The New York Deli Phenomenon

One of my biggest pet peeves is whenever I order a deli sandwich, the deli guy sometimes forgets one or more of my requested ingredients. For example, if I order a roast beef on a roll with lettuce, tomato, mayo, mustard, onions and sweet peppers, the last few ingredients are typically left out. Usually, it's the ingredients listed at the end, never the first few items. Ever since I noticed this, I watch the sandwich maker like a hawk. I hate it when they have to turn their backs to me to make a sandwich, since I can't see what they're doing. Every time I let my guard down, I always regret it.

You may be asking by now what this has to do with sleep and breathing and medicine in general. Unfortunately, too much.

When it comes to medical diagnoses, many physicians are guilty of the same phenomenon. For example, when I had to learn about obstructive sleep apnea in medical school, I had to memorize a long list of signs and symptoms. Usually, they're listed in order of importance. By the time you get to the 39th or 40th sign and symptom, your brain can't memorize any more. Most multiple test exams in medical school test you on the more common signs or symptoms, and rarely an unusual one. So by default, we tend to memorize the items higher on the list.

But this is where the problem starts. For example, going back to the obstructive sleep apnea example, the most frequent findings that are mentioned in textbooks or in a lecture are: older, obese, snoring, male, and big neck. Since these were the features first described in obstructive sleep apnea, no wonder. But if you read further down the list or look at published studies on this condition, you'll find dozens or even hundreds more common and uncommon features that no one has time to list out when asked about this condition. So lecture after lecture, I've seen the same description about obstructive sleep apnea: typically seen in older, snoring, obese men, and untreated, can lead to diabetes, high blood pressure, heart disease, heart attacks and strokes. It still continues to this day, even with numerous studies showing that obstructive sleep apnea can occur even in young thin women that don't snore. Of course, in a young thin woman complaining about sinus infections or fatigue, sleep-breathing problems are near the bottom of the list.

Despite the facts that doctors know about obstructive sleep apnea in the typical patients, they forget about the second part: the link with heart disease, heart attack and stroke. It's shocking to me how many people I see that have suffered from heart attacks or strokes that are found to have significant obstructive sleep apnea when eventually tested. The same can be said about sinusitis, throat infections, ear infections, etc. Too often, ear pain alone with no obvious infection is treated with antibiotics.

It's obvious that a human being is not a deli sandwich. To label a person with "sinusitis" is like saying, remember to add nasal congestion, yellow pus, fever, facial pain, poor sleep, ear fullness, or post-nasal drip. The problem is that this list gets whittled down to yellow pus and facial pain. Or that obstructive sleep apnea patients snore and are overweight, Yes, the majority of people with these symptoms will have the respective conditions, but you're missing out on many other patients that only have poor sleep or ear fullness for sinusitis and post-nasal drip for obstructive sleep apnea.

So if you have post-nasal drip, and are treated for allergies, no wonder the medication didn't work. Without getting a full and complete medical history and thorough physical exam, it's hard to get a complete picture of what's going on. In this age of managed care and rushed doctor's visits, it's no wonder that we end up treating the symptoms only and almost never the true cause of the illness, leading to missed diagnoses and incorrect treatment regimens.

Unfortunately, the New York Deli phenomenon will continue, with doctors making diagnoses and prescribing treatment based on incomplete pictures. Just as an incomplete sandwich just doesn't taste right, an incomplete history and examination can lead to an unsatisfying outcome.