Author: Mao Frances
Date: October 2007
I stood under the operating lights, holding a retractor and sweating into my mask and scrubs. The orthopedic surgeon sat on a stool next to me, busily cutting and trimming tissue within the incision on the patient's left knee. "Now there is another ligament we have to find.sometimes it's not so easy to locate under the fat.ah, here it is!" He gestured for me to take a look, and I bent over to examine the cut. Under a mat of bloody, spongy tissue, there it was: a whitish thread-like muscle, barely visible amongst the musculature and gore. The surgeon, who was also the head of the orthopedic surgery department, cut the ligament without hesitation. How was the surgeon so sure that the ligament he cut was the correct one? Aside from the surgeon's vast training and experience gained over many years, there is an inevitable point in medicine where knowledge overlaps with the uncertain. Despite this, doctors are forced to deal with uncertainty in a way that is unique to the medical profession.
Uncertainty in Science versus Medicine
As undergraduates working in research, we deal with uncertainty on a daily basis. Inherent variation always exists in our reagents, cells, and model organisms. Yet despite our best efforts to control this in our experiments, they do not always behave exactly as we expect. More often than not, procedures fail without any clear indication of what precisely went wrong. But what can we do? There is often no choice but to start again tomorrow, with no permanent cost to us other than the disapproving glare of our supervisor.
Many students who do research as undergraduates are also aspiring doctors. However, the uncertainty in science differs radically from dealing with uncertainty in medicine. While not ideal, a failed experiment is not the end of the world. Additionally, not only is it acceptable to carry out experiments based on incomplete information, it is practically expected. In radical contrast, a death of a patient resulting from a failed treatment is unacceptable. Doctors are also forced to make decisions based on incomplete information, but they bear the additional burden of being able to form a correct diagnosis, as well as a safe and effective treatment.
A Higher Sense of Intuition
Medicine is expected to be perfect. Yet, humans are inherently prone to error. How can this be reconciled to produce top-notch health care? This central question is mulled at length in Complications: A Surgeon's Notes on an Imperfect Science, a collection of short stories written by Atul Gawande, an acclaimed writer and endocrine surgeon. Through his experiences as a resident at Brigham and Women's Hospital in Boston, Gawande portrays medicine as much more of an uncertain endeavor that most physicians would like to admit. Some examples are as simple as untreatable cases with unexplainable causes: the chronic, unrelenting blush; the extreme nausea that persisted right up until the end of a normal pregnancy. Other examples are more serious, including one case where Gawande's sheer intuition saved a patient's life. The patient, a young woman in her twenties, presented with a seemingly benign skin infection called cellulitis on her left leg. After examining her, Gawande did not think that the initial diagnosis was incorrect, but could not rid his mind of another, nagging possibility: that this was potentially a case of necrotizing fasciitis, or flesh-eating bacteria. Infection by this extremely rare strain of bacteria is usually fatal without swift and drastic intervention. Although Gawande felt that this hunch may have been influenced by his recent involvement in a similar case, he could not exclude this diagnosis without performing a skin biopsy. Sure enough, after the biopsy revealed a positive result and the patient's leg was opened, the muscle and soft tissue of her left leg had already been rendered gray and dead by the bacteria. Surgeons, including Gawande, faced no other choice except for complete surgical removal of 75% of the tissue in her leg. Fortunately, the woman was able to recover almost fully from her ordeal, after long months of physical therapy.
Undoubtedly, lucky choices (such as the decision to biopsy the patient's leg) are equally balanced by unfortunate ones, and Gawande balances such success stories with anecdotes describing when doctors make mistakes. In an interview with the Lancet, Gawande is refreshingly pragmatic when describing the writing process: "On the one hand, I've tried to be very forthright about how it is that things work and about what is good about medicine and what is bad about it. But at the same time I've tried to convey some of the sense of how incredibly difficult it is as a profession, that this is the most ambitious endeavor mankind has ever attempted,to take the entire range of human misery and illness and provide for every single person on an individualized basis the best possible care. It's striking that we can succeed at all, especially given how hard it is."
Growing Insight into Uncertainty
This new awareness of modern medicine, with all of its weaknesses and strengths, becomes important in regards to the issue of health care reform in America. With books such as "Complications" and "How Doctor's Think" (by Jerome Groopman, M.D.) that are written for mainstream audiences, the public will only grow increasingly aware that medicine is not a cookbook science. Effective medicine, like effective experimentation, is based on previous successes, but is truly achieved only when an individualized regimen is developed for the specific situation. However, uncertainty is still very much a factor in both science and medicine, and it is especially important in medicine because it is a doctor's burden to minimize its effects to provide the best care.
"Complications," by Atul Gawande. Picadour: 2002.
Lunch with the Lancet: Atul Gawande. The Lancet: Vol 361, January 11, 2003. Accessed at: http://image.thelancet.com/extras/02bkr111web.pdf
- Written by Frances Mao
Reviewed by Nira Datta
Published by Pooja Ghatalia.