Summary Of Mystery, Uncertainty By Atul Gawande

Gawande (2002) writes: “As pervasive as medicine has become in modern life, it remains mostly hidden and often misunderstood. We have taken it to be both more perfect than it is and less extraordinary than it can be.” (p. 8) His book explains this idea, that medicine is both over and under-estimated, in three parts: “Fallibility,” “Mystery,” and “Uncertainty.” In each he gives personal stories, exhibiting medicine as an imperfect science.

Gawande’s writing shows that doctors are people, prone to mistakes just like everyone else. He writes that on occasion, doctors do not know what to do. They are faced with a case where the patient shows no troubling symptoms, yet they are unable to shake the feeling that something is seriously wrong. On these

occasions, doctors have to listen to their gut instinct. Gawande says: “In the absence of algorithms and evidence about what to do, you learn in medicine to make decisions by feel. You count on experience and judgement. And it is hard not to be troubled by this.” (p. 237) Intuition is a hard thing to trust, because the results are uncertain. At times a risk might be taken that yields a positive outcome; but others, a grave one. While the results of following your gut are unpredictable, it cannot be disregarded; because what if it is right? Intuition should not be relied on, but it cannot be ignored.
It is impossible for a doctor to make a decision without uncertainty. Even with today’s advances in medicine, there is rarely a diagnoses that comes with complete confidence. It is in these cases where a doctor must use follow their intuition. Gawande writes: “For however many times our judgement may fail us, we each have our improbable save.” (p. 250) In this quote, he is referring to a doctor’s intuition, the ability to consider something to be plausible based on instincts rather than reasoning. Gawande describes an instance like this: recapping a case of his where all the signs pointed to a basic cellulitis (skin infection). However, he could not dismiss the feeling that his patient had a more severe, life threatening skin disease: necrotizing fasciitis. He was right. Because of Gawande’s gut feeling, he was able to convince the woman to have a biopsy that confirmed his suspicion, and was ultimately able to save his patient’s life. Doctors find this troubling, because, in a majority of cases, their hunches do not yield such a favorable outcome. Really, when it comes to following basic intuition, results tend to be erroneous; owing to the fact that doctors make mistakes. On this, Gawande says: “ It is because intuition sometimes succeeds that we do not know what to do with it. Such successes are not quite the result of logical thinking. But they are not the result from mere luck, either.” (p. 247) Had he not followed his feeling, his patient would have died. But on the other hand, had he required the biopsy but found it negative for necrotizing fasciitis, there would have been consequences (for lack of evidence pre-biopsy). There is a lot of guesswork in medicine, which both doctors and patients find scary. Physicians spend eight plus years of their lives studying healthcare, only to be faced with a situation where their brain, their idea is not flawless. “We look for medicine to be an orderly field of knowledge and procedure. But it is not. It is an imperfect science, an enterprise of constantly changing knowledge, uncertain information, fallible individuals, and at the same time lives on the line.” (p .7)
A large part of the hesitation towards following intuition is based on the idea of uncertainty. Doctors yearn to know the exact outcome of each situation, but that can never be promised. They rely on algorithms and evidence to make important decisions, which makes it easier to see a concrete solution. On the other hand, intuition depends heavily on previous experience and judgement to make a resolution. In cases like this, knowledge does not always inform decisions. This can be very controversial. In the medical field -especially when dealing with patients- not having a clear answer is unacceptable. How often does a situation arise when a doctor is able to say “I really just do not know what to do,” without evoking an uneasy feeling in the patient? While some do appreciate the honesty, they still find themselves unsure if they went to the right doctor. “Amy Fitzpatrick said that the doctors she liked best were the few who admitted they didn’t know how to explain her nausea or what to do about it… She did acknowledge having some contradictory feelings about such admissions. At times, they made her wonder if she had the right doctors…” (p.144) Patients turn to doctors for a clear answer as to why they are ill. They put their lives in doctors’ hands with complete faith, and just hope that they know what they’re doing. But as it turns out, every few cases, doctors fly by the seat of their pants; and occasionally harm the patient. According to Gawande: “In recent years, we in medicine have discovered how discouragingly often we turn out to do wrong by patients. For one thing, where the knowledge of what the right thing to do exists, we still too frequently fail to do it. (p. 236) Too often the results of intuition are too unpredictable for it to be used, convincingly, in the medical field. Yet, it manages to save lives, so it cannot be ignored. What is the happy-medium? Do doctors ignore intuition all together, or try to figure out a way to know when it is right or wrong?
The decisions that doctors make are, quite literally, life and death.

The choice to treat appendicitis with antibiotics instead of removing the organ all together could very easily result in a patient’s passing. This idea alone is what troubles people when doctors work off of a hunch. Without concrete facts to back up their ideas, what would happen if they were wrong? Physicians are given access to some of the most modern technology in the world, so mistakes are not taken lightly; nonetheless, they still happen. Yet there are cases where a doctor’s intuition is wrong, but their plan works. Gawande speaks of a patient, Lee Tran, who had a tumor obstructing his airways and needed immediate aid. His team of doctors had only one idea: put in a catheter to drain the fluid from the tumor, in the hopes it would shift and open the airway to Tran’s left lung: a high-risk procedure. “It was little more than a guess about what to do - a stab in the dark, almost literally. We had no backup plan should disaster have occurred.” (p.7) The doctors were fortunate that day, and not only was the path to the left lung completely opened, so was the right’s. Lee survived. However, what would have happened had the outcome not been so favored? Gawande wrote that after he did research on similar cases, he found there was another option; a safer option. For the most part Gawande’s oversight is forgivable. Doctors are allowed to make mistakes; after all, humans are prone to error. But at what point does it turn from “following your gut” to actual negligence? There is a grey area between the two, and more often than not, a doctor’s unconscious choices are more at fault than their conscious ones. On this Gawande remarks: “In most cases it wasn’t technology that failed. Rather, the physicians did not consider the correct diagnosis in the first place. The perfect test or scan may have been available, but the physician never ordered it.” (p. 198) Humans are fallible, but in the healthcare

industry mistakes matter. Even the smallest oversight can cost someone their life: a technological malfunction, doctor’s mistake, or an incorrect gut feeling. On the other hand, Doctors do incredible things and save countless lives everyday; but errors are still probable.
In conclusion, intuition is not something to take for granted. Humans have been given an almost supernatural ability to know when something is wrong. Nevertheless, intuition may still lead us astray. Conversely, because it is sometimes accurate, we do not know what to do with it. Our instincts have the capability to save lives, but also to take them away. Because of this, intuition should not be relied on, but it cannot be ignored.