A Simple Question and The Hydra of Diagnosis
OR: Language, Complexity, Canaries, and the Cartography of Care
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By David E McCarty MD FAASM (but you can call me Dave)
1 June 2025
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“The limits of my language mean the limits of my world.”
— Ludwig Wittgenstein, Tractatus Logico-Philosophicus, 1922
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As a recovering English Major with no real plan for rehabilitation, I’m not afraid to tell you that I love language and I love words.
So, I like to get them right when I can.
There’s been one word that’s been fluttering around my intellectual crawlspace over the past few weeks saying “LOOK AT ME! LOOK AT ME!”, a canary in my subconscious coalmine that escaped its cage to flap and peck and scratch at me, until I realized a gas leak was present, which, unredressed, could blow the whole house to smithereens.
One word, with that much power?
Yes, Life-Fans!
And what might this powerful, beautiful, dangerous, flapping uncaged word be, that has been tormenting my peace and disturbing my slumber, you may ask?
In medicine, it’s perhaps the most basic word of all. The word is diagnosis.
There’s a lot packed into that word. First off, it’s a MEDICAL word…a word that people with white coats use, which means that it has some mystique and meaning swirled in. It’s a word implying that someone with heaps of specialized training put some thought into whatever finishes this sentence: “Your diagnosis is ______”. In a courtroom, the trained physician’s diagnosis is admitted as rock-solid fact. It’s the final stop in a patient’s intellectual journey when seeking answers to the question “What’s wrong with me?”
The canary in my coal-mind urged me to explore what happens when this magical word—diagnosis--gets filtered through the cracked lens of FRAGMENTED HEALTHCARE DELIVERY SYNDROME (FHDS), and to do it, I asked our favorite everyman, Claudio Mahoney, ambassador for the patient experience to the ISLE OF SLEEP APNEA, to allow us to ride along with him during his brush with FHDS…
…with Theremin sound effects and blurring of the visuals, the scene transitions to a youngish-old man—our Claudio—sitting with his elbows on his kitchen table, fingers raked through his blonde cowlicks, with a confused expression on his face. A piece of paper stares at him blankly. We can see that it’s labelled “Sleep Study Results.”
The camera zooms in on the summary metrics, and for a moment, they shimmer, as if refracting the whole spectrum of light, before settling into standard text:
CMS (4%) AHI: 4/hr
AASM (3%/arousal) AHI: 6/hr
RDI (Apneas, 3%Hypopneas, RERAs): 16/hr
As Claudio’s head descends to the table, his eyes drop. He is muttering something softly…softly…as he drifts off to sleep…
“It was…a simple…question…”
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Scene 1: A Simple Question
In the dream, Claudio is in a small room. He is not alone. He holds his Sleep Study results up to a backlit figure in a white coat, the paper fluttering in a breeze that should not be here, not this far into the building, not in this room with no windows and no doors. This scenario, though unusual, does not trouble Claudio.
“Hello,” Claudio says with a smile, “I want to know if I have a problem called ‘Sleep Apnea’—you see, I’ve been having the following issues—"
The figure holds his hand up, dramatically, the way you do when you want someone to just stop talking, like a traffic cop stopping a bus. Claudio stops talking.
The figure seems to smile—Claudio could see the wrinkles next to the eyes that were all but concealed by his spectacles, and could see that his teeth were exposed.
“My dear sir,” the figure says, “my name is International Classification of Sleep Disorders, 3rd Edition, Text Revision. You can call me ICSD-3-TR, for short, or, if you’re feeling lazy or ill-informed, you can call me by my Daddy’s name, ICSD-3!”
“How do you do?” Claudio answers.
“Very well, thank you,” says ICSD-3. “Do you have any idea who I am?”
“No sir,” Claudio replies, honestly.
“Well,” says ICSD-3,”I’ll have you know that I’m the final academic arbiter—WORLDWIDE YOU SHOULD KNOW, WORLDWIDE--of who DOES and who DOES NOT ‘have’—as you say—the thing that we all call Sleep Apnea!” ICSD-3 looks at his nails and smiles happily, feeling heard.
Claudio brightens at having such a knowledgeable friend. “Well,” he smiles again, “do I have Sleep Apnea or not?”
ICSD-3 smiles confidently. “I didn’t even need to know anything about you!” he blushes (Claudio thinks, though the blue complexion of his skin makes it hard to tell). “You see, according to my new rules, if you have an RDI>15—that’s more than 15 obstructive events per hour of sleep—and that includes apneas, 3%hypopneas, and respiratory effort related arousals (or “RERAs”)—then you ‘HAVE’ the diagnosis of Sleep Apnea—full stop! BOOM!! GEE-FOUR-SEVEN-DOT-THREE-THREE, BABY!! You don’t even need to have any symptoms!!!”
ICSD-3 makes “finger-guns” and grins enthusiastically.
Claudio grins and nods along. He feels like he’s starting to like this guy.
And then: a tearing sound. The figure is changing shape, getting impossibly…wider.
With a burst of confetti, a second head pops from the expanding shoulder-line. The head has a similar blue complexion but sports a black slicked over haircut. Again, the eyes are hidden behind glinting round spectacles.
“NOOOOOPE! No! Nope! Nah! You DON’T have Sleep Apnea! Now, you just go on and move along!”
Claudio does a double take, like a cartoon character. “Whaaaaa?” he intones, his favorite thing to say when he simply has no words. “Why would you say that? Why would he say that?”—turning to ICSD-3 for support but getting none, ICSD-3 shaking his head, mouthing words in cartoonishly exaggerated facial gestures: WE …DON’T… KNOW…EACH…OTHER…
Claudio turns back to his new adversary. “Who are you?” Claudio asks. The head with the slicked black hair sighs impatiently. “I’m the head Doc at CPAP’s ‘R’ US! You have Medicaid, dummy! Your CMS AHI was less than 5, and according to Medicaid, YOU DON’T HAVE SLEEP APNEA! It’d be INSURANCE FRAUD for me to write in your chart that you have something you don’t! So, get your shoes off my carpet and take your business someplace else!”
ICSD-3 leans over to Claudio and shakes his head curtly to negate the “insurance fraud” comment. “It’s not fraud,” he says.
Claudio can’t process this, and instead feels like he’s been slapped. “But I snore! And I sleep poorly! And I have all kinds of difficulty with brain fog during the day! What do I have??”
The black-haired blue head sighs again, like an unhappy air compressor. “I guess since it’s not Sleep Apnea, you must have Upper Airway Resistance Syndrome.”
“Whaaaaa?” Claudio explains to little effect. He’s never heard this term before, so it’s the best he could do. ICSD-3 leans over and whispers in Claudio’s ear in an annoying Shakespearean sotto vocce: “We retired that term with my father’s edition, ICSD-3, back in 2014, because it was SUBSUMED into the diagnosis of obstructive sleep apnea!” At SUBSUMED, it’s worth mentioning that he quits with the sotto voce and begins to bellow with true Shakespearean flair.
“Psst!” a new blue head says, erupting with more confetti and fabric-ripping noises, this one wearing a pink operatory cap. “Psst! Hey, you! They’re all morons, and they don’t even know it! Upper Airway Resistance Syndrome is totally a thing, because breathing through the mouth is bad for you! And HEY! Don’t you know that it’s not really Sleep Disordered Breathing?”
“What the flying fried frijoles are you frittering on about?” Claudio ejects, exasperated.
“I’m an Airway Focused Dentist! I never fritter! LISTEN: What you REALLY ‘have’ should be called ‘BREATHING DISORDERED SLEEP’ because it’s actually the breathing that’s disturbing your sleep by altering your autonomic balance!! Don’t you see? Don’t you see?”
“Well, I don’t know,” Claudio says, trying to be reasonable, but feeling increasingly uncomfortable. “My friend ICSD-3 told me…”
“Who?” interrupts the blue head in the pink cap.
“ICSD—”
“JESUS CHRIST!!” bellows a new blue head—this one with spots—popping up with the alarming sound of ripping polyester and more brightly-colored confetti, right next to the blue head with the pink cap.
“Who’s that?” whispers Claudio to ICSD-3.
“That’s the American Academy of Sleep Medicine,” ICSD-3 replies with reverence. “That’s my boss.”
The blue head with spots appears bewildered, bordering on enraged.
“We did everything all those crybabies at Stanford asked for!!” he bellows. “We changed the definition of hypopnea to incorporate arousals! We changed the criteria for G47.33—what we all call ‘Sleep Apnea’—to allow RERAs alone to cinch the diagnosis!! What more do you all want from us??”
Claudio is motionless.
“Can’t you see how this is making me feel?” the head with spots sputters, shaking disdainfully.
The look on Claudio’s face is trapped in a logjam of non-moving ideas. His bottom lip begins to move, an almost imperceptible quivering, as the question forms:
“Well…what do I have…what do I do?” he intones.
The answer, delivered by all the heads in unison, makes our dear Claudio scream himself awake:
“TALK TO YOUR DOCTOR!!”
AAAAND....SCENE!
(lights fade to black as the PAC-MAN “bew-bew-bew-bew-BOINK” death knell plays….)
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Scene 2: The Babel Effect. Or: When Language Diverges
There is no greater illusion in modern medicine than the belief that we are all speaking the same language.
On the Isle of Sleep Apnea, our hero Claudio walks into a clinic with one body, one set of symptoms, and one earnest question:
“Do I have Sleep Apnea?”
But the body is not treated as one. Nor is the question. Because the language of medicine is not singular—it is siloed, disputed, and often dictated by agenda, reimbursement policy, or subspecialty dogma.
This is not merely a matter of definitional quibbling. It is epistemic fragmentation—a fracturing of how knowledge is created and applied. Claudio’s question is translated differently by each interpreter:
CMS hears: “Do you qualify for reimbursement under our regulatory schema?”
AASM hears: “Does your data acquired in the Sleep Lab meet Accreditation criteria under our latest consensus paper?”
Dentistry hears: “Is there an anatomical explanation for your complaints that reflects our scope and training?”
The ICSD hears: “Does your report meet diagnostic criteria based on published classifications?”
And yet, who speaks for our Claudio? Though it should be the ICSD-3, our CPAP Slinging Provider saw things differently, and we see the downstream consequences, when the language of “diagnosis” …diverges.
We confuse definitions with truth, and thresholds with meaning.
This is the Babel Effect—a quiet epidemic of lexical divergence that makes coherent care impossible. When each discipline has its own dialect and no Rosetta Stone to link them, patients fall through the gaps—they get “left behind.” Or worse, they are told conflicting things by different heads of the same healthcare hydra.
And perhaps most insidiously, the harm is not always felt as harm. It’s felt as confusion, doubt, distrust. A sense that maybe I’m the problem because the experts can’t agree. This is the psychic violence of fractured language:
It makes the patient feel crazy.
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Scene 3: Granularity and the Geometry of Understanding
The tragedy of Claudio’s nightmare isn’t that any of the voices are wrong.
They are all right—at their level of granularity. Each definition of Sleep Apnea. Each threshold. Each diagnostic schema. They all contain a fragment of truth—but no ability to synthesize across scales.
This is the core wound of fragmented healthcare delivery syndrome: not that knowledge is absent, but that knowledge is isolated…zoomed in too close, or hovering too far above. A primary care physician may see hypertension and GERD. A dentist may see a narrow arch. A sleep technologist may see leg movements leading to respiratory oscillation. A psychiatrist may see anxiety and anhedonia.
An efficiency-driven Sleep Medicine practice may see a “normal” CMS AHI.
Each sees something.
No one sees Claudio.
To see Claudio requires a different strategy: a kind of optical humility—zooming out to glimpse the patient in context, while remaining capable of zooming in when it matters. This is where Retired US Army General Stanley McChrystal enters the frame—not as a sleep specialist, but as a cartographer of complexity.
In his bestselling book Team of Teams: New Rules of Engagement for a Complex World, McChrystal learned the hard way that centralized control collapses in the face of distributed complexity. His solution?
Push complexity to the edge.
Let the people on the ground—in his case the field operatives from Delta Force, Navy SEALS, Air Force Special Tactics, and Army Rangers, along with all the drivers, translators, intelligence analysts and PBX operators—hold the complexity, so long as they are armed with shared granularity and shared language. He found that distributing the complexity--de-centralizing it—was the key to overcoming and adapting to an emerging and complex opponent called Al Qaida in Iraq.
Here in peacetime, we have a battle of our own with a complex entity that behaves similarly emergently, an entity we all walk around calling Sleep Apnea. Here, McChyrstal-like, we must empower all members of our Team of Teams with a shared understanding for the complexity of the navigational space. I’m talking a shared language between board-certified Sleep Medicine Physicians, Airway Focused Dentists, field advance practice provider clinicians, back-office administrative staff, front-office phone-jockeys, along with all the other physicians in the patient’s orbit, like primary care, psychiatry, or cardiology.
It's a delusion of ultimate inter-connectedness, and it begins with language.
And that language hinges on one word, flapping like a canary in my coal-mind. The word is DIAGNOSIS.
This is not simplification. It’s sophisticated dissemination.
It’s the difference between saying “Your study is negative for Sleep Apnea” versus saying:
“You have an RDI of 16/hr, mostly driven by RERAs, which meets our current criteria for the diagnosis of Obstructive Sleep Apnea (G47.33). The CMS AHI is 4/hr, which falls short of Medicaid’s coverage criteria for the treatment of Sleep Apnea, so, unfortunately CPAP isn’t covered in this circumstance. But you do have fragmented sleep, and that matters. Here’s one source of what’s driving it.”
This requires a shared understanding of thresholds, definitions, their origins, and their limits. It requires clinicians to speak across silos…to know that “UARS” was retired by the AASM, and why that label is a nether-region of misunderstanding and confusion…to understand that CMS didn’t invent AHI—they just yoked it to reimbursement. It requires a culture of integration.
In McChrystal’s words:
“It takes a team of teams.” But more than that—it takes a shared map.
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DENOUEMENT: A Compass Made of Language
Claudio never asked for a taxonomy. He asked for help.
But what he received instead was a symposium of siloed tongues, each fluent in their own dialect, yet deaf to the others. It would be funny if it weren’t so familiar—this spectacle of conflicting truths, all orbiting a single suffering human, not able to converge.
It’s important to realize that this clinical failure is no individual’s fault. It is a failure of integration, a symptom of a deeper disease.
Claudio’s suffering happened due to a failure of language.
Fractured Healthcare Delivery Syndrome.
And yet, not all is lost.
Because every map begins in the unknown. Every journey of intellectual discovery begins with a question.
Do I have Sleep Apnea?
What if, instead of debating whose language is correct, we began by asking whose experience is being left out?
What if we trained our young clinicians not only in the definitions of “apnea” and “hypopnea”, but in their genealogies—where those definitions came from, who shaped them, and what the numbers leave behind?
What gets lost in translation?
What if we taught them that precision is not the enemy of compassion—but its most articulate form?
Because when you share granularity—truly share it—you don’t just empower the provider. You empower everyone in the system to see clearly together.
This is what McChrystal discovered. It’s what the Rebis Health project is betting on.
Not simplification. Not hierarchy. But a participatory fluency—a grammar of complexity that can be held at the edge.
Claudio didn’t need all the heads to agree. He just needed them to speak to each other, and he needed a partner who would help him find the best way forward for him, on his terms. A team and an ecosystem that can say: “Yes, these numbers mean different things in different contexts—but let us tell you what we see when we put them together.”
Let us offer you—not a final answer—but a map. And in your hand, a compass made of language.
So, yes, Claudio. You DO have Sleep Apnea!
Let’s spend our mental energy now exploring what can be done about it, and how we can get you closer to Pleasant Dreams Beach!
And maybe, just maybe, this coal-mind canary can help us find our way.
David E McCarty, MD, FAASM
Boulder, Colorado
1 June 2025
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Recommended reading:
McChrystal, Stanley, et al. Team of Teams: New Rules of Engagement for a Complex World. Portfolio/Penguin, 2015