Circulation 84,122 • Volume 25, No. 2 • Summer 2010   Issue PDF

Technological Intensification Revisited

Rahul Mishra, DO (Resident); John Hall, MD, JD, MBA

To the Editor

We thoroughly enjoyed the article “The Challenges of Technological Intensification.”1 At a time when anesthesia is demonstrably safer than ever it is important to note that complexity in anesthesia is relevant only if four conditions are met:

  1. Complexity, or complex interactions to be true to Perrow, must be unambiguously defined.2 The current definition “if there are many alternative sub-tasks at any point in its completion” appears to be dependent on both the size of the system as well as its lifespan. Since either could be arbitrary the definition reduces to an arbitrary subset of any given universe of interactions. In such a case the definition reduces to a hollow assertion.
  2. Complexity must be unambiguously linked with outcome. This raises the secondary problem of agreeing on a definition of outcome. It is possible that manipulating the definition of outcome drastically changes the incidence of “successful” anesthetics and surgical procedures. We need look only as far as cardiac surgery with its subtle neurologic injury, severe neurologic injury, and death as three recognized outcomes.
  3. Complexity must be controllable. We must be able to reliably control the interactions of a given system. Yet this hinges on being able to reliably define complexity.
  4. Finally, if complexity is controllable then it must be controllable in such a manner as to optimize the affect on definable outcomes.

As new technology becomes available the degree of complexity seems less relevant than demonstrable effects on definable outcomes. In essence complexity as a poorly defined concept makes technological analysis unnecessarily complex while adding little to understanding.

Rahul Mishra, DO (Resident)
John Hall, MD, JD, MBA
Associate Professor
Department of Anesthesia
Texas Tech University Health Sciences Center, School of Medicine
Lubbock, Texas


  1. Webster CS, Stabile M, Merry AF. The challenges of technological intensification. APSF Newsletter 2009; 24(3):33,35,43.
  2. Perrow C. Normal Accidents: Living with High-Risk Technologies. Princeton, NJ: Princeton University Press, 1999.