Atul Gawande’s The Checklist Manifesto reviewed

Every now and then, I read and enjoy a book, but only later fully appreciate it as its lessons and insights slowly become apparent. Judging by the number of times I’ve said, “That reminds me of Gawande’s observations about ___” over the past month, The Checklist Manifesto is one such book.

In this short, deceptively simple volume, Atul (who I count as both friend and inspiration) discusses the history of “the lowly checklist,” the impact of checklists on various industries, how he came to understand the value of checklists to medical care, and what makes a useful checklist. Most of this content could have been written by a thoughtful healthcare journalist. But Atul put his interest in checklists to practical use, spearheading a WHO initiative to test a checklist-based “safe surgery” program in 8 diverse hospitals around the world, an effort that saved hundreds of lives. His description of this program forms the core of the book.

Which is as it should be, since these autobiographical elements highlight what is unique about Atul, and his book. Yes, he is a gifted journalist (of course, aided by a surgeon’s insider knowledge and access – as demonstrated by last year’s game changing article about healthcare in McAllen, Texas). But he is also a healthcare leader, whose clear aim is not only to explain attitudes and policy, but to change them. It would be as if Malcolm Gladwell had tried to create a Tipping Point himself, and written up the experience. The whole thing gets very “meta” very quickly, and in the hands of a lesser person, might even threaten to become a bit dicey. (Is he a medical George Plimpton – trying out checklists in the OR to provide fodder for his writing?) But there’s no such worry here: Atul’s passion for patients and humility are so obvious that one never questions his methods or motives.

I won’t focus this post on the Hopkins-Michigan central line and the WHO surgery stories, which are both well known to readers of this blog. Nor will I concentrate on the book’s recitation of the history of checklists in fields as diverse as building construction, investing, and aviation (while illuminating and often fascinating, some of the examples, particularly the investment analogies, are a bit thin, a point made elsewhere). Finally, I won’t cover what Atul learns about how to create a great checklist from his field trip to Boeing’s “Checklist Factory,” beyond saying that this part of the book is actually a useful primer for those getting into the checklist business.

Instead, I’d like to focus on the subjects that don’t come through in reviews and interviews (such as Atul’s charming appearance on The Daily Show) but, I believe, are much deeper and more valuable.

“For nearly all of history, people’s lives have been governed primarily by ignorance,” Gawande writes. But in healthcare, he points out, we now know so much about so many things (and can treat so many maladies with our arsenal of thousands of medications and procedures) that when we don’t get it right, “the problem we face is ineptitude… making sure we apply the knowledge we have consistently and correctly.”

This, of course, helps explain why the public is so unsettled by our patient safety and quality flaws. Patients no longer give us the benefit of the doubt, attributing our failures to ignorance. Instead, they assume that we do know the right thing to do, but simply screwed it up. “The public was spoiled by the discovery of penicillin,” Atul said at a recent lecture at UCSF, since it gave people the illusion that curing illness was pretty easy.

In observing that medicine has problems that range from simple (getting the dumb stuff right) to the profoundly complex, he notes that,

… under conditions of true complexity – where the knowledge required exceeds that of any individual and unpredictability reigns – efforts to dictate everything from the center will fail.  People need room to act and adapt.

Is he arguing against his central premise, the value of checklists in healthcare? Well, no. He continues,

Yet they cannot succeed as isolated individuals, either – that is anarchy. Instead, they require a seemingly contradictory mix of freedom and expectation – expectation to coordinate, for example, and also to measure progress toward common goals.

This is one of the book’s epiphanies: checklists can not only ensure that people perform multi-step processes correctly, but can also remind us to talk to each other and coordinate our activities at particularly crucial junctures. Atul learned that the value of the preoperative checklist, coupled with the Time Out, was not simply in ensuring that the team gave the preop antibiotics or had units of blood on hand, but in forcing all the team members to introduce themselves to each other. It was as much a culture-changing intervention as a cookbook.

In fact, the most interesting parts of the book are ones in which Atul describes our culture; it is this culture that explains why checklists rub so many caregivers the wrong way.

In medicine, he writes,

we have the means to make some of the most complex and dangerous work we do… more effective than we ever thought possible. But the prospect pushes against the traditional culture of medicine, with its central belief that in situations of high risk and complexity what you want is a kind of expert audacity… Checklists and standard operating procedures feel like exactly the opposite, and that’s what rankles many people.

In broadening this point, he plumbs an even deeper truth: “All learned occupations have a definition of professionalism, a code of conduct… [with] at least three common elements,” he observes: selflessness, an expectation of skill, and an expectation of trustworthiness.

Aviators, however, add a fourth expectation, discipline; discipline in following prudent procedure and in functioning with others. This is a concept almost entirely outside the lexicon of most professions, including my own. In medicine, we hold up ‘autonomy’ as a professional lodestar, a principle that stands in direct opposition to discipline…. The closest our professional codes come to articulating the goal [of discipline] is an occasional plea for ‘collegiality.’ What is needed, however, isn’t just that people working together be nice to each other. It is discipline.

These insights about medicine, and particularly the physician psyche, are not only profoundly interesting; they are vital to understand if we are to make healthcare better. Checklists can’t solve all our problems, but they – and other safety-oriented activities like standardization, simplification, forcing functions, and double-checks – can help us deliver healthcare that is far safer and more reliable. In applying these solutions, though, we need to understand that they challenge some of our most deeply held beliefs about the nature of medical practice and what it means to be a good doctor.

We have met the enemy, and it is us.

Bob Wachter is chair, American Board of Internal Medicine and professor of medicine, University of California, San Francisco. He coined the term “hospitalist” and is one of the nation’s leading experts in health care quality and patient safety. He is author of Understanding Patient Safety, Second Edition, and blogs at Wachter’s World, where this post originally appeared.

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  • alex

    “Aviators, however, add a fourth expectation, discipline; discipline in following prudent procedure and in functioning with others. This is a concept almost entirely outside the lexicon of most professions, including my own. In medicine, we hold up ‘autonomy’ as a professional lodestar, a principle that stands in direct opposition to discipline.”

    It’s almost as though aviation isn’t an exact metaphor for medicine or something. Madness, isn’t it? All those times every day that pilots need to deviate from usual protocols for the good of their passengers are exactly analogous to medicine.

    “Autonomy” is the only thing remotely keeping the interest of the patient first and foremost. It’s certainly not the increasing “synergy” of hospital-doctor-insurance, where they’re merging into one bloc systemically designed to extract every dollar from your pocket with maximal efficiency.

  • R Watkins

    But we don’t ask aviators to going back in the cabin during takeoff to ask who ordered the fruitplate, do we?

    There is definitely value in checklists, but I would posit there would be more value in freeing physicians from the crushing distraction of worthless administrative chores.

  • yollom

    It is interesting to note that there was a great deal of controversy regarding checklists in aviation during the first push in that field for safety and standardization. Many pilots who trained during the wars felt much in the same way that I imagine a lot of doctors do – safe aviation is built through experience (many of the first jet pilots were WWII veterans) and checklists hindered the “art” of operating an aircraft in dangerous situations. It wasn’t until a series of horrible crashes because of lack of communication in the cockpit and dangerous risk taking that reform was finally pushed through. Both the military and airlines realized that they could save both money and time by standardizing cockpit procedures and removing veteran aviators who, while talented, were often times a malignant presence in the workplace. The reform mandated both the use of checklists and training in crew resource management. Crew resource management broke the old school practice of the good copilot being “seen but not heard” and made all crew members responsible for the safety of the aircraft, while fostering better communication up and down the chain of command.

    As a aviator and military officer who is entering medical school this fall, I find it easy to understand both the lack of motivation for checklists in medicine and their necessity while performing complicated procedures (in any field). Many see checklists as a method of “control” by some outside body – which is of course partially true, but the results in aviation of both the “checklist culture” and crew resource management speak for themselves.

  • yollom

    Also, in my experience – a good checklist is oftentimes the most basic, and rarely has to be deviated from. There isn’t a checklist for everything, or every procedure, just the most basic things that are vitally important but routine. Deviation is allowed, but you better have a good reason and be able to explain why later.

  • abower

    Aviation checklists are for doing the same thing over and over. In procedures this has some merit but not in diagnostics and the messy business of treating multiple conditions. Even guidelines fail here. Back to the procedure thing, I have to take a “time out” before excising a cyst on the skin. The time out is to avoid wrong side surgery but it is absurd in the out patient or even the inpatient were the lesion is obvious. More Surgical procedures are performed in a year than flights in a few months. Excess regulation has a price in inattention due to the limits of a human brain.

  • Amelia

    Checklists are pointless if you have the luxury of time. But the better we get at things, the more we’re asking to do in less time until, figuratively speaking, you’re flying through things and under stress. So the wrong burger in the takeout bag isn’t going to kill someone. But the testing of a flight or defense system, just as with the doctors, is no time to miss a detail, there’s too much at stake.
    The doctor was less than thrilled to have to draw a little X on my surgical site and for my circumstance was not valuable. But if this habit saves one person’s limb/etc., then really, is that too much to ask?

  • Geoff

    In commercial aviation pilots’ flying hours are strictly regulated. Not so in medicine, where doctors (especially young ones) work ridiculously stupid hours and make mistakes due to exhaustion.

    It is not just about the checklists – medicine needs a safety culture and regulations as strict as aviation.

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