die? Was the disease controlled as well as possible by the treatments? Will there be any unexpected findings? Pathologists almost never know the patient that they autopsy, and they become accustomed to the gruesome parts of the autopsy. If you can't get used to working with dead bodies, then it doesn't make much sense to become a pathologist. Still, even pathologists have feelings. The autopsies that bother me the most are the ones on young people about your age who have suffered a great deal before they died. We all have to die sometime, but it seems to me that everyone should have the chance to grow up first.

There is a joke among pathologists that we think about food when we do autopsies. Many findings seen at autopsy are named after food, probably because food is so familiar to everybody. Examples: NUTMEG LIVER, CASEOUS NECROSIS, BREAD AND BUTTER PERICARDITIS, SUGAR-CAKE SPLEEN, etc. (These terms were invented by nineteenth century German pathologists, and a lot of young people these days don't even know what a nutmeg or sugar-cake look like.) Put a few of these phrases into google.com on the internet, and see what you get.

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What do pathologists do, besides autopsies?

It might surprise you to learn that non-medical-examiner pathologists do not spend much of their time performing autopsies these days. Pathologists like myself spend most of their time looking at specimens that surgeons and other doctors remove from a living patient. We prepare the specimens and look at them under the microscope, so we can tell the patient's doctor what is wrong with the patient. Most working days for a pathologist are about the same as for other professional people, like lawyers, teachers, and businessmen. It is a long, somewhat unpredictable work-week, but most pathologists do not work at extremely odd hours, like surgeons or emergency-room doctors. There ARE emergencies in pathology, but they don't happen very often. Usually, a pathologist must be called to the hospital if a patient needs emergency surgery, and the surgeon needs to know the diagnosis (that is, what disease) before he/she finishes the operation. In these emergencies, the pathologist quick-freezes the specimen that the surgeon removes from the patient, and makes a diagnosis, so the surgeon knows what to do next. Most routine specimens in pathology take several days to process, sometimes longer if there are special tests.

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Does the autopsy always give a conclusive answer?

Every honest pathologist will admit that at least one in ten medical-type autopsies does not tell us why the patient died. I don't know what the percentage is in forensic autopsies, but it is probably a lot smaller. Still, there are some things so wierd that a criminal can do, that you couldn't figure it out in your wildest imagination. A German-speaking pathologist once told me a little rhyme about forensic autopsies. If you won't be offended by a slightly off-color joke, then you can enter the keywords UMSUNST BILL MOORE on google.com. (Don't worry; the rhyme is translated.)

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How important are findings at the crime scene?

The crime scene can be very important, depending on the particular case. The pathologist's findings are only part of the puzzle, and the observations obtained at the crime scene are necessary to put together the whole picture, and make sense out of the autopsy results.


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ADDITIONAL NOTES:


1. Supporting material for this interview is posted on a private website, at URL:
http://www.netautopsy.org/axsop/axsoptoc.htm
Procedures 202-227 are particularly relevant to autopsies.

Please note that the above, private website is only an approximate copy of some sections in the Anatomic Pathology Procedure Manual of the Baltimore Veterans Affairs Maryland Health Care System. The document is uncopyrighted, public-domain, draft copy, and has NO OFFICIAL STATUS. The document may be copied freely. It is offered as a model electronic document, in a spirit of cooperation with other pathology laboratories worldwide, who are considering developing an electronic pathology manual at their medical institutions. The authors assume no responsibility for any damages that might arise from the use of the present document. See disclaimer:
http://www.netautopsy.org/axsop/axsopint.htm
2. In the State of Maryland, a Medical examiner's case is defined as "any death which is the result, wholly or in part, of a casualty or accident, homicide, poisoning, suicide, criminal abortion, rape, therapeutic misadventure, drowning, or a death of a suspicious or unusual nature, or of an apparently healthy individual, or a case which is dead on arrival at the hospital." The State of Pennsylvania has a similar law.

The website for the Office of Medical Examiner, State of Maryland, is:
http://www.dhmh.state.md.us/ocme/law.htm


3. Related interview:
http://www.netautopsy.org/billgrow.htm

4. Description of an autopsy:
http://www.deathreference.com/A-Bi/Autopsy.html

5. G. William Moore, MD, PhD. Curriculum Vitae.
http://www.gwmoore.org/gwmcv.htm

6. Association for Pathology Informatics. Honorary Fellow Award. Recipients.
Sidney A. Goldblatt, MD. 2002.
Donald P. Connelly, MD, PhD. 2003.
William R. Dito, MD. 2004.
Raymond D. Aller, MD. 2005.
Bruce A. Friedman, MD. 2006.
G. William Moore, MD, PhD. 2007
http://www.pathologyinformatics.org/FellowAward.htm
Last tested: September 3, 2007.

7. Definition: Pathology is the study of the etiology and pathogenesis of disease. Our modern understanding begins with the publication of Giovanni Battista Morgagni's De Sedibus et causis morborum per anatomem indagatis (1761) (On the seats and causes of diseases, demonstrated by anatomy). In the twentieth century, the work of George N. Papanicolaou, MD, PhD, saved more lives than any other single advance in pathology.

8. Mortality statistics involves drawing inferences from large quantities of mortality, data, collected systematically and repetitively. The name derives from mors (Latin: death), and status (Latin: the state), because the first mortality statistics were the Bills of Mortality, collected by the British government in 18th century London. In European countries with inheritance taxes, dead citizens and the causes of their demise have always been a serious matter to the government. See also: coroner (latin: corona=crown), originally a British tax official who determined the cause-of-death, and thus the disposition of the decedent's estate.

The 18th century British gentleman, John Graunt was the first person to organize these statistics (i.e., summary data on many persons), and use them for descriptive and predictive purposes. Graunt documented the XXXXX epidemic in London, and was able to conclude that there was an outbreak of XXXXX localized in the unsanitary conditions of the poorer districts of London, leading to social reforms.

9. Sushruta. Indian anatomist. Performed the first autopsy in 5000 BCE. From Wikipedia: http://en.wikipedia.org/wiki/Sushruta .

10. Hippocrates. (`Iπποκρατης, 460-370 BCE)
Hippocrates. Volume I.
Jones WHS, transl. Loeb Classical Library. Cambridge, MA: Harvard University Press. 1923.
ISBN 0-674-99162-1, 361 pages.
Hippocrates is the Father of Medicine.
The above book includes Hippocrates' Oath, with explanatory notes. Every doctor swears a version of this oath upon becoming a physician.
"First, Do No Harm" is not in the Hippocratic Oath, but rather in Epidemics, Bk. 1, Sect. 11. One translation reads: 'Declare the past, diagnose the present, foretell the future; practice these acts. As to diseases, make a habit of two things: to help, or at least to do no harm.'

This note supplied by Harris G. Yfantis, MD.

Ancient Greek medicine was based upon the concept of four humors (blood, bile, phlegm, and urine), as well as the location of the patient, season of the year, and nearby epidemics. Many medical terms that we use today, such as bronchitis, nephritis, hepatitis, carcinoma, etc., have their origins in the writings of Hippocrates, although we have a much different view of pathogenesis that did these ancient physicians.

11. Galen Greco-Roman physician (129-200). (Latin: Claudius Galenus) "of Pergamum was a prominent ancient Greco-Roman physician, whose theories dominated Western medical science for over a millennium."

"...Galen's writings on anatomy were the mainstay of the medieval physician's university curriculum, but they had suffered greatly from stasis and intellectual stagnation. In the 1530s, however, Belgian anatomist and physician Andreas Vesalius took on a project to translate many of Galen's Greek texts into Latin. Vesalius's most famous work, De humani corporis fabrica, was greatly influenced by Galenic writing and form. Seeking to revive Galen's methods and outlook, Vesalius turned to human cadaver dissection as an evolution of Galen's natural philosophy. Galen's writings enjoyed a revival at the hands of Vesalius, who promoted Galen and expounded on him through books and hands-on demonstrations. Since most of Galen's writings were also translated into Arabic, the Middle East knows and reveres him." From Wikipedia: http://en.wikipedia.org/wiki/Galen .

12. Avicenna (Ibn-Sina) (980-1037). (Abu `Ali al-Husayn ibn `Abd Allah ibn Sina al-Balkhi; Latinized as Avicenna). Persian Muslim physician, philosopher, and polymath: physician, astronomer, alchemist, chemist, logician, mathematician, metaphysician, philosopher, physicist, poet, scientist, theologian, statesman, and soldier. Avicenna was born in Afshana near Bukhara in Khorasan (now part of Uzbekistan), and died in Hamadan (now in Iran).

Avicenna authored some 450 books on a wide range of subjects, many of which concentrated on philosophy and medicine. His most famous works are: The Book of Healing and The Canon of Medicine, which was for almost five centuries a standard medical text at many Islamic and European universities. Avicenna's medical system was that of Islamic medicine, which was influenced by the medical system of Galen, Aristotelian metaphysics, and early Persian and Arabian medicine. Avicenna is regarded as the father of modern medicine, and the father of the fundamental concept of momentum in physics. From Wikipedia: http://en.wikipedia.org/wiki/Avicenna .

13. Andreas Vesalius (1514-1654), Belgian anatomist, author of De Humani Corporis Fabrica (On the workings of the human body), one of the most influential books of human anatomy. From Wikipedia: http://en.wikipedia.org/wiki/Andreas_Vesalius .

14. Giovanni Battista Morgagni (1682-1771). Italian anatomist, born in Forlì, Italy. Father of modern anatomic pathology. Morgagni published his "great work which, once for all, made pathological anatomy a science, and diverted the course of medicine into new channels of exactness or precision: De Sedibus et causis morborum per anatomem indagatis (1761) (On the seats and causes of diseases, demonstrated by anatomy) which during the succeeding ten years, notwithstanding its bulk, was reprinted several times in its original Latin, and was translated into French (1765), English (1769), and German (1771)." From Wikipedia: http://en.wikipedia.org/wiki/Giovanni_Battista_Morgagni .

For the younger readers, please note that this monumental work was the product of Morgagni's mature years.

15. Karl Baron of Rokitansky. (1804-1878). Czech-Austrian Pathologist. Father of modern autopsy pathology methods. From Wikipedia: http://en.wikipedia.org/wiki/Carl_Rokitansky

16. Rudolf Virchow (1821-1902). German Pathologist. Father of modern cellular pathology. From Wikipedia: http://en.wikipedia.org/wiki/Rudolf_Virchow

17. Franklin P. Mall (1862-1917). Born "in Belle Plain, Iowa. He received his MD from the University of Michigan, in 1883 and for the next three years was involved in postgraduate study in embryology and physiology in Germany. He came to Baltimore in 1886, as one of William H. Welch's first fellows in pathology. Mall left Johns Hopkins in 1889 to become an adjunct professor of vertebrate anatomy at Clark University, Worcester, MA. From there he went to the University of Chicago, Chicago, IL, for a year as professor of anatomy, before returning to Johns Hopkins in 1893 as the first professor of anatomy at the school of medicine. His research included embryology and the relationship between structure and function in adult organs, particularly the spleen, liver, and heart. Mall, together with Welch, conceived the idea of a full-time faculty in medicine with salary support sufficient to allow time for research." From The Johns Hopkins archives.

18. William H. Welch (1850-1934), American pathologist and microbiologist, for whom the bacterium Clostridium welchii is named. "He was first dean of the Johns Hopkins University School of Medicine. Born in Norfolk, Virginia, Welch was educated at Norfolk Academy and the Winchester Institute. He entered Yale College in 1866, where he studied Greek and classics. As an undergraduate, he joined the Skull and Bones honorary fraternity. In 1912, upon its creation, Welch was appointed to the Board of Scientific Directors of the preexisting Eugenic Records Office. This organization attempted to find the hereditary connection for "feebleminded" individuals between generations; with the understanding they could eradicate these and other undesirables through isolation, sterilization and euthanasia. The ERO had contributers such as the Rockefeller Foundation and the Harriman Family.

"From 1901 to 1933 he was founding president of the Board of Scientific Directors at the Rockefeller Institute for Medical Research. He was an instrumental reformer of medical education in the United States, as well as a president of the National Academy of Sciences from 1913-1917. He was also president of the American Medical Association in addition to other prestigious associations. He was a founding editor of the Journal of Experimental Medicine." From Wikipedia: http://en.wikipedia.org/wiki/William_H._Welch .

19. Karl Albert Ludwig Aschoff (1866-1942), German pathologist, for whom Aschoff bodies in the heart (a morphologic finding in rheumatic heart disease) are named. Prof. Aschoff "... was one of the most productive of the group of German pathologists who flourished in the late nineteenth and early twentieth centuries. He is especially remembered for describing the reticuloendothelial system, and the bodies that bear his name. He studied in Bonn, Strassburg, and Göttingen, and graduated from the University of Bonn in 1889. He was conferred doctor of medicine in 1889; in 1894, he was habilitated [associate professorship] for pathological anatomy; and became first assistant at the Institute of pathology in Göttingen under Friedrich Daniel von Recklinghausen (1833-1910). He became professor of pathology at Marburg, in 1903; and from 1906 onward was professor in Freiburg im Breisgau, where he spent the rest of his career, retiring in 1936. At Freiburg, he established an institute of pathology that attracted students from all over the world.

"Aschoff made important studies on appendicitis, gallstones, jaundice, scurvy, and thrombosis, and wrote classical histological descriptions of rheumatic conditions. He is, however, particularly remembered for having recognized the phagocytic activity of certain cells found in diverse tissues, and named them the reticuloendothelial system.

"His outstanding textbook on pathological anatomy went through many editions, and was used as a standard text for many years.

"Aschoff was the publisher of Beiträge zur pathologischen Anatomie und zur allgemeinen Pathologie [Contributions to Pathologic Anatomy and General Pathology; now: Pathology, Research and Practice.] and Veröffentlichungen aus der (Kriegs-), Gewerbe und Konstitutionspathologie. [Publications from (Wartime-), Commercial, and Constitutional Pathology.]"

From: http://www.whonamedit.com/doctor.cfm/251.html

20. George L. Wied (1921-2004) "... was no longer here, having passed away in Salzburg, Austria, on July 25th. But as the meeting unfolded, I realized that George's mark was deeply imprinted on the entire scientific program, and that his legacy was carried by most of the people in attendance.

"George Papanicolaou is attributed with the discovery of the cytologic method for detecting epithelial tumors. His laboratory at Cornell Medical Center in New York was the culture medium for the discipline, instructing such notable cytologists as Leopold Koss and George Wied. The medical specialty itself, however, owes its success to George Wied, for without him, it is doubtful whether it would have survived the skepticism of most other medical specialists.

"Dr. Wied had faith in the importance of cytology that was unwavering and his conviction was transmitted to all who followed him around the globe. A survivor of Nazi Germany, he was a fierce defender of individual freedoms, and he translated that zeal into inclusion of all peoples in his vision. He was an instinctual teacher and taught those around him to convey the criteria of those strange cellular samples via the Tutorials of Cytology. His attention to detail was impeccable, a trait that he insisted his faculty emulate.

"...But where Dr. Wied had the most fun was in the realm of cytology automation. As I listened Sunday to the presentations of experiences with the "new" imaging systems and their integration into the clinical cytology laboratory, I recalled the numerous conferences devoted to development of computerized scanners. As early as 1951, Dr. Wied recognized that computers would become an essential part of our daily lives, for data management and communication. He also realized that the task of screening slides was work intensive, subjective, and fraught with opportunities for error. If Dr. Wied didn't have the knowledge himself, he immediately reached out to others who did, and drafted them to the cause of automating his specialty. One of those recruits was Peter Bartels, a gifted optical scientist and incredibly creative problem solver. Together they built a team of researchers at the University of Chicago that attacked each obstacle to success like an army of dragon slayers...."

Rosenthal DL.
Remembering George L. Wied, MD, February 7, 1921-July 25, 2004.
CytoJournal. 2005;2:2.
From: http://www.cytojournal.com/content/2/1/2

21. George N. Papanicolaou (1883-1962) "was born at Kimi on the island of Evia, in Greece. He was a pioneer in cytology and early cancer detection. He studied at the University of Athens, where he received his medical degree in 1904. Six years later, he received his PhD from the University of Munich, Germany. In 1913, he emigrated to the USA, in order to work in the Department of Pathology at New York Hospital and the Department of Anatomy at the Weill Medical College of Cornell University.

"Papanicolaou first reported that uterine cancer could be diagnosed by means of a vaginal smear in 1928, but the importance of his work was not recognized until the publication, together with Herbert Traut, of Diagnosis of Uterine Cancer by the Vaginal Smear in 1943. The book discusses the preparation of the vaginal and cervical smear, physiologic cytologic changes during the menstrual cycle, effect of various pathological conditions, and the changes seen in the presence of cancer of the cervix and the endometrium of the uterus. He thus became known for his invention of Papanicolaou's test, now known as the Pap smear, which is used worldwide for the detection and prevention of cervical cancer and other cytologic diseases of the female reproductive system.

"In 1961, Papanicolaou moved to Miami to develop the Papanicolaou Cancer Research Institute at the University of Miami, but died in 1962 prior to its opening. Dr. Papanicolaou was a recipient of the Lasker Award." From Wikipedia: http://en.wikipedia.org/wiki/George_Papanicolaou .

Papanicolaou's work saved more lives in the twentieth century than any other single advance in pathology.

22. Berman JJ. Tumor classification: molecular analysis meets Aristotle.
BMC Cancer. 2004 Mar 17;4:10.
PMID: 15113444
PubMed Entry

23. Embryogenesis. Embryology is the basis for our understanding of cancer. See:

Willis RA.
The Borderland of Embyology and Pathology.
London: Butterworths. 1958;:.
ASIN: B0007IXPWK, 33 pages.

Willis RA.
The borderland of embryology and pathology.
Bull N Y Acad Med. 1950 Jul;26(7):440-460.
PMID: 15426876.
PubMed Entry


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Published within the series: "Studies in Fuzziness and Soft Computing", Physica-Verlag Heidelberg, a Springer-Verlag Company.

35. Rosenthal DL.
Remembering George L. Wied, MD, February 7, 1921-July 25, 2004.
CytoJournal. 2005;2:2.
From: http://www.cytojournal.com/content/2/1/2

36. Petersdorf RG, Beeson PB.
Fever of Unexplained Origin.
Medicine. 1961;40:1-30.
Remark about "Sutton's Law" on p. 27. "Sutton's Law" reflects the uncertainty of a medical diagnosis.

37. Sutton W, Linn E.
Where the Money Was. The Memoirs of the World's Greatest Bank Robber.
New York: Ballantine Books. 1976;:.
ISBN 0-345-25371-X-195, 422 pages.
Part Two: Breaking Out. Sutton's Law, pp. 148-150.
Sutton's Law (Willie Sutton, 1901-1980; American bank robber.)
Report's question: "Willie, why do you always rob banks?"
Willie's Answer: "Because that's where the money is."

38. Groopman J.
How Doctors Think.
Boston: Houghton Mifflin Company. 2007;:.
ISBN-13 978-0-618-61003-7, 307 pages.
ISBN-10 0-618-61003-0, 307 pages.
A description of Sutton's Law, Black Swan, etc., in action in clinical medicine.
Chapter 5. A New Mother's Challenge. pp. 101-131.
p. 126. "Common things are common."
p. 126. "When you hear hoofbeats in the street, think about horses, not zebras.
p. 127. "... the phrase `zebra retreat' ... describes a doctor's shying away from a rare diagnosis."

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Last Updated: 12/5/2007, by G. William Moore, MD, PhD.

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