For readers familiar with his earlier work, Atul Gawande’s most recent book, The Checklist Manifesto: How to Get Things Right, has about it the air of a journey that has reached its destination — though not its final destination.
In his first book, Complications: A Surgeon’s Notes on an Imperfect Science (2002), Gawande, who is both a surgeon and a staff writer for The New Yorker, asked broad questions about medical care. In his second book, Better: A Surgeon’s Notes on Performance (2007), Gawande cast a wide net in search of answers. Now, in The Checklist Manifesto, heoffers a simple and elegant solution to one of the most basic questions facing the medical establishment: How can doctors reduce the errors and omissions in care that make hospitals — and particularly operating rooms — such dangerous places, even for patients in the most developed countries?
The answer, of course, is a checklist. The Checklist Manifesto takes us on the journey that Gawande traveled as he developed the idea — finding, assimilating and honing the ideas of others, medical professionals included. He shows us a variety of contexts in which lists have been used to good effect, from the aviation industry to urban construction to busy restaurant kitchens. He takes us inside the pilot program he launched under the aegis of the United Nations’ World Health Organization (WHO), in which eight hospitals across the globe implemented a surgical checklist program on a trial basis. And then he shows us the numbers. He makes a strong rhetorical case for his argument, but, as a scientist, he gives us evidence, not merely anecdote.
The results are compelling; the evidence looks solid. It may be that we are on the cusp of broadly adopting a fairly simple and inexpensive set of practices (in fact, they would generate net savings) that will radically slash the mortality rate in hospitals around the world, in rich countries and poor countries alike.
Or maybe not. Because what Gawande also found on his journey is resistance toward change, both in the behavior of physicians and of what we might refer to as the Medical Industrial Complex. The roots of that resistance bear further scrutiny and this is an area Gawande attends to but somewhat scantily.
Too Much to Handle
The edifices of our modern, technologically advanced societies are beginning to cave in on themselves. Think of the millions of Toyotas that were recalled for acceleration and braking problems that may be software related; consider the number of steps — and the inevitable glitches — involved in simultaneously connecting a BlackBerry to a home computer, to the cell phone network, and to a business server. In medicine and in a variety of fields, Gawande tells us in his introduction, complexity is the enemy. He writes:
“Here, then, is our situation at the start of the twenty-first century: We have accumulated stupendous know-how. We have put it in the hands of some of the most highly trained, highly skilled, and hardworking people in our society. And, with it, they have indeed accomplished extraordinary things. Nonetheless, that know-how is often unmanageable. Avoidable failures are common and persistent, not to mention demoralizing and frustrating, across many fields — from medicine to finance, business to government. And the reason is increasingly evident: the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us.”
How can we respond to this? Gawande’s answer: Use checklists.
We need to acknowledge complexity by taking recourse to simplicity; we need to systematize the implementation of our overly complex systems by being humble enough to tick off a few boxes each and every time we perform certain life-threatening procedures — from launching an airplane to anesthetizing a patient; and we need to shunt ego to the side and democratize those procedures, empowering the least powerful person on the team to stay the hand of even the most powerful when error is imminent.
Gawande sets up the medical context of his argument in the first chapter, with the story of an Austrian girl who falls into an icy pond, is fished out quickly, but remains in a state that would have to be characterized as “clinically dead” for a period of at least two hours as she is worked on by various medical teams. Three years old at the time of the accident, she is ultimately resurrected and is neurologically and physically completely normal again by age five.
“To save this one child,” he stresses, “scores of people had to carry out thousands of steps correctly: placing the heart-pump tubing into her without letting in air bubbles; maintaining the sterility of her lines, her open chest, the exposed fluid in her brain; keeping a temperamental battery of machines up and running. The degree of difficulty in any one of these steps is substantial. Then you must add the difficulties of orchestrating them in the right sequence, with nothing dropped, leaving some room for improvisation, but not too much.”
Having read about this case in the Annals of Thoracic Surgery, and having noted that this save took place not in an urban, high-tech, medical center, but in a small community hospital in the Austrian Alps, Gawande tracks down the surgeon at the center of the case, Dr. Markus Thalmann. He finds, of course, that the hospital had a list — or a series of lists — for exactly this sort of case, covering everyone involved, starting at the bottom of the pyramid with the first points of contact: the rescue squads and the hospital telephone operators.
Who’s in Charge Here?
That bottom-up strategy is crucial, and it was not Dr. Thalmann’s first choice. After previous cases, in which the hospital routinely failed to resuscitate people who had been chilled and oxygen deprived, Thalmann tried “the usual surgical approach to remedy this — yelling at everyone to get their act together,” Gawande tells us. Attempts simply to exercise greater authority didn’t work. What did work was using lists, which turned the people working on such cases into a tightly integrated team.
So why don’t all doctors do this in all hospitals at all times? Why is this not the standard of care? One key reason is that it would represent a fundamental cultural shift. In the ongoing health care reform debate in the U.S., one bone of contention has been “evidence-based medicine.” At first blush, it’s hard to understand how one could be against encouraging medicine to go in this direction — and one might immediately wonder, if medical practice has not been evidence-based, what has it been? But what critics have successfully argued is that the phrase is really code language for “taking decision-making authority away from your physician,” a kind of cold, bureaucratic intrusion into the intimate relationship between doctor and patient.
In the U.K., the House of Commons Science and Technology Committee recently recommended that the National Health Service neither provide nor pay for homeopathic medicine, citing a lack of scientific evidence to support its efficacy. That pronouncement as well has been derided as an attack on the autonomy of both physicians and patients.
Part of what change comes up against is tradition. In the U.S., for example, it’s not uncommon for physicians’ offices to be clustered in what are sometimes called “Medical Arts” buildings. The phrase, if somewhat archaic, is evocative of some of the deep history of the practice of medicine: for millennia, illness was largely addressed via shamanic practices; we are only in the second century of medicine as a genuine and rigorous science; we can locate “the physician as artist” somewhere between those two extremes.
Scientists are — or should be — evidence-based. Both the Shaman and the Artist, however, take recourse to more subtle and flexible sources of truth. They interpret; they are not dictated to. A crude way to boil this down would be to say that medical professionals could trade away some of their authority in exchange for a greater rate of success — which is to say, to the degree that this is not being done, patients are being killed by overinflated egos.
Gawande knows, as well, the degree to which culture — particularly the attitude toward gender — plays a crucial role in the acceptance or rejection of this kind of change in hierarchy. These lists do something to empower all members of the surgical team, not merely to act but to publicly correct anyone else on the team, the surgeon included. Given that surgeons are usually men and nurses, for example, are usually women, the line being crossed when a nurse corrects a surgeon — particularly in more traditional societies — may be significant.
Gawande acknowledges this issue, and recounts the story of an operation he observed in Prince Hamza Hospital, in Amman, Jordan. “The staff didn’t hesitate to discard the formalities when necessary,” he writes. During a gallbladder operation he observed, for example, “the surgeon inadvertently contaminated his glove while adjusting the operating lights. He hadn’t noticed. But the nurse had.
‘You have to change your glove,’ the nurse told him in Arabic. (Someone translated for me.)
‘It’s fine,’ the surgeon said.
‘No, it’s not,’ the nurse said. ‘Don’t be stupid.’ Then she made him change his glove.”
Owner or Manager?
One way to look at this resistance — and Gawande touches on this, if only glancingly — is as a business metaphor. If you’re a franchisee and own a mainstream fast-food restaurant, part of the business package provided to you is the manual that spells out in minute detail how virtually everything is run. That’s why McDonald’s fries are the same, wherever you buy them.
The alternative, at the other end of the spectrum, is the master chef who owns her own business and follows her own plans. Would physicians and surgeons prefer to see themselves as corporate-drone fry cooks or as celebrity chefs? The question answers itself.
Another way to look at who might be more receptive to following protocols and who might be more inclined to resist them is to take greater account of context. As noted above, Gawande looks at the use of lists in a variety of fields other than medicine — cooking and construction among them — but he spends more time on the aviation industry than on any other.
He opens one chapter with a description of the disastrous 1935 crash of the prototype Boeing B-17 Flying Fortress, which killed the Army Air Corps’ chief of flight testing, Major Ployer P. Hill, temporarily cost Boeing the contract and led a group of test pilots to come up with the first aviation checklist. In another chapter, “The Checklist Factory,” he visits Boeing, in Seattle, to see how checklists are made, implemented and honed; and then directly experiences the use of such lists in a flight simulator. Finally, in his penultimate chapter, “The Hero in the Age of Checklists,” he recounts the story of Chesley “Sully” Sullenberger, the US Airways pilot who landed an Airbus A320 in the Hudson River last year when the engines were disabled shortly after takeoff from New York’s LaGuardia Airport.
Lauded as a hero, Sullenberger tells the media, at every opportunity, that the Miracle on the Hudson was a “crew effort.” The outcome, in Sullenberger’s view, “was the result of teamwork and adherence to procedure as much as of any individual skill he may have had,” Gawande notes. And, of course, at the heart of the incident, key to the successful landing and the evacuation of passengers and crew, Gawande finds not one but several checklists, methodically run down by pilot, co-pilot, and cabin attendants.
“The crew of US Airways Flight 1549,” he writes, “showed an ability to adhere to vital procedures when it mattered most, to remain calm under pressure, to recognize where one needed to improvise and where one needed not to improvise. They understood how to function in a complex and dire situation. They recognized that it required teamwork and preparation and that it required them long before the situation became complex and dire.
“This was what was unusual. This is what it means to be a hero in the modern era. These are the rare qualities that we must understand are needed in the larger world.” Gawande’s point about a redefinition of heroism — from rugged, solitary, individual effort to stalwart, organized, team effort — is both perceptive and crucial.
Not given sufficient attention, however, is the military thread that runs through the aviation examples from the genesis of list making in the crash of a bomber prototype, to the military contractor — Boeing — which is the mother ship of aviation checklists, to Sullenberger himself, who served in the U.S. Air Force for seven years before becoming a commercial pilot. While the trend has shifted in recent years, the cadre of airline pilots has traditionally drawn the great majority of its ranks from the military.
Doctors are not soldiers, however. To be in the armed forces is to learn — and fast! – how to take orders; most physicians are better at giving orders.
Saving Lives, Saving Money
The U.S. has a medical system based primarily on private insurance provided via employers, which costs more than any other system in the world and fails to cover tens of millions of people. Most of the other advanced industrial countries have universal coverage, in one configuration or another, with lower but still significant costs. China and India, the rising giants, struggle to provide care for vast numbers of people over vast distances, with resources and infrastructure that are growing but still not adequate to the task. Across the globe, providing safer, more efficient, more effective medical care would not only save lives by reducing error, it would also save additional lives by freeing up the money that we now waste on complications that could be greatly reduced.
One of the early projects that Gawande tracks was undertaken first at Detroit’s Sinai-Grace Hospital, then spread across the state of Michigan. It involved a checklist designed to reduce the rate of infections caused by flawed procedures in the insertion of central lines.
“In December 2006, the Keystone Initiative published its findings in a landmark article in the New England Journal of Medicine,” Gawande writes. “Within the first three months of the project, the central line infection rate in Michigan’s ICUs decreased by 66%. Most ICUs — including the ones at Sinai-Grace Hospital — cut their quarterly infection rate to zero. Michigan’s infection rates fell so low that its average ICU outperformed 90% of ICUs nationwide. In the Keystone Initiative’s first eighteen months, the hospitals saved an estimated $175 million in costs and more than 1,500 lives. The successes have been sustained for several years now — all because of a stupid little checklist.”
In the end, Gawande serves here not as the originator of the checklist approach, but as its analyst and advocate, taking us on a journey, telling us a complicated and engaging story, giving us the data: An estimated $175 million in costs and more than 1,500 lives; in a single American state, with a population of roughly 10 million people.
All the obstacles of bureaucracy, ego and culture notwithstanding, if our way of “doing medical business” does not change, this would represent not merely a failure of the market to promote best practices, but an almost incomprehensible moral failure as well.