“Red-tailed Hawk, Buteo jamaicensis: The hawk commonly seen perched on trees, poles, or fenceposts along roads or fields. Because it is so numerous and easily seen, this species is the one against which all other buteos are compared.” – David Allen Sibley, The Sibley Field Guide to Birds of Eastern North America

I

Drive on nearly any interstate in the United States and, with a little focus diverted away from the road ahead and instead directed towards the countryside speeding by at seventy miles per hour, you will soon begin to notice Red-tailed Hawks. Widespread and abundant, these large raptors are identified by a combination of their considerable size, eponymously colored tails, and sheer prevalence. One may spy a red-tail, as they are nicknamed, perching stoically atop a denuded tree, soaring in lazy circles over parched landscape, or partaking in a furry meal aside a drainage ditch. Red-tails are simultaneously unassuming and noble – they inhabit bulky brown-and-white bodies, yet flash brilliant rust-colored tail feathers; they frequent scenery both dreary and magical; they celebrate the evolutionary sacrament of feathered flight in sparkling winter skies and gloomy overcast alike.

As is painfully evident, I am a bird-watcher, known in the field as a “birder”. Once one stumbles upon an initial love of birds, life never feels quite as it once did before every solitary chirp or flutter of wing beats became salutations from a parallel world of ecological splendor. Birding is, at its core, a cherishing of the omnipresence of avian life, and finding beauty in both the rare and the common. For example, the Northern Cardinal is an abundant bird east of the Mississippi River, and therefore written off by some misguided, list-preoccupied birders as “boring”, yet its brilliant red plumage and inconspicuous flair are anything but. Conversely, the Clay-Colored Robin sports an unadorned coat of pale brown, but sightings north of the Rio Grande are exceedingly chance encounters. A birder of true spirit appreciates both of these birds, each for their respective uniqueness, and refrains from establishing a value hierarchy by which to poison their enjoyment of the diversity of life.

Birding also appeals to me for its inherent elements of identification, a quality which strikes me increasingly through my medical schooling as similar to diagnostics. Upon catching a mere glimpse of a departing songbird in a densely wooded thicket, one must rely on slivers of memory of its general appearance, impression, size, and behavior, as well as context clues from the location, in order to make a reasonable identification. While timing may not pose a similar challenge to many instances of diagnosis, the same principles of evidence integration follow, and as a second-year medical student I am invigorated daily by the comparisons in the practice of my two intellectual loves, birding and medicine.

In regards to roadside raptor sightings as described by David Sibley and experienced by many a motoring birder, Red-tailed Hawks perfectly exemplify the great axiom imparted to generations of medical students: “When you hear hoof beats, think of horses, not zebras”. If you observe a bulky hawk on a telephone pole as you speed by, chances are, you have spotted a red-tail. Spy a hasty flap of large wings descending into a yard behind a grim salt-stained noise cancellation wall in suburbia? Likely a red-tail. Shield your eyes from the blazing desert sun to discern a distant silhouette coasting in a cerulean sky over a vermillion mesa? I would be willing to put money down on red-tail, my friend. For birders aiming their gazes and binoculars skyward in hopes of witnessing zebras, red-tails are the horses of the sky – and their hoof beats are always a welcome greeting to me as they echo across the canyon-scape of clouds above.

II

In the winter of my first year of medical school, I met a gentleman who had been dismissed as a Red-tailed Hawk by his healthcare providers. In a program called “Classics”, volunteer patients with notable findings or stories exhibited themselves in order to impress upon us, as newly minted medical students, valuable lessons about approaching the practice of medicine. This particular session involved patients with abdominal cases, and a small pod of fellow students and I rotated from room to room for these brief encounters. Towards the end of the session, we entered the room of one Mr. Smith, whose name I have changed for privacy. After performing my newly-learned rite of hand sanitization with an accompanying warm “Hello”, I stood patiently with my peers awaiting his story, as yet unaware of the insight and lasting effect his experience was about to have upon me.

Mr. Smith spun the tale of his medical odyssey, which began with vague episodes of feeling unwell, followed by abdominal swelling, fluid retention, gastrointestinal distress, and, ultimately, jaundice. Alarmed by this untoward turn in his health, he sought the opinion of his doctor, who delivered the sobering news: his liver was failing. Regrettably for the sake of this narrative, many of the details of who knew what at what time have escaped me over the year; however, I recall that Mr. Smith soon faced prejudice and stigma from his medical team, who were confident that his liver woes derived from alcohol abuse, despite his assertions that he rarely drank. According to Mr. Smith, his healthcare providers treated him as if he were yet another patient who had bathed his liver in alcohol and transformed it into a shrunken, dysfunctional, cirrhotic rock.

At some point, someone managing Mr. Smith’s care thought to consider other diagnoses, and discovered that Mr. Smith was not lying about alcohol abuse, as they had assumed. Instead, Mr. Smith suffered from alpha 1-antitrypsin deficiency, a condition in which this enzyme cannot be secreted properly, accumulates in the liver, and leads to cirrhosis and liver failure. Mr. Smith was indicated for liver transplant, and following an agonizing wait on the transplant list, a donor was found, permitting him to undergo the operation. Next came the most poignant moment of Mr. Smith’s story – one night during the recovery period in the hospital after the transplant, Mr. Smith had managed to get up and shuffle to the bathroom for the first time since the surgery. There, in the mirror under the glare of the unforgiving fluorescent lights, he stared at his reflection – the sclera of his eyes, yellowed with jaundice for many months before his transplant, now shone brilliant white.

The error of attitudes that befell Mr. Smith also takes place among birders, when one is disappointed by the commonness of a sighting. Ideally, the spirit of birding is as alluded to before: every individual bird is beautiful, unique, valid, and worthy of our appreciation; to be regarded as elegant, airborne descendants of dinosaurs; as winged celebrations of the ongoing spiraling fractal of evolution and biodiversity. This unconditional adoration of our feathered friends, however, is not shared by all.

The hearts of some birders are instead gripped with the desire to become aforementioned “listers”, preoccupied not with the simple joy of viewing birds familiar and rare alike, but instead intent upon completing a checklist of sighted species, thereby disregarding the beauty abounding around them and hell-bent on seeking one novelty in its midst. These most rabid of listers corrupt the appreciation of birding, and drive a stake of doubt into the hearts of those purer birders who derive excitement from seeing a new species, prompting the question, “do I sink as low as they do, for being excited about this new bird?” They have ruined it for all of us, albeit in small doses.

Though I am still a student of medicine, I see this attitude played out on two related fronts: choosing a specialty, and imagining a hierarchy of diagnosis importance. Too often, already, I have heard individuals say, “I don’t want to go into pediatrics – I could never stand to treat ear infections all day”, and I have even caught myself saying, “I could never be a surgeon. I don’t want to spend my career performing a single type of operation.” While these may, on a personal level, be practical outlooks that influence our choices, should these attitudes be so readily advertised, creating an atmosphere of negativity? Why vocally denigrate the nobility of providing relief to children suffering from ear infections, just because you would be more intellectually stimulated by treating a medulloblastoma? Why cast down the necessity of surgical repair just because I would rather spend my time in a clinic speaking with patients and providing longitudinal care? How these sentiments play out in the later years of training and practice I cannot yet say from firsthand experience, but I certainly gleaned a sense of it from Mr. Smith’s story. “He’s just another alcoholic…” I can imagine his medical team saying, “…nothing interesting about him”. These caregivers have done wrong. Not only did they ignore the possibility that he could have been misdiagnosed, but they erred by failing to appreciate him as a patient in need of empathy and care just like everyone else.

III

The interstate of our encounters carves a trench through the landscape of lives we traverse as physicians. We speed onward, through medical school, residency, and beyond, at first only seeing nondescript fields and shadows of avian movement, unskilled yet in delving into our patients’ experiences. With practice we slowly learn to identify details and facets of our surroundings, the characteristics and quirks of our patients. And we begin to witness and recognize birds. The first red-tail you reliably identify in your early days of birding may feel like the first diagnosis of angina pectoris in a standardized patient, or awareness of the sickling of cells on a blood smear. Further experience compounds, knowledge accumulates, and soon we make calls with greater sophistication, but still rely upon the foundation of essentials, which remain useful and relevant in the face of our advanced abilities.

The raptors perched on the periphery of these fields are the pathologies that beset our patients, and in time we begin to recognize them quickly. Our careful lines of questioning in our histories, as well as our inspection, percussion, palpation, and auscultation, combined with lab results, imaging, and biopsies, all filtered through our intuition and knowledge, provide us with our diagnoses. So it is with the birds. We learn to characterize and categorize. We learn to know.

Horses and zebras alike deserve equivalent respect and appreciation. Yet while we cherish our gift of daily horses, each of which is unique even among its commonness, we must keep an eye out for the zebras; for while they must not be unduly elevated at the expense of the horses, they are worth noting for their own uniqueness. After all, if a zebra such as Mr. Smith, wrongly-diagnosed as a horse, could benefit profoundly from correct identification, it falls to a birder of a physician with a keen eye and a proper attitude to remedy the situation so he may look into his cured eyes.

During our many cross-country drives together, my fiancée and I make delightful note of the birds along the road. The raptors, many of which are red-tails, enjoy a special facet to their uniqueness as one of the first categories of bird we learned to identify together. On one such trip, she noticed a suspicious form that gave her pause – “I think this one isn’t a red-tail…” and sure enough, it proved to be a Red-shouldered Hawk, a species less widespread than its ubiquitous cousin.  Having established a long-term appreciation for every lovely red-tail that we have encountered, this red-shouldered stood out almost instantly, and for that duality of goodness we relished in our discovery. If this appreciation is applied to every patient, one may stop grouping patients as either “boring” or “interesting”, and possibly think twice before dejectedly and wrongfully writing off a patient as a red-tail. This attention and intention is why I bird, and why I am devoted to a life of love in medicine.