Complications

Harvard trained surgeon Atul Gawande explores the power and limits of modern medicine in “Complications: A Surgeon's Notes on an Imperfect Science.” On the forty-second page he writes (emphasis added):

results in medical treatment, many doctors are not fully convinced. And they have been particularly reluctant to apply the same insight to the area of medical diagnosis. Most physicians believe that diagnosis can't be reduced to a set of generalizations—to a "cookbook," as some say. Instead, they argue, it must take account of the idiosyncrasies of individual patients.

This only stands to reason, doesn't it? When I am the surgical consultant in the emergency department, I'm often asked to assess whether a patient with abdominal pain has appendicitis. I listen closely to his story and consider a multitude of cators: how his abdomen feels to me, the pain's quality and location, his temperature, his appetite, the laboratory results. But I don't plug it all into a formula and calculate the result. I use my clinical judgment—my intuition—to decide whether he should undergo surgery, be kept in the hospital for observation, or be sent home. We've all heard about individuals who defy the statistics—the hardened criminal who goes straight, the terminal cancer patient who miraculously recovers. In psychology, there's something called the broken-leg problem. A statistical formula may be highly successful in predicting whether or not a person will go to a movie in the next week. But someone who knows that this person is laid up with a broken leg will beat the formula. No formula can take into account the infinite range of such exceptional events. That's why doctors are convinced that they'd better stick with their well-honed instincts when they're making a diagnosis.

One weekend on duty, I saw a thirty-nine-year-old woman with pain in the right-lower abdomen who did not fit the pattern for appendicitis. She said that she was fairly comfortable and she had no fever or nausea. Indeed, she was hungry, and she did not jump when I pressed on her abdomen. Her test results were largely equivocal. But I still recommended appendectomy to the attending surgeon. Her white blood cell count was high, suggesting infection, and, moreover, she just looked sick to me. Sick patients can have a cer[tain]

(But see page 43: "...The radical implication of the Swedish study is that the individualized, intuitive approach that lies at the center of modern medicine is flawed—it causes more mistakes than it prevents...." Very interesting reading.)

More information about “Complications: A Surgeon's Notes on an Imperfect Science” (and the book itself) is available from:

• Powell's Books
• Amazon.com
• Barnes & Noble

(Picador, April 2003. Paperback, 288 pages. ISBN: 0312421702; EAN: 9780312421700.)

Comments

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