Complications by Atul Gawande

superspecialization raises the question of whether the best medical care requires fully trained doctors. None of the three surgeons I watched operate at the Shouldice Hospital would even have been in a position to conduct their own procedures in a typical American hospital, for none had completed general surgery training. Sang was a former family physician; Byrnes Shouldice had come straight from medical school; and the surgeon-in-chief was an obstetrician. Yet after apprenticing for a year or so they were the best hernia surgeons in the world. If you’re going to do nothing but fix hernias or perform colonoscopies, do you really need the complete specialists’ training (four years of medical school, five or more years of residency) in order to excel? Depending on the area of specialization, do you—and this is the question posed by the Swedish EKG study—even have to be human?
    Although the medical establishment has begun to recognize that automation like the Shouldice’s may be able to produce betterresults 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 factors: 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 certainunmistakable appearance you come to recognize after a while in residency. You may not know exactly what is going on, but you’re sure it’s something worrisome. The attending physician accepted my diagnosis, operated, and found appendicitis.
    Not long after, I had a sixty-five-year-old patient with almost precisely the same story. The lab findings were the same; I also got an abdominal scan, but it was inconclusive. Here, too, the patient didn’t fit the pattern for appendicitis; here, too, he just looked to me as if he had it. In surgery, however, the appendix turned out to be normal. He had diverticulitis, a colon infection that usually doesn’t require an operation.
    Is the second case more typical than the first? How often does my intuition lead me astray? The radical implication of the Swedish study is that the