Has anybody here had the chance to read Atul Gawande’s latest book, The Checklist Manifesto: How to Get Things Right ?
I am a big fan of Dr. Gawande’s writing — his New Yorker articles always tell me things I didn’t know, and his first two books (Better and Complications) deserve every accolade they’ve collected. But with his new “manifesto”, Gawande seems to be moving beyond medicine in a global society (a wide enough topic on its own) towards a larger framework. Possibly too large. The Malcolm Gladwell review quoted on Amazon certainly reminded me of a lot of the political discussion over the past few weeks, and not just about HCR either:
Gawande begins by making a distinction between errors of ignorance (mistakes we make because we don’t know enough), and errors of ineptitude (mistakes we made because we don’t make proper use of what we know). Failure in the modern world, he writes, is really about the second of these errors, and he walks us through a series of examples from medicine showing how the routine tasks of surgeons have now become so incredibly complicated that mistakes of one kind or another are virtually inevitable: it’s just too easy for an otherwise competent doctor to miss a step, or forget to ask a key question or, in the stress and pressure of the moment, to fail to plan properly for every eventuality. Gawande then visits with pilots and the people who build skyscrapers and comes back with a solution. Experts need checklists–literally–written guides that walk them through the key steps in any complex procedure…
In any case, I’m going to order a copy for myself, but I’m curious to hear your opinions / reviews.
Yutsano
I forget exactly where, either the University of Michigan or the Mayo Clinic, but they implemented a system where every single step in a surgical procedure was followed and checked off from pre-op to recovery. Accidents in surgery dropped like a stone.
MaximusNYC
Yes — there was a fascinating article about this in the New Yorker a few years back (possibly also written by Gawande). The “checklist effect” is stunning: hospitals are often reluctant to implement checklists, but when they do, infections, accidents, and death rates plummet dramatically. Unfortunately, it still hasn’t caught on very widely.
jenniebee
I’m a little terrified that they aren’t all using checklists now. But then I’m She Who Lives By the Backlog (and the Scrum) so they’re more or less a way of life for me. Because apparently software development is less forgiving of errors in process than is surgery. Le sigh.
MaximusNYC
Here’s the article:
Annals of Medicine: The Checklist
by Atul Gawande
December 10, 2007
jenniebee
@MaximusNYC: Comment of the day to whomever finds the first libertardian objection to this piece on the grounds that checklists stifle innovation.
jeffreyw
I had a checklist made to assure quality commenting but I forgot where I left it.
Silver
@jennibee
I’m sure Megan McFucktard will be along shortly…
The Main Gauche of Mild Reason
@jenniebee:
I can’t tell you that, but I can tell you the exact form it will take:
Conservatives/libertarians love to cite TV shows as hypothetical “evidence”. Hence, a comparison will be made to tv’s Gregory House, who is as far as you can get from the checklist manifesto. Even though abnormal treatment cases are extremely rare (the bulk of treatments are banal concerns), they will argue that a checklist would prevent doctors from seeing the 1 in 20,000 time when a cough really is the sign of a rare form of superagressive viral lung cancer spread by the south african nematode. Hence, checklists can never be used, since obviously every doctor is an iconoclastic diagnostic genius who would be stifled by the structure of checklists.
They may additionally suggest that doctors will go Galt in response to checklists.
Notorious P.A.T.
Having not read this book yet, I will say it is probably good.
Batocchio
I heard an NPR story on the checklist for hospitals, and it sounded great. A simple measure with significant results.
jenniebee
The Scientific Method stifles innovation. Because, you know, there’s nothing creative about a method.
jenniebee
Cats stifle innovation by sleeping on its face. No, wait, that’s babies. But probably innovation, too. Moral: adopt dogs.
Linkmeister
Grins. John’s going in for surgery tomorrow and Anne posts a quote like this:
Were you attempting to scare him or reassure him? ;)
Yutsano
@Linkmeister: With any luck he’s already passed out by now. Of course he does have night owl tendencies, I think he would have weighed in by now if he were awake. Possibly with a torrent of curses to make a sailor blush.
Ailuridae
@Yutsano:
Doctors, broadly are a rather proud (in the Biblical sense) group and that is the source of the problem with medical malpractice.
In Better Gawande discusses the amount of infections that are stopped if proper hand-washing protocols are instituted and then is pretty annoyed to find out how resistant hospitals are to use them.
http://www.myshelf.com/haveyouheard/07/washinghands.htm
Crusty Dem
@Yutsano:
Cursing would be appropriate.
I also heard the NPR story and was very intrigued, since I perform surgery for my research. What was most interesting was how odd some of the items on the checklist seemed; “Everyone introduce themselves by name to everyone”, “Talk about what we hope to accomplish during the surgery”, it sounded pretty hippie.. The main point was that surgery today is performed by a team and all too often the dictatorial surgeon creates problems by not communicating with his fellow team members. Hard to argue with the massive reduction in complications (~1/3)…
Yutsano
@Crusty Dem: I have a friend who is currently doing his residency in surgery. I’ll have to ask him if he does the checklists when he assists (he’s not qualified to operate on his own yet) and what he would think of the results.
jenniebee
@Crusty Dem: That’s really interesting, about the discussing the goals of the surgery. It’s an important part of other processes, like software development, because you might be handed a list of requirements, but the requirements aren’t complete without an understanding of the overall goal and priorities. Are you trying to turn this around by a certain date and whatever you can develop fastest is what you’re going to have to go with, or do you have more time? Are you trying to create and establish repeatable processes and a reusable code base? Are you coding for performance? Are you coding for easy maintenance, or are you interested in developing a more complex, more groundbreaking solution?
I have no idea if this applies to surgery, but I know that in my field, the big problems we usually run into come when we aren’t all on the same page about our overall goals and priorities before we start design.
Calming Influence
@jenniebee:
Thanks, I just splurted coffee on my screen. Cats also stifle innovation by insisting on lying on your keyboard while you’re typing. We would be driving flying cars right now if it wasn’t for cats – hey! what the [mmmrrrpphh] cALrMInG INflerUnSE JusT LUrvS CatZ AN sEz u ShUd giV tHem sTuf K?
Crusty Dem
FWIW, here’s a great (and aptly titled) blog with details of running a hospital. It’s written by the CEO of Beth Israel, who is (surprisingly) not an MD and has a very interesting perspective on several issues, particularly his courageous stand following a wrong-side surgery (which usually results in a quiet payoff).
@jenniebee: Exactly, but I think it’s only recently that surgeons have begun to acknowledge that they’re not the only person in the room.
Pseudonym
One of my uncles was a former safety officer for McDonnell Douglas, then Boeing, and is now working on applying the safety expertise learned in the commercial airline industry to other situations such as medical care. I think it’s a little more complicated than just checklists but there are certain elements of the safety culture, of scrupulously cordoning off certain areas of procedures from possible contamination or failure through systematic and mechanistic procedures, that might apply equally as well to medicine as to air travel.
Anne Laurie
@The Main Gauche of Mild Reason:
Admitting this will destroy what little street cred I might have, but the first time I remember hearing about medical checklists was on an episode of ER. During the final season’s bringing-back-all-the-old-stars arc, Former Hot Surgeon of Color (Peter Benton / Eric LaSalle) scrubbed in as a guest on Former Sensitive Young Newbie’s (John Carter / Noah Wiley) kidney replacement. Despite the grouching of the One-Shot-Old-Tyrant kidney-surgeon-in-charge, ‘Peter Benton’ insists on going through the surgical checklist, and then holding up the busybusy operating team until some arcane emergency backup chemical is procured (even though the Tyrant points out that he’s “never” needed to use that arcane backup). So, of course, it turns out to be that one-in-a-thousand operation where the emergency backup actually is necessary, and John Carter’s new kidney (harvested by Former Hot Pediatric Surgeon George Clooney, in a cameo) is SAVED, yay for the medical checklist! (Hey, if people are going to learn their medicine from television dramas, it might as well be useful medicine, right?)
mai naem
There was a Brit ortho surgeon who made any staff who dealt with her patients post op, wear disposable gowns and decreased post-op infections my some ridiculous numbers – over 60 percent or something. I asked two friends of mine who are nurses if they wash their nursing jackets everyday – no they didn’t. It was a definite ewww moment for me.
DonBelacquaDelPurgatorio
Speaking as a former commercial pilot and flight instructor … uh, yeah. Checklists are essential. There is no alternative to them when humans are asked to perform complex tasks.
This from an Amazon review:
To me, the need for checklists is so absolute and so basic, I just can’t understand why anyone would do any complex task without one. I used to tell my flying students a simple rule: Don’t ever let me see you take off without using the checklist. Period.
Now I work in IT. You’d be amazed at the critical complex tasks that IT people try to do without checklists or documentation of what they are doing. Amazed, or shocked, depending.
matt
I’m going with “possibly too large”. A little industrial engineering may be just what the doctor ordered, but just because checklists work for assembly line workers like doctors doesn’t mean it’s something that people who think for a living need.
DonBelacquaDelPurgatorio
@jenniebee:
Dogs stifle innovation by slobbering on it, and humping its leg.
Adopt cats.
Cerberus
Yeah, checklists are crucial and doctors are way overdue to start using them. Maybe this is also why so much blood work is done in medicine today, because that way the checklist work can be punted to some poor bastard in the blood lab.
But yeah, important delicate tasks require a checklist before hand. In the sciences, checklists are primary and no experiment can progress without doing up a checklist of what you are doing so you can figure out where you went wrong. For something like surgery which requires a lot of delicate tasks that are often very similar in form, checklists really should have been mandatory decades ago. Surgery isn’t one of those fields where creativity of process is a good thing. Especially when so many surgeons are dramatically overworked and often exhausted or going into their 24th hour heading into the chamber.
arguingwithsignposts
@The Main Gauche of Mild Reason: It’s not lupus. Props for the House mention.
As we all know from Megan McArglebargle’s lectures, EVERYTHING stifles innovation except sweet cash from big business and the Free Market ™.
superking
Better isn’t that good of a book, imo. He offers a bunch of easy answers to health care problems and his writing is insubstantial.
bob h
I believe it was Gawande who had an interesting article in a recent New Yorker about the parallels between agriculture in America around 1900 and the healthcare complex today. Inefficient, consuming too many of the nation’s resources, a drag on the nation. It was the Federal government stepping in to introduce modern techniques, making agriculture more efficient, and freeing resources that made possible economic growth in other areas.
WereBear
Absolutely there should be checklists. I’m, as always, astonished that something with such proven pluses has to be forced onto so many needed processes.
Well, I guess it doesn’t surprise me any more…
But checklists are vital even if you know something cold; because you can be interrupted. Being interrupted on autopilot means you lose all track of where you were. If you’ve ever arrived at work and wondered if you have underwear on, you’ve experienced how autopilot doesn’t make a stop at short term memory.
And it doesn’t matter how vital that thing is. There was a case of a woman mountain climber, 20 years experience, who was asked a question while she was buckling up her harness. Something wasn’t fastened properly and she plunged 10 stories, landed in a tree, and lived.
So, yeah.
ericblair
This doesn’t surprise anybody who’s involved in process engineering: doctors have always been the number one example of the Hero mentality. This is why most hospitals and clinics feel like a bunch of doctors sharing the same bathroom instead of an actual coordinated organization. While the science has advanced enormously in the last hundred years and the actual doctors are very highly skilled, a lot of medical practice is ridiculously archaic. If there’s any other field that performs critical functions without strict procedures I don’t know of it.
zmulls
My wife loves checklists. I am awash in them.
Platonicspoof
Do any of these books or articles explain why checklists are not used more in medicine?
E.g., would a surgeon be worried about a ‘paper trail’ if he decided a particular step in a particular case could be skipped, and it turned out he was wrong?
I have vague memories of aircraft maintenance records being altered or fudged and being discovered by investigators following an accident a few years ago.
Maybe not a relevant example.
jibeaux
You know, I am beginning to think there is really no such thing. Yes, they EXIST, in ether of the time-space continuum, but implementation is a bitch. And if implementation is a bitch, then are they really easy? /end of metaphysics lecture
dr. bloor
@matt:
Would you like fries with your bypass surgery, sir?
Seanly
As a structural engineer who designs bridges, I would agree with the doctor’s sentiment. Checklists showing some of the key steps & decision points in bridge design would be very helpful even for a very experienced bridge designer like myself. When I am talking junior staff through a design there are often little steps I leave out or mess up the order. There are some flowcharts listed in the AASHTO and some state codes for bridge design (both the design as a whole or for just the complicated portions like seismic design). The flowcharts can serve as a checklist after a fashion, but are of course not ideal for that.
However, engineering is mostly a team collaborative effort. In bridge engineering, almost all calculations are checked. Many agencies require that signed and checked calculations are required in addition to the signed drawings. I was trained after college to look at checking as an integral & important step in the design. Some places make the mistake of using the less experienced staff to check the work of the more senior staff. However, the better procedure IMHO is for the junior staff to perform the work and the more senior staff to check it for math errors and also errors of judgement/assumptions (though the reverse is not necessarily bad).
Herbert Hoover has a great quote about engineers – follow the Link.
Mum
@Crusty Dem:
I was awake for my last surgery (it was carpal tunnel surgery), and I went to one of the best hand surgeons in the country at one of the best teaching hospitals in the country. I was astonished at how careful and considerate they were: marking the correct hand ahead of time, even though they knew I was going to be awake; explaining the anesthetic to me; explaining the procedure to me as they were working, etc. I mistakenly thought they would be more cavalier about it, possibly caught up in their own egos.
Violet
@Platonicspoof:
Not sure if they do, but from a lot of experience working with doctors, many of them surgeons or surgeons-in-training, I can tell you that ego is definitely one of the reasons. Superheros don’t need checklists!
@Anne Laurie:
Heh. I saw that episode too. I think a lot of people learn their medicine from shows like ER. It’s important that it’s done accurately. I remember that back in the day the doctors I used to work with really liked ER because it was so accurate.
Mum
@bob h:
I think that using agribusiness (which is actually what you are talking about when you are talking about “modern” agriculture) as a model for any program or industry or practice is unwise. We may be reaping the deadly harvest of agribusiness and its cousin, factory-farming, for decades to come.
Scuffletuffle
@Calming Influence: Win!
Crusty Dem
@Mum:
I think most of the surgeons have come around, hearing your experience, I think that level of care is part of what would make someone “one of the best hand surgeons in the country”..
Liberty60
As an architect, I love checklists, but like others here, am astounded by the need to so often point out their necessity.
But I suppose that checklists are an irritant to those who imagine they possess some intuitive genius.
However, as I told one young intern, who was trying to impress with his ability to cite portions of the building code from memory- “if you can memorize the code, you are a genius- if you think that that is a wise thing to do, you are an idiot.”
Hence the segue into the glibertarians; the belief in singular genius is itself a collossal stupidity, the foolishness that only brilliant people lull themselves into thinking.
Like the code-quoting intern, John Galt spurns the ready wealth of information and wisdom of others, relying only on his own brilliance, for no other reason than his own self-aggrandizement.
Mr. Wonderful
@ Ailuridae–
I heard some doctor interviewed years ago who, when asked of the one modern procedure he would send back to the middle ages via time machine in order to save lives, answered, “The importance of washing hands.”
Rich Webb
Checklists? Ask the ghost of ADM Rickover or any living Navy nuc or submariner. Not only checklists — for things you may have done 100 times before — but an independent second check by another qualified individual.
Sometimes there just is no margin for “Oh, shit!”
Skepticat
One of the things on some of the checklists I’ve heard about is counting instruments and surgical sponges before closing up. Now they’re putting computer chips in the sponges (which really are gauze pads) to be sure that they all come out!
Neutron Flux
@Rich Webb: I work at a nuclear power plant. I was on a nuclear submarine. After TMI, we are waaaaay past anything we did in the Navy. And yes, they work very well for us. The industry is expanding, in part because of our excellent safety record, post TMI of course.
Chad N Freude
@matt: Right. Using shopping lists when you go for groceries is so unnecessary, because grocery shopping is not a complex process. I really hope you didn’t mean what your comment sounds like.
Chad N Freude
@bob h: Yes. I found it fascinating. And plausible.
I also heard the NPR interview with Gawande. He acknowledged that he resisted the idea of using a checklist himself because of course he was highly experienced and knew what he was doing — until he actually ran a real-life checklist test.
Charity
I’m not a doctor or anything. I work in a financial data company. My error rates were reaching uncool levels, to the point where my boss was pulling me into a conference room for a serious “chat.” I read a review of this book and started implementing a checklist for myself, with all the details I most commonly missed. It seems to have REALLY helped. I bought the book but haven’t read it yet. I’ll have to put that on a to-do list! But even the concept expressed in the review helped me a lot. If a surgeon can take the time to do a checklist for an important procedure, I can surely do it for my job.
BombIranForChrist
Thanks for the tip, Anne. This is going on my book list! My very large book list.
matt
@Chad N Freude: Huh? Lists for groceries, lists for pilots, lists for surgery—great! Lists as a solution to Life’s Problems because a doctor discovered them after years of ridiculously high pay and surgeries botched nonetheless—bah. Put it this way, why turn to the least efficient industry in the country for advice about work habits? Seems like everybody here who’s a fan of checklists already knew their value years ago.
tootiredoftheright
@Mr. Wonderful:
Sheesh no wonder so many people get infections in hospitals. Perhaps this doctor just wants to know the four humours and just do bloodletting all the time rather then anything difficult that involves using the brain. At least using leeches as some medical benefit as does using maggots but not washing hands?
lahke
I have read the book and, while it’s a little repetitive, it makes the point well and draws good parallels from other fields besides airplanes, chief among them the building trades. His arguments were seconded in a good David Leonhardt article in the NY Times Sunday magazine a couple of months ago on the same topic. As the doctor quoted in that article said, “show me your mortality rates.” There were a lot of protests by hero doctors to checklists at Intermountain Health, but they dropped death rates dramatically and I can’t see how you can argue against them. Yes, there will always be outlier patients who don’t respond to standard care, but docs owe it to us to try it the checklist way before going off onto some other path.
arguingwithsignposts
@Calming Influence:
nicely played, sir(ma’am?). {golf clap}
phein
#34:
Do any of these books or articles explain why checklists are not used more in medicine?
We do checklists for environmental and safety for the world’s largest organization, and we’re supposed to do them for occupational health as well.
The OH office’s arguments usually run something like this:
1. You can’t put our knowledge into a checklist, or use a checklist based on it without having great training/experience. 2. No checklist will be useful in any particular situation, as individual situations are all too different and safety judgments have to be made based on expert judgment on the scene. Therefore, 3. Making checklists will just empower inexperienced/unqualified individuals, and you will die.
The other argument is: We know more than you do, so why don’t you just piss off?
Barry
@arguingwithsignposts:
“As we all know from Megan McArglebargle’s lectures, EVERYTHING stifles innovation except sweet cash from big business and the Free Market™.”
No, it’s sweet cash *to* big business.
shadowfax MD
Checklists (in their various forms) are definitely something we are doing more and more of as systematic organizational quality measures become part of daily life in medicine. Gawande may be a bit glib, a la Gladwell or freakanomics, but he’s onto something.
My take as an ER doc over at Movin’ Meat.