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Book Review: Complications

13 Post author: Annoyance 01 July 2009 06:39PM

Atul Gawande's Complications:  A Surgeon's Notes on an Imperfect Science is a mixed bag for rationalists. Written as a series of essays organized into three sections entitled Fallibility, Mystery, and Uncertainty, the book as a whole is of questionable value, but the sections need to be considered individually for their worth to be accurately recognized.

Fallibility examines a number of issues involving error and how it can be avoided in medicine, including but not limited to:  how computers are better than humans at making diagnoses, the factors that are known to negatively influence human reasoning when applied to diagnosis and treatment, how and why doctors make errors, what happens when doctors "go bad", and ways that the system fails and succeeds at curbing irresponsible physicians.  The section dealing with the field of anesthesiology is especially interesting, as Gawande recounts the changes that made it possible for the death rate due to general anesthesia to be reduced to a twentieth of its previous value midway through this century.

What is distressing is that Mystery and Uncertainty do not represent good examples of the principles that Gawande demonstrates he understands in Fallibility, supporting his assertions with vivid anecdotes instead of reasoning from principles.  One story is especially obnoxious, as Gawande recounts how a "gut feeling" about a case of infection causes him to persuade a patient to undergo an extensive biopsy which reveals she has life-threatening necrotizing fasciitis, caused by the popularly-known "flesh-eating bacteria".  He explicitly acknowledges that he had no logical reason for regarding the case as unusual, that all appearances indicated a routine cellulitis which was approximately three thousand times more likely than necrotizing fasciitis was - and that he had recently taken care of a patient who had died agonizingly from a massive infection of the flesh-eating bacteria.  And yet the story is presented as an example of how to deal with uncertainty.

If a normal infection had been present, the incident would likely not have been recounted and possibly not even remembered with clarity by Gawande.  We don't know - and likely Gawande doesn't know either - whether his hunches are more likely than not to be accurate.  As he discusses himself earlier in the book, such hunches are known to be usually wrong, but they make vivid anecdotes - which renders them potent and dangerous lures for erroneous thinking.

On other problematic topic, he decries the relative rarity of autopsies and notes that they demonstrate that doctors are wrong about the cause of death and diagnosis of roughly one-third of patients who die while in care.  Yet despite also noting that this fraction has not changed since the 1930s, he implies that the reduction is due to the unwillingness of doctors to trouble grieving family members rather than drawing the obvious conclusion that doctors don't utilize or care about autopsy results.

The book is worth reading, both to gain knowledge about the troubling subject of medical error and how it is and isn't reduced, and as an object lesson in how difficult it is for even intelligent and informed people to actually apply principles of proper reasoning.

 

Comments (11)

Comment author: Yvain 02 July 2009 12:00:47PM 3 points [-]

One story is especially obnoxious, as Gawande recounts how a "gut feeling" about a case of infection causes him to persuade a patient to undergo an extensive biopsy which reveals she has life-threatening necrotizing fasciitis, caused by the popularly-known "flesh-eating bacteria". He explicitly acknowledges that he had no logical reason for regarding the case as unusual, that all appearances indicated a routine cellulitis which was approximately three thousand times more likely than necrotizing fasciitis was - and that he had recently taken care of a patient who had died agonizingly from a massive infection of the flesh-eating bacteria. And yet the story is presented as an example of how to deal with uncertainty.

I agree Gawande isn't especially virtuous here; it would be nice if he'd sought statistics on how often his hunches were correct. But don't condemn him too quickly either. There are some theories, even some ones with experimental support, that suggest intuitions are often the sum of reasoning processes that don't reach the conscious level. The case you describe: where everything seems okay but you have a nagging feeling in the back of your head that it isn't - is especially a red flag in that regard. I recommend Jonah Lehrer's How We Decide for more on this.

Comment author: Annoyance 02 July 2009 02:01:02PM 4 points [-]

Yes, but they're also the sum of prejudices, irrational convictions, short-circuited reasoning processes, and other biases.

Gawande discusses the decision to try to remove only the affected tissue rather than go for amputation - a decision which seems to work out. Then he asks how he and the other doctors knew they could spare the leg.

That's a fundamental failure, changing a guess to knowledge in highsight.

Comment author: Emile 02 July 2009 07:45:22AM 1 point [-]

On other problematic topic, he decries the relative rarity of autopsies and notes that they demonstrate that doctors are wrong about the cause of death and diagnosis of roughly one-third of patients who die while in care. Yet despite also noting that this fraction has not changed since the 1930s, he implies that the reduction is due to the unwillingness of doctors to trouble grieving family members rather than drawing the obvious conclusion that doctors don't utilize or care about autopsy results.

Wouldn't the obvious conclusion be that doctors don't want to be sued, so won't go out of their way to prove they were wrong?

Comment author: tut 02 July 2009 11:07:37AM *  2 points [-]

Wouldn't the obvious conclusion be that doctors don't want to be sued, so won't go out of their way to prove they were wrong?

If that is the reason, might we see more autopsies in countries where doctors are at a smaller risk of getting sued for a mistake?

Comment author: MichaelBishop 02 July 2009 11:10:44PM 1 point [-]

Yes, but of course many other things differ in those countries so it won't be easy to draw a conclusion.

Comment author: Annoyance 02 July 2009 02:02:09PM 1 point [-]

That's certainly an issue, probably a contributing one. But the statistics strongly suggest that autopsy results aren't used to reduce error, as doctors are just as wrong now as they were eighty years ago.

Comment author: Cyan 02 July 2009 04:45:33PM *  1 point [-]

...doctors are just as wrong now as they were eighty years ago

... in cases where the patient dies. (The cited statistic does not refer to the overall error rate.)

Comment author: Annoyance 07 July 2009 06:03:33PM 1 point [-]

Yes. But that isn't the point. It holds across all deaths, not those necessarily caused by the error.

Comment author: cousin_it 02 July 2009 09:08:33AM 1 point [-]

Annoyance's obvious conclusion includes your obvious conclusion as a special case.

Comment author: JGWeissman 01 July 2009 07:53:30PM 1 point [-]

What is distressing is that Mystery and Uncertainty do not represent good examples of the principles that Gawande demonstrates he understands in the first section, supporting his assertions with vivid anecdotes instead of reasoning from principles.

On my first reading, I interpreted "supporting his assertions with vivid anecdotes instead of reasoning from principles" as applying to the first section you were comparing the others to. After reading the full context, it seems you meant it to apply to the sections Mystery and Uncertainty, which makes more sense.

Suggested rewrite:

Unfortunately, in Mystery and Uncertainty, Gawande supports his assertions with vivid anecdotes, unlike the first section in which he used reasoning from principles.

Also, did Gawande back up his reasoning from principles with scientifically gathered data? This would make the point more powerful.

Comment author: Annoyance 02 July 2009 02:02:48PM *  0 points [-]

In the first section, yes. In the later sections, no.

Preferring minimal changes, I've altered the sentence you had a problem with - but not in the way you suggested. Your way is fine, too. I just like mine better.