Surgeon and journalist, Atul Gawande, is getting quite a bit of deserved press and blog attention for his new book, The Checklist Manifesto: How to Get Things Right. The premise of his book is simple – checklists are an effective way to reduce error. But behind that simple message are some powerful ideas with significant implications for the culture of medicine.

One of the biggest ideas is that medicine has culture – a way of doing things and thinking about problems that subconsciously pervades the practice of medicine. This idea is not new to Gawande, but he puts it to powerful practice.

The Humble Checklist

Gawande tells not only the story of the checklist but of his personal experience designing and implementing a surgery checklist as part of a WHO project to reduce morbidity and mortality from surgery. He borrowed the idea from other industries, like aviation, that use checklists to operate complex machinery without forgetting to perform each little, but vitally important, step.

The surgery checklist includes things like making sure the patient received pre-op antibiotics, making sure that blood is on hand for emergency transfusions, and also making sure that every member of the surgical team knows everyone else’s name.

In those hospitals in which the checklist was enforced surgical complications decreased on average by more than a third. That is a significant reduction, and saved hundreds of lives. This kind of impact is akin to the introduction of sterile technique.

Checklists are effective, Gawande argues, because some systems in our civilization have become too complex for the human mind to master. We have essentially crafted a civilization that is beyond our ability to manage using just raw brain power. Further, the consequences of minor mental error can be catastrophic – forget to flip one switch on a jet bomber and the plane may crash, killing everyone aboard. Make a decimal point error in dosing a medication and the patient may die.

Checklists minimize the probability of these small but consequential errors occurring.

This much of the story has been told numerous times on countless blogs and interviews as Gawande is conducting his book tour.

But the really interesting stuff are the other concepts behind the checklist, especially those that have to do with the culture of medicine.

The Culture of Medicine

Culture can be a strange and powerful thing – bestowing upon individuals a suite of assumptions, morals, attitudes, and mental habits of which they may not even be aware. In my opinion the most powerful part of Gawande’s book is when he steps back to consider what the culture of medicine is and how it affects practice (of course, with particular focus on the checklist).

He observes that in medicine the problem of increasing complexity has been handled by increasing expertise and specialization. Mistakes are minimized by training and repetition – so that procedures and patient management become routine. There is something to be said for training and repetition, but Gawande argues that medicine is now too complex for this strategy to be adequately effective. It is a setup for failure.

Rather we need to take the approach that other industries have taken – assume individuals will fail, but create a system that will catch them – the checklist.

This approach works, but may rub some physicians the wrong way – those trained in the culture of individualism and personal prowess and responsibility (sometimes referred to within medical circles as the “cowboy” approach – a term meant to be a little derogatory, although simultaneously containing a measure of respect).

Here I think that Gawande may be a little biased by his surgical background, and I think he may underappreciate that each specialty within medicine has its own subculture. Coming from a specialty at the more nerdy and less cowboy end of the medical cultural spectrum, I find nothing threatening about the concept of checklists or similar safeguards.

I also think this culture is generational – my experience with younger doctors in training is that they readily, even eagerly, adopt systems that help them avoid mistakes. They never knew a day when medicine was not so horrifically complex and ever changing that physicians could not use some external help to aid their inadequate brains.

Discipline and the Rise of the Machines

Another aspect of medical culture that Gawande touches on is the broader culture of professionalism itself. He argues that most professions are built upon the ethics of selflessness, expertise, and trustworthiness. However, some professions include the additional ethic of discipline – an ethic that is perhaps lacking in medicine.

Discipline in this context means doing the right things in detail every time. People and cultures have varying ability to be rigidly disciplined, but in general humans lack the kind of discipline that would preclude even the occasional lapse. A checklist is an outside imposition of discipline – to shore up a specific human weakness.

Taking this concept one step further, I would add that discipline is something machines do very well. If you give a computer a set of instructions, you can count on it to perform those instructions millions of times without variation.

I recently discussed elsewhere that there will likely be an increasing role of expert systems in the practice of medicine. This  includes things like systems for analyzing radiographic studies and highlighting potential pathology, checking for drug-drug interactions when new prescriptions are written, suggesting possible diagnoses to be considered, and, yes, running through checklists or algorithms of proper evidence-based management. This may be as simple as reminding a physician to consider prescribing cardiovascular prophylaxis to their 60 year old patient with hypertension (something which does not happen as often as it should).

The checklist is therefore just one of many similar interventions that can aid all health care providers in the practice of their profession. And the advent of computers will likely aid in the implementation of checklists, algorithms, reminder systems, and automatic cross-checks – all with the goal of minimizing error and optimizing the practice of medicine.

Conclusion

Science-based medicine has been incredibly successful in extending and improving human life. It is also, in some ways, a victim of its own success. We now have more knowledge than any single expert can hope to know. We have developed advanced medical technology that works wonders, but amplifies the consequences of even minor errors. And we have raised the bar of expectation and professionalism to dizzying heights.

Gawande’s book not only provides us with an additional tool to deal with this growing complexity, but he encourages the entire profession (and other professions) to step back and look at the culture(s) and systems of medicine – to examine and challenge our assumptions, assess our approach to problem solving, and reconfigure ourselves to move forward.

I would like to step back even further and observe that Gawande’s book represents the deepest strength of the medical culture – it is earnestly self reflective. Harriet Hall’s post from yesterday represents another example of this, reflecting on the need to optimize the human element of every patient interaction, in the face of advancing technical demands.

Meanwhile the overarching purpose of science-based medicine is to reflect upon the optimal relationship between science and the practice of medicine.