The Checklist Manifesto: How To Get Things Right (A Book Review)

bn_checklist_manifesto_medical_malpractice.JPGMedicine has made amazing advances over the past century. At the beginning of the century, doctors killed more patients than they saved. We’ve only known the that hypertension, smoking, diabetes and cholesterol contribute to heart disease for a few decades, yet we’ve made incredible strides in treating heart disease.
How have our doctors changed in response to the changes in medicine? By becoming more and more of a professional class. At the beginning of the twentieth century, you only had to have a high-school diploma and a one-year medical degree if you wanted to be a doctor. Now you need a college degree, a four-year medical degree, an additional three to seven years of residency training (where you work eighty plus hours a week in a clinical setting), and, in recent years, many young doctors have started capping off their formal training with a one- to three-year fellowship.
Today’s doctors are orders of magnitude better-trained and better-educated than their counterparts from a century ago. But despite this enhanced training, knowledge and expertise, doctors and other medical professionals continue to commit an astonishing number of routine medical errors. For every patient in an Intensive Care Unit, doctors and nurses perform an average of 178 actions a day – and commit an average of one to two mistakes per day in their treatment. So-called “line infections” – easily preventable bacterial contamination of IV lines – affect eighty thousand patients a year in the United States and are fatal between five and twenty-eight percent of the time. Virtually all central line infections could be avoided if doctors and nurses followed the simple five-step procedure for putting in a central line, but studies show that at least one-third of the time, one of the steps gets skipped.
Is there anything we can do to reduce the rate of medical error – a rate that doesn’t seem to be much improved from decades past? Dr. Atul Gawande, a favorite of this blog, proposes one such solution in his new book: The Checklist Manifesto: How To Get Things Right. And the answer, as his title suggests, is simple: have doctors and medical professionals adopt checklists.
As seen in the TV interview below, Dr. Gawande suggests that we’re at our “B-17 moment” when it comes to medicine. He is referring to a 1935 test flight of Boeing Model 299 (later known as the B-17 Flying Fortress). The plane had four-engines, a 103-foot wingspan and was light years more sophisticated than what the Wright Brothers flew at Kittyhawk three decades earlier. On its first test flight, the B-17 crashed and burned. Newspapers proclaimed that it was “too much airplane” for man to fly.
What Dr. Gawande finds most interesting about the Boeing engineers’ reaction is is what they did not do. They did not suggest that the chief pilot undergo longer and more intensive training before getting in the cockpit. (They did not add another year to medical school). Instead, Boeing a set of checklists for the pilots. Flaps down, check. Rudder straight, check. And the rest is history: planes are bigger and more complex than ever, but very safe to fly.
In 2006, the World Health Organization (WHO) reached out to Dr. Gawande for his assistance in developing a global program to reduce avoidable deaths and harm from surgery. Dr. Gawande understood that the program could not be an ivory tower one. Surgeons in Tanzania or in India did not have the same resources that he had in Boston.
The solution that Dr. Gawande and his colleagues eventually hit upon was a low-cost one that drew upon the insights of those early Boeing engineers and some pioneering work by Johns Hopkins researcher Dr. Peter Pronovost: it was (as you’ve guessed) checklists.
The end result of the WHO project was a nineteen-step checklist that, in a worldwide pilot study, reduced deaths by 47 percent and major complications by 36 percent. There are some signs that the checklist is catching on. Lord Darzi and Sir Liam Donaldson of Britain’s National Health Service are attempting to implement it throughout Britain. But only twenty percent of American hospitals have adopted it.
When I was reading Gawande’s book, I couldn’t help but think that an analogy to another era of aviation might better capture where medicine is today (an allusion that Gawande eventually makes in his final chapter “The Hero In The Age of Checklists”). Rather than American medicine being at its “B-17” moment, I think perhaps it is in its “Right Stuff” -era, the era of the early space program, as chronicled by Tom Wolfe in his eponymous book.
As Wolfe tells it, the early astronaut corps drew from the ranks of the country’s finest test pilots. They were a high-testosterone group with an undeniable swagger, culled from the military’s ranks on the basis of their superior reflexes, their astonishing visual acuity and their overall physical fitness. In short, they were an elite who believed they possessed The Right Stuff, the qualities necessary for successful flight.
Yet, when their version of The Right Stuff wasn’t needed for the space program – when the space program didn’t need their reflexes or their vision – (the astronauts were just basically men strapped to a rocket they couldn’t steer or control; chimpanzees had served the same purpose in earlier flights) – the astronauts rebelled and insisted that the spacecraft be fitted with functionless windows and manual overrides that actually made space travel less safe.
Doctors too are undoubtedly believers in the cult of The Right Stuff. Not everyone has what it takes to be a doctor. I certainly don’t. In reading one passage in “The Checklist Manifesto,” about a patient’s intestines bulging in and out of his open abdomen with each CPR chest compression, I nearly gagged as I visualized the scene.
But now, doctors’ belief in The Right Stuff – the idea that they are an elite whose work requires an autonomy commensurate to their expertise – may be endangering patients. It seems that doctors should be doing more checklist-following and less aerobatics.
Following checklists can be valuable for several reasons. First of all, checklists are obviously a valuable aid to fallible human memories. But, as Gawande suggests, checklists’ effectiveness might also lie in the fact that they take doctors down off their pedestal and make the hospital more democratic. (Checklists open up a space for nurses and other non-MDs to speak their minds and provide the surgeon with important information and warnings).
This thesis – that the importance of checklists lies not in their aids to memory – but in their undermining hierarchy, receives some endorsement from Gawande but surprisingly little critical analysis from him. The idea that checklists succeed by undermining hierarchical command structures seems especially important to me in light of another anecdote from aviation history – one that I came across in Malcolm Gladwell’s book Outliers. In the early 1980s, Korea Airlines (KAL) was, by far, the world’s least safe airway. Its crash rate was startling.
Yet, from all outward appearances, KAL was a first-rate airline. It had top-notch equipment and pilots with years of experience who trained at the same facilities as other pilots worldwide.
An American executive eventually took over KAL and discovered the problem that lay at the heart of KAL’s troubles: the authoritarian relationship between the pilot and his crew. Co-pilots bowed to their pilots, made them tea and carried their luggage.
This culture led to co-pilots and others fearing to speak up and provide the chief pilots with important information, ultimately causing disastrous consequences. Gladwell reviews the black box tape of one crash where a deferential co-pilot fails to set a pilot straight on an error, resulting a crash into a mountainside. When KAL instituted new policies, including abolishing the bowing to the pilot, KAL’s safety record became exceptional.
Gawande relates one anecdote about being in an Operating Room and watching a surgeon order a surgical resident who dared to question him to go stand in the corner until he “felt sorry.” It may be that the single best thing we can do to reduce the incidence of medical malpractice is to rid the medical community of doctors like that surgeon, who embody the mentality of The Right Stuff, and replace them with ego-less checklist technicians.
I may blog one later post about a sort of philosophical premise of “The Checklist Manifesto”: the idea that the world, or at least the human body, is irreducibly complex and therefore we cannot always checklist or flowchart our way to proper diagnosis or treatment. I may challenge that idea in a later blog. Until then, you can hear a good summary of the book from Atul Gawande himself in this excerpt from The Daily Show:

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