Anesthesiology, Synergy, and Black Swans

The following is adapted from Vigilance by Nabil Othman.

During my third year of medical school, I decided to become an anesthesiologist. Anesthesiologists and intensivists have more than a few things in common: both manage vital functions when patients cannot do so themselves, both interpret complex physiologic changes in real time, and both prevent catastrophic events in uncertain situations. In fact, the ICU was invented by an anesthesiologist in 1952 when Danish anesthesiologist Dr. Bjørn Ibsen applied operating room ventilation strategies to a ward of paralyzed polio patients in Copenhagen, Denmark.

Several features make anesthesiology unique from other medical specialties. Our patient is always minutes away from death, and we must tolerate long periods of uncertainty interrupted by short bursts of unexpected intensity. We don’t have time to consult anyone when complications occur. Working at a high speed with limited information, anesthesiologists learned how to think statistically about life-threatening conditions, such as bradycardia (low heart rate), hypoxia (not enough oxygen in the blood), and hypotension (low blood pressure). Over the years, we’ve become experts in the recognition, management, and prevention of emergencies occurring in high-uncertainty situations.

To save the lives of our patients, we’ve traded a simple cause-and-effect view of reality for a systems-based approach. Because we manage every organ system in the body — in real time, as they adapt to their internal changes and the changing surgical environment — we view the operating room in terms of synergy.

Synergy is the random, unintentional, and oftentimes invisible interactions between components of a system. As the number of components increases, synergistic interactions also increase. If the number of random interactions is high enough, they organize into events. A few events will cause desirable changes, most will cause no changes, and some will cause undesirable changes. Eventually, if enough synergy is present, a catastrophic event will destroy the system. In anesthesiology, the system is our patient, and the events are hypoxia, hypotension, and bradycardia. Outside of the operating room, these events are called Black Swans.

Black Swans are unpredictable, cataclysmic events retrospectively “obvious” due to psychological biases. They are named after the ancient metaphor rara avis, which means “rare bird” in Latin. The metaphor was originally used as a compliment, meaning “one of a kind.” In Ancient Greece, the expression evolved into Black Swan because, at that time, all known swans were white. Black Swan meant “someone so exceptional they have never been seen before.”

The modern expression — popularized by Nassim Taleb in 2007 — means “a cataclysmic, unexpected, unpredictable event beyond the scope of human knowledge when it occurred.” Black Swans are unexpected and unpredictable because they form from a random combination of synergistic interactions. Historical examples include the US stock market crash of 1929, World War II, and the sinking of the Titanic. Modern examples include the 9/11 New York City terrorist attack, the Sandy Hook Elementary School shooting, and COVID-19.

Over the last 70 years, the world’s political and economic systems have become increasingly synergistic. In their complexity, these systems generate unprecedented wealth and innovation. However, that same complexity also makes them vulnerable to Black Swans. As we move forward, Black Swans will become more intense and occur more often because complexity and connectivity create more synergy, and more synergy creates Black Swans. Our world is a car accelerating toward the edge of a cliff.

So what does all this talk about synergy and Black Swans have to do with anesthesiology? Well, anesthesiologists already have a solution.

To learn about the solution, Vigilance can be found on Amazon.

Nabil Othman, MD, is an anesthesiology resident physician at Cedars Sinai Hospital in Los Angeles. A serial innovator, Dr. Othman helped design an electronic medical record system for a primary care clinic in rural Haiti and studied a novel clotting assay to protect infants after congenital heart surgery.

In his free time, Dr. Othman enjoys exploring nature on far-flung trekking adventures. He has hiked the Annapurna Circuit in Nepal, Mount Whitney in California, and, most recently, the Kalalau Trail in Hawaii. He blogs at airwaybagelcoffee.com.