False Negatives

Old school general surgeons will say that if you don't get false negative appendectomies, then you aren't operating enough. That is to say, the diagnosis of appendicitis is not specific enough for any surgeon to be 100% sure for every single patient whether she has appendicitis or not. If every time he operates, he finds an inflamed appendix, then he is missing the diagnosis in some of those cases in which he thinks there is no appendicitis. Only by overoperating - that is, performing an appendectomy but finding a normal appendix - can he be sure that he has actually gotten all the cases of appendicitis.

In the same way, in the ICU, one could say that if you aren't re-intubating patients, then you aren't aggressive enough in extubating them. I believe this; the duration of intubation has a lot of risks, especially ventilator associated pneumonia. But to be aggressive enough in extubation so that everyone gets a chance at being extubated early, some subset of those patients won't fly and will require re-intubation. This is often seen as a failure, but in truth, if we waited for the tail end of that bell curve, everyone else would have the tube longer than necessary.

I kind of like this thought process (though articulating it is tough). I'm not sure whether it's true or not, but as I progress in residency and get a better sense of risks and benefits, I begin to find this sort of justification compelling.