On Hot Dogs, Bayes' Theorum and a Good Ear 

Dr. Waj Nasser shares a lesson on listening

About 15 years ago I saw a patient in his mid 20s who had been feeling poorly for months. His concerned wife finally prompted him to come to the ER. His physical exam was normal and the more questions I asked, the murkier his condition seemed to be. I was at a loss to explain his symptoms, so I ordered some blood tests and to my surprise, his glucose level was alarmingly high. He had developed diabetes; but not the kind that kids get when the pancreas quits making insulin. He had the adult form that usually develops slowly after decades of a poor diet and little exercise. But he looked reasonably fit, stayed active and had what he described as a fairly normal diet, so I was still confused. I called a diabetes specialist who kindly confirmed that something didn't make sense. I went back into the exam room to discuss his results, and he appeared genuinely shocked by my findings. His wife, on the other hand, didn't seem the least bit surprised.

"Tell him," she said to her husband sternly.

"Tell him what?" he responded defensively.

"Tell him more about what you eat."

"Well, doc, I probably should eat better," he admitted with a sigh.

"So what exactly do you eat?" I asked pointedly.

"Oh, I like hot dogs."

"Well, who doesn't like an occasional hot dog?"

"He eats them every day," his wife interjected.

I looked at him, seeking confirmation of what I considered to be an odd revelation.

"Yep, every day," he acknowledged.

"What do you eat for breakfast?"

"A couple of hot dogs, doc."

"Lunch? Dinner?"

"Just hot dogs."

And so it went. Eventually he admitted that all he had been eating for the last year were hot dogs, to the exclusion of all other food. This was, as we say in medicine, a diagnostic key. You might imagine that I looked at him a bit differently at this point.

"Why?" I asked, dropping all pretense of professional decorum.

He shrugged his shoulders and answered simply, "I just prefer hot dogs."

I bring up this case for a few reasons. It represents what I find most enjoyable about medicine, which is getting to know people in all of their maddening complexity. Yet it also reminds me of the threat that health care reform poses to doctors' most potent diagnostic tool—our ears. In this situation, the patient didn't actually believe that his diet was the reason he felt poorly. (And he's not alone. I recently saw someone who only ate SpaghettiOs. It took a lot of time and questioning, and in the end, insistence from his wife, to solve the mystery of his diabetes. One of the consequences of health care reform, and its incumbent electronic medical records, is that doctors will be spending more time documenting information mandated by the federal government, rather than having the liberty to exercise discretion. So, increasingly, doctors will be pursuing preordained data to input into computers and engaging less with patients. And when we don't have time to properly listen to our patients tell their stories, we lose our most important means of making the right diagnosis.

An oft-referenced medical aphorism states that, "it's more valuable to know the patient who has the illness rather than the illness the patient has." My job would be joyless and my diagnostic skills substantially handicapped, without the opportunity to understand my patients intimately. It may sound touching and anachronistic, but the medical literature is replete with studies which show that the history alone will render an accurate diagnosis roughly 90 percent of the time.

William Osler, one of the founding members of Johns Hopkins Hospital, said that "medicine is a science of uncertainty and an art of probability." Physicians typically make decisions based on likelihoods and not certitude. In order to improve the veracity of our conclusions, we modify our plans as more information is known. This is essentially a Bayesian statistical application, where the probability of an outcome is updated as more data becomes available. Thomas Bayes lived in the first half of the 18th century, yet his theorem is a powerful tool broadly utilized in contemporary medicine to help us understand, for example, the value of screening tests. For my purposes as a family doc, as I gather more diagnostic clues, my confidence increases that I'll find, if you will, the smoking hot dog.

About 10 years after that first encounter with the "hot dog guy," he came into my clinic for a checkup. I was excited not only to see how he was doing but to also confirm my recollections about his story. I walked into the room and was greeted with open arms.

"Remember, me doc?" he asked with a Johnny Cash smile.

"Of course," I replied.

Dr. Wajeeh Nasser is a family practitioner at Capital City Family Medicine, a former Boise Weekly contributor and "Best Local Doctor" winner in the 2014 Boise Weekly Best of Boise poll.
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