Atul Gawande in San Francisco

Tonight I heard Atul Gawande speak about the issues in his new book, The Checklist Manifesto. He led with a case report of a 3-year-old girl who fell into a frigid lake in Austria and was not only revived, after many patient interventions at a local hospital, but was restored to normal function over a period of regular therapy. He then discussed the development and hitches of the WHO project to develop a checklist for surgical procedures that could consistently improve the safety of surgical procedures.

Gawande is an engaging speaker, with a calm and quiet demeanor that must be immensely reassuring to his patients. I have met a lot of surgeons, and they aren’t always as nice to their coworkers as they are outside the hospital, but he clearly gets it: checklists don’t just enhance safety and improve outcomes, they also provide support for any team member to say, hey, wait a minute, is this right? Gawande reports thinking, even as he embarked on this project, that he didn’t need to use checklists himself. After all, these lists were intended to improve care in developing nations; he was at Harvard. But he used them anyway, and they improved outcomes. He seems to embrace the way they democratize the team, too, fully understanding the significance of one the items that got the most resistance: that everyone introduce himself by name. And that most team members in the operating room used first names, but surgeons don’t.

As a person who’s done some rock climbing and who has flown in a friend’s single-engine plane, I don’t find the idea that a checklist is important to be new – and this applies not “even” but especially to experts, who are somewhat prone to presumption. It’s almost a little absurd to think of an individual assuming that he personally (and in surgery, more than two-thirds of the time, it’s a he) knows so much about everything that can happen in the operating room that he can afford to be dictatorial, and not even know his team member’s names. This seems obvious in medicine, which has changed so much during the careers of still-practicing surgeons. But it is illuminating to learn that airplane pilots had to come around to checklists, too, beginning as surgeons have with highly heirarchical teams that they directed with little opportunity for questions.

A couple of European countries have reported full adoption of the WHO-sponsored surgical checklist, but Gawande told us that in the United States, uptake is around 1 hospital in 5. It is wrong to suggest that doctors don’t understand as well as airline pilots that lives can be lost if they make a mistake, and yet it’s not enough to note that it’s expected in medicine that some lives will in fact be lost, and that’s nobody’s fault. I was struck by one particularly big difference: a pilot or a climber is also at risk of death if they make a mistake or miss something – a risk most surgeons don’t face in the operating room. I hope that’s not what it takes to make American surgeons use checklists.

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