“Where were we?” His voice projected over the microphone. A piercing screech followed from the microphone. Lyle tapped it, and the interference receded. He glanced at his notes.
From the audience, a woman shouted, “Saudi Arabia!” The voice rang just at the same moment Emily was saying the same thing—“Saudi Arabia”—from behind the curtain to Lyle’s left.
“Saudi Arabia,” Lyle said. “That’s right. Hickam’s dictum.”
He looked up.
“Hickam’s dictum,” he repeated. “We’ve talked about Occam’s razor.”
Occam’s razor, a key principle in medicine, says that when there are competing theories to explain a medical condition, the doctor should favor the simpler one. Or, as Sir Isaac Newton restated the fourteenth-century logic: “We are to admit no more causes of natural things than such as are both true and sufficient to explain their appearances.”
Lyle glanced at the group. “It can be tempting to look for complex causes and diagnosis. But that often is a form of self-deception, the seeds of imagination, vain hope. Often, things are just as simple as they might appear, much as we are inclined to dupe ourselves.”
Again, he paused, something odd. Where exactly was he going with this?
Dr. Martin, Emily mouthed inaudibly, wishing she could whisper in his ear.
The silent admonition seemed to make its way to him through the ether, or maybe he realized he was getting off track. “As a clinician, it is not necessary to overcomplicate things, Occam’s razor. Much as we’d like to discover something extraordinary, it’s usually, I’m sorry to say, just a head cold.” Some laughter. “Bed rest and fluids will do the trick.
“But then, along came Dr. John Hickam. He gave us permission to get our money’s worth out of medical school.” Lyle explained that Hickam’s principle allows that multiple symptoms often can be explained only by multiple diagnoses—not just a single disease or pathology but, in fact, several. This comes into play, in particular, when you have a patient with a compromised immune system.
Lyle scanned the auditorium. “There’s a great phrase to describe Dr. Hickam’s dictum. It goes like this: the patient may have as many diagnoses as he damn well pleases.” Laughter. “Which brings us to Saudi Arabia.” He told them previously that he’d done some early training in the Epidemiology Outbreak Office for the Centers for Disease Control. After doing a stint like that, the government would occasionally ask Lyle, or others in the program, to visit a place or person in need of a specialized medical consult.
“A guy in the State Department called and asked me if I’d go visit a government minister in Riyadh,” Lyle told the audience. He said the State Department officer told him that the guy had MERS and wasn’t responding to treatment. First class ticket, three-day turnaround, Lyle could stay at a palace.
Lyle seemed not to notice how much he had his audience rapt. He did, though, notice the dean, standing in the aisle near the back, and, more than her, he noticed the man next to her, wearing the too-tight suit. The man stood solidly, not rocking back and forth impatiently like the dean, watching Lyle, studying him.
“I’m sure you’ve read up on MERS,” Lyle addressed the students. “But as a refresher…” He told them about Middle East respiratory syndrome coronavirus. It reared its head in 2012 in Saudi Arabia, thought to originate in camels. Symptoms include severe cough, gastrointestinal issues, kidney failure. It can be fatal. Lyle flew to King Khalid airport in Riyadh, got whisked past to a midlevel palace and an opulent bedroom turned medical suite with a man in his seventies prone in a gold-posted bed under a canopy. The minister.
Next to the bed stood a bodyguard in telltale fatigues, and a nurse with ice for the old man’s lips and, cross-armed, his doctor, looking grave. The doctor gave Lyle an update: a CT scan showed a nodule on the lung, consistent with a MERS diagnosis, diarrhea, mostly consistent with it, and also stiff neck, light sensitivity, bouts of confusion.
“What’s lesson number one?” Lyle asked his audience.
Voices from the audience in dystonic harmony: “Take a history.”
So much of infectious disease diagnosis comes from taking a careful patient history. That was the thing Lyle told this class, and every class, on day one. Get a pet history, food history, sexual history, ancient history, and new history. Frontline doctors, in the emergency room or even at clinic, can see symptoms consistent with a pathology, make a fairly reached conclusion about diagnosis but one that is at odds with history.
“I pulled up a chair next to the minister. People need to feel you are the same level that they are on. Never forget the power of your white coat to unnerve; there’s almost nothing you can do to diminish it. So find the humblest place you can. The less arrogance you communicate, the more likely that most patients will share a real history with you. In the case of the minister, the second that I sat down, he dismissed everyone in the room with a wave of his hand. The bodyguard didn’t move and then the minister swatted him out as well.” Lyle then explained that he had asked the minister basic questions to establish a baseline of communication and gauge cognition. How old was he (seventy-one); where was he born (outside Medina); what was he a minster of (domestic police); did he have a family (yes, wife, two sons, and a daughter); did he have much interaction with animals (no); what was his diet like?
“Are you a doctor?” the minister asked Lyle.
“Yes.”
“Then get on with the doctoring,” the man said. He had a white beard and he had been heavy once. Sleeplessness tore at his eyes and left cracked skin at each corner of his mouth. Fear and inner ugliness trickled out in his voice, the sound of a powerful person unaccustomed to feeling helpless.
“The minister’s comment that I should get on with the doctoring was an important moment,” Lyle explained to the students. “It told me that this might be one of those people who actually preferred me to be in a position of authority, rather than one of mere expertise. I don’t want to make more of bedside style than necessary, but I also want to tell you how essential the role of listening, really listening, is. In this case, he was telling me I didn’t need to be so humble after all.” He paused. “So I could just go ahead and be the arrogant jerk my wife tells me that I am.”
There was a smattering of laughter but not so much. Lyle continued with the story. Next to the minister’s bed, Lyle cleared his throat.
“May I examine you?”
The man struggled to pull himself up on his bed.
“Just turn over,” Lyle told him. “Please, pull off your shirt.”
The minister removed the body-length nightshirt, his back exposed. Lyle ran his hand along wrinkled skin over depleted back muscles. He spent some time moving the skin around on the man’s neck.
“Right-handed, played a sport. You have slightly more developed muscles and scar tissue on the right.”
“Hound hunting.”
“You’ve had some hearing loss.”
“Yes.”
“Did the hunting cause your hearing loss?”
“No. How can you tell about my hearing?”
“Small mark on the skin around your ear. Sometimes, that area can get itchy if the nerves get irritated from a hearing aid. Behaves like dry skin.”
“My hearing loss is a state secret. I have to pretend I’m listening to the king.”
“Of course. Doctor/client privilege. How long have you been married?”
“Sixty-one years.” The minister was starting to relax. That was the goal. Yes, Lyle was looking for any unusual external markings, bites or lesions, signs of infection. Mostly, he was getting the man to relax. This was a veritable backrub.