Atul Gawande and Complexity: the Flaw in his Argument

In a fascinating but commonplace confluence of circumstances, I’ve just started reading Atul Gawande’s The Checklist Manifesto at the same time as Gawande gave the commencement address at Stanford medical school (and Buckeye Surgeon blogged about it). Reading the latter felt like deja vu in places, as Gawande plagiarized himself making his points about complexity; specifically the increasing complexity of medical care in the 21st century:

The truth is that the volume and complexity of the knowledge that we need to master has grown exponentially beyond our capacity as individuals….

Half a century ago, medicine was neither costly nor effective. Since then, however, science has combatted our ignorance. It has enumerated and identified, according to the international disease-classification system, more than 13,600 diagnoses—13,600 different ways our bodies can fail. And for each one we’ve discovered beneficial remedies—remedies that can reduce suffering, extend lives, and sometimes stop a disease altogether. But those remedies now include more than six thousand drugs and four thousand medical and surgical procedures….

It should be no wonder that you have not mastered the understanding of them all. No one ever will. That’s why we as doctors and scientists have become ever more finely specialized. If I can’t handle 13,600 diagnoses, well, maybe there are fifty that I can handle—or just one that I might focus on in my research. The result, however, is that we find ourselves to be specialists, worried almost exclusively about our particular niche, and not the larger question of whether we as a group are making the whole system of care better for people.

Wow! Over 13,000 diagnoses in ICD-9-CM! Actually, while there may be more than 13,000 entries in ICD-9, there are huge swathes of them that aren’t really medical diagnoses at all. I like to say that ICD-9 represents over 13,600 reasons to see a doctor. V70.0, periodic health examination of the well adult (V20.2 for a child), shouldn’t count as one of the “different ways our bodies can fail.” Nor should V76.12 (screening mammogram) or V72.31 (routine gynecological exam).

But I digress. I will grant that scientific advances of the last century have resulted in a much expanded understanding of the function and failings of the human organism, such that its complete knowledge is indeed beyond the mastery of any one individual. And I agree that this fact necessitates specialization — even super-sub-specialization — for mastery of the most arcane sub-specialized details. But Gawande is still wrong.

Here’s why: even though he quotes average numbers of diagnoses per patient (usually double-digits, mainly for hospitalized ones, though he also includes similar numbers for outpatients) that imply every case is mind-numbingly complicated, NOT EVERY PATIENT IS THAT COMPLEX. In point of fact the simple, straightforward medical cases vastly outnumber the ridiculously complicated ones. Offhand, I would say the ratio is at least nine to one, based on the oft-quoted statistic that 10% of the population uses 90% of the medical resources.

Gawande’s figures on outpatients with dozens of diagnoses in their electronic medical records are also misleading. Typically they include every diagnosis the patient ever had. Pink eye three years ago does not materially increase the complexity of dealing with your right lower quadrant abdominal pain now. Even ongoing chronic conditions like hypertension or psoriasis don’t meaningfully impact management of your penile discharge.

It’s easier to lose sight of this fact when you spend most of your time in the hospital. Inpatients are sicker than outpatients. (Where’s Captain Obvious when you need him?) When every patient you see requires ten specialists just to get him through til dawn, the complexity is indeed overwhelming, and it can seem appropriate to generalize one’s observations to the practice of medicine as a whole. But this “denominator effect” leads to the incorrect conclusion that specialization is the only answer.

There are plenty of patients (90-95% of what walks in my door, per AAFP figures) with medical needs that do NOT require Gawande’s or anyone else’s super-dee-duper-sub-specialized skills. There really is such a thing as a simple sore throat, a straightforward case of hypertension, and uncomplicated diabetes. And it really is possible for a single doctor, a well-trained family physician — me! — to manage these patients.

An enormous part of my job is to identify those patients with problems too complex for me to handle, or who require treatment beyond my scope of practice. Even then, my job is to correctly identify which of the myriad of super-sub-specialists is the best choice for a given patient; frequently a very complex decision in and of itself!

So to the two or three graduating Stanford seniors (statistically) going into primary care, don’t worry. Gawande may be a rock star, but his reports of the death of the generalist physician are greatly exaggerated.