Wednesday, December 12, 2007

The Black Swan gets a CT scan!


The Black Swan by Dr. Nassim Taleb is an excellent book for many reasons, and I highly recommend it to all (it was the #1 highest selling non-fiction book on Amazon for all of 2007; click here for Amazon). Since this book is so outstanding, I will not reveal its abundant fruits and will instead link Taleb's work to my earlier posts on decision making in medicine. 

Overall, Taleb's central thesis challenges readers to reconsider how they juggle the paradox of searching versus acting. The story of the discovery of black swans (click here to read about this story!) serves as a reminder of the epistemic problem of induction: one single observation can turn beliefs, dogmas, and alleged certainties completely upside down. 

Bridging similarities between Taleb's insights in The Black Swan and Groopman's message in How Doctor's Think is easy. As a physician, Dr. Jerome Groopman embraces the problem of induction and hedges against it with his mantra, "What else could it be?" This mantra helps him keep his mind open to new information, flashes of insight, and shifts in perspective; he has no problem changing course with a patient in light of new observations. Confronting reality, Groopman knows that a single observation can dramatically shift how he diagnoses, treats, and interacts with a patient. Consequently, he studies physician cognition, practices self-awareness, and analyzes his decision-making processes to improve his ability to recognize and act upon these critical observations. 

At its core, Groopman's analysis of how to better juggle searching and acting in medicine leads him to consider and try to figure out why we think the way we think. Throughout The Black Swan, Taleb follows a similar course as his interdisciplinary inquiry leads him to try to understand why we are the way we are. Answering these "why" questions is not easy, but I find that these pursuits improve my grasp of the humble limits of being human and of practical ways to search and act effectively in our complex world. 

For example, upon reading a recent New England Journal of Medicine article that examined physicians' overuses of diagnostic tests like CT scans (significant since CT scans expose patients to radiation that can cause cancer), I tried to imagine tricks of the trade that would assist physicians' efforts to order tests more efficiently and effectively. Resolving this problem is tricky. Algorithms, decision trees, and protocols based on clinical research provide some mechanistic (black and white) approaches to ordering tests more efficiently - only when needed based on clinical findings. But I wondered: What other trade tricks do physicians employ in gray cases when numbers and facts do not agree with nice, neat, human-derived templates? What about preventive screenings that may help physicians prevent diseases in patients and thus avert many more diagnostic tests later down the road? How do physicians decide, on a case-by-case basis, whether preventive screenings are appropriate? Clearly, I do not pretend to know the answers to these questions, but I ask these questions because I know that doctors have developed concrete, tangible ways to approach this problem of searching - "Is this test necessary?" - and acting - "Yes, I will order the test."

Finally, if you are still unsure about reading The Black Swan, I encourage you to give Taleb's book a CT scan - I am pretty sure that it will not give you cancer!

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