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Observational Detectives—A Commentary by Ian Ayres ’86

The following commentary was published on New York Times.com on August 19, 2009.

Observational Detectives
By Ian Ayres ’86

Lisa Sanders, the diagnosis columnist for New York Times Magazine (and, I should disclose, my close friend), has just published a truly interesting book, Every Patient Tells A Story, on how good doctors go about making difficult diagnoses.

I personally benefited from Lisa’s own diagnostic prowess just last week, when I mentioned to her my wild nightmares at the height of my battle with swine flu (which I wrote about here). I also told her that I awoke the next morning with a terrible sprain in my hip. I felt as if I’d been through a Jacobean “struggle with God”. I figured I must have been flailing around during my dream and pulled a muscle.

Lisa’s responded, “I bet you were taking Tamiflu.” While I had diagnosed the flu as the cause of my bad dreams and by extension my sore hip, Lisa figured that Tamiflu might have been a contributing cause. She’d heard that some patients had reported very vivid dreams while on Tamiflu. Maybe both my nightmares and flailing had occurred during a Tamaflu-induced delirium. She told me that real dreams occur during REM sleep when your muscles are basically immobilized — so it is unlikely that I would have been physically flailing around and stressing my hip while I was in deep sleep.

Before reading Lisa’s book, I thought that the process of diagnosis was much more a kind of formulaic pattern recognition: if you can remember that Lemierre’s disease normally presents with pain and swelling on one side of the neck, then you are going to want to include Lemierre’s in your differential for any patient with this kind of pain. In Super Crunchers, I conjectured that predictive analytics was going to invade physicians’ autonomy in the front-end job of making diagnoses — much as number crunching has already done in the back-end job of choosing the best treatment. But Every Patient Tells a Story convinces me that I missed the important and non-formulaic role that good physicians will continue to play in acquiring and analyzing the raw information needed before any formulaic algorithms can be applied:

Medicine — to the extent that it can be called a science — is a sensual science, one in which we collect data about a patient through touch and the other senses according to a systemic method in order to make a diagnosis.

Lisa shows how touch, sight, hearing, smell, and even taste are critical tools for diagnosis:

We are trained from a very early age to avert our eyes from abnormalities. Children are fascinated by people whose appearance differs from what they’ve come to expect. And we teach them to ignore that interest. My daughter Tarpley once asked a cashier if she was a man or a woman. My husband flushed with shame for the discomfort it cause the homely, hirsute woman. … Afterward he explained to our daughter just how much that kind of comment must have hurt the woman. She doesn’t ask those kinds of questions anymore. She’s learned not to stare.

Medical school forces you to undo that training. You mustn’t avert your eyes from abnormality. You need to seek it out. You need to figure it out. And it doesn’t just turn off when you leave your office. I frequently (quietly I hope) point out to my husband pathology that I see on the street — the rolling gait of a man with an above-the-knee prosthesis; the strange gray-tone tan of a man with iron overload syndrome … the schizophrenic woman’s restless lips and mouth, a long-term side effect of many antipsychotics.

I recently had a chance to hear Lisa give a fancy lecture to Yale’s Sherlock Holmes Society. To a packed lecture hall, she argued that TV was experiencing a resurgence in what she called “observational detectives.” Shows like Lie to Me, Monk, and especially House featured sleuths who, like Sherlock Holmes, relied primarily on their powers of observation.

Lisa knows of what she speaks when she comes to Gregory House, the brilliant but emotionally dysfunctional diagnostic detective, because she’s been a consultant on the show and her New York Times column was one of the inspirations for creating a show centered on trying to figure out what was causing a patient’s illness. I’m a big fan of the show, so Lisa blew my mind when she pointed out how directly the House character was based on Sherlock Holmes: both have names that sound like a domicile (Holmes/House); both are addicted to narcotics (cocaine/Vicodin) and both are sufficiently dyspeptic that they have only one friend (Watson/Wilson). In the opening episode of the show, House encounters a man whose skin is orange and in truly Holmsian fashion not only deduces the illness but predicts that the man’s wife is having an affair (because otherwise she would have noticed his new skin tone).

In the lecture, Lisa wondered why observational detectives were coming back into vogue now. I think Jerry Seinfeld might be part of the answer. After all, it was Seinfeld (following in the footsteps of George Carlin and others) who made observational comedy so dominant. Seinfeld is the guy who spotlights the quirky things that the rest of us miss.

Indeed, in a world with so much observational detecting and observational comedy, it maybe shouldn’t come as a surprise that we are also seeing an uptick in “observational economics.” In many ways, Lisa’s fascination with abnormal medical conditions reminds me of Steve Levitt’s freakish economics. They are both observational detectives ferreting out the hidden side of everyday life.