Automatic for the people

In Complications, Dr. Atul Gawande visits the Shouldice Hospital in Toronto. They do hernia repairs there. In fact, that's pretty much all they do. Inguinal hernias all day, every day. Shouldice may mark the start of a new trend, the proliferation of health care "focused factories."

Not surprisingly, the Shouldice surgeons are the best in the world at hernia repairs. They have far fewer complications, and their hernia repairs are less likely to need revision ten or fifteen years down the road. What's more, they are faster than general surgeons. They can see more patients. And, not insignificantly to me, their 'surgeons' require a lot less training -- in some cases just a year, as opposed to five years of residency for an American general surgeon.

Doesn't the lack of variety get boring? Apparently, the doctors there take pleasure in the pursuit of perfection. And general surgeons here will tell you every operation gets to be routine after a while.

In fact, Gawande links the Shouldice operation with other 'routine' stuff requiring lots of training -- reading EKG's, diagnosing appendicitis, and the like. I used to think that giving someone lots of time to get the job done would help reduce errors and improve results. That's not true. Dr. Lucien Leape notes that "a defining trait of experts is that they move more and more problem-solving into an automatic mode."

This, I think, is why residency is so grueling. The goal is not just exposure to a wide variety of problems, but to force automatic decision-making. It's surprising to me, but as Gawande says, "Novel situations ... require conscious thought and 'workaround solutions' which are slow to develop, more difficult to execute, and more prone to error."

I think a lot of people go into medicine because they enjoy tackling interesting problems. And yet, the goal of medical training is to make these encounters routine and uninteresting.

I keep coming back to the airline industry, which I suspect is in agreement with Dr. Gawande. No one wants pilots who pause to enjoy the unique challenge of a foggy night landing. In research, it's not easy to get grants without using familiar techniques to tackle predictable, solvable questions. And in medicine, I guess, patients don't want their doctors to say "This is really interesting!"