Atul Gawande's 'Checklist' For Surgery Success
'The Checklist Manifesto' Cover
Speaking about dealing with unexpected challenges in medicine, Atul Gawande — a surgeon who writes for The New Yorker when he's not at his day job at Harvard Medical School — relates a story about a man who came into an emergency room with a stab wound.
"It was a single wound, about an inch in size, in his belly," Gawande tells Morning Edition host Steve Inskeep.
The man's injuries didn't appear life-threatening, but his condition quickly turned.
"About 10 minutes later, he crashed," Gawande says. "When they got him open they found that the wound had gone — this is a pretty big guy — straight through more than a foot into him, all the way into his back and sliced open his aorta. And so afterwards they asked a few more questions of the family. 'How did this happen?' 'Well, it was a Halloween party.' 'What exactly went on?' And then they learned that the guy who had stabbed him was dressed as a soldier carrying a bayonet. And if they had understood it was a bayonet, they would have thought about it quite differently."
Gawande uses this anecdote, a simple miscommunication with the potential to cause so much tragedy, to illustrate an argument he makes in a new book called The Checklist Manifesto: How to Get Things Right.
"Our great struggle in medicine these days is not just with ignorance and uncertainty," Gawande says. "It's also with complexity: how much you have to make sure you have in your head and think about. There are a thousand ways things can go wrong."
At the heart of Gawande's idea is the notion that doctors are human, and that their profession is like any other.
"We miss stuff. We are inconsistent and unreliable because of the complexity of care," he says. So Gawande imported his basic idea from other fields that deal in complex systems.
"I got a chance to visit Boeing and see how they make things work, and over and over again they fall back on checklists," Gawande says. "The pilot's checklist is a crucial component, not just for how you handle takeoff and landing in normal circumstances, but even how you handle a crisis emergency when you only have a couple of minutes to make a critical decision."
This isn't the route medicine has traveled when dealing with complex, demanding situations.
"In surgery the way we handle this is we say, 'You need eight, nine, 10 years of training, you get experience under your belt, and then you go with the instinct and expertise that you've developed over time. You go with your knowledge.' "
To see if surgeons might perform better if the intricate steps necessary to avoid catastrophe were made explicit, Gawande and a team of researchers studied what happened when doctors used a reminder — what Gawande calls "a bedside aide" — to navigate complex procedures. (Click to see a sample "Surgical Safety Checklist".)
"We brought a two-minute checklist into operating rooms in eight hospitals," Gawande says. "I worked with a team of folks that included Boeing to show us how they do it, and we just made sure that the checklist had some basic things: Make sure that blood is available, antibiotics are there."
How did it work?
"We get better results," he says. "Massively better results.
"We caught basic mistakes and some of that stupid stuff," Gawande reports. But the study returned some surprising results: "We also found that good teamwork required certain things that we missed very frequently."
Like making sure everyone in the operating room knows each other by name. When introductions were made before a surgery, Gawande says, the average number of complications and deaths dipped by 35 percent.
"Making sure everybody knew each other's name produced what they called an activation phenomenon," Gawande explains. "The person, having gotten a chance to voice their name, let speak in the room — were much more likely to speak up later if they saw a problem."
How did surgeons respond to the suggestion that they should change the way they operate? Says Gawande, many were resistant at first.
"You can imagine the response" to the idea of running through a checklist before surgery, Gawande says. But when his team surveyed the doctors who used the checklist, "There was about 80 percent who thought that this was something they wanted to continue to use. But 20 percent remained strongly against it. They said, 'This is a waste of my time, I don't think it makes any difference.' And then we asked them, 'If you were to have an operation, would you want the checklist?' Ninety-four percent wanted the checklist."
So why does Gawande think professionals have such a hard time admitting that having a reminder might be a good idea?
"Partly I think we have a hard time admitting weakness," he says. "And one of the things we have to grapple with is that we have to assume we are fallible, even as experts."
That's a tough pill to swallow, and one made even harder given the way in which the media and entertainment industry present profiles of people who succeed in demanding situations.
"One of the things that struck me about the 'Miracle on the Hudson,' when 'Sully' Sullenberger brought the plane down that saved 155 people after it was hit by geese over Manhattan and landed it in the river," Gawande says, was that "over and over again we wanted to say, 'Look at this hero who piloted this plane down,' and the striking thing was how much over and over again he said, 'There was nothing that hard about the physical navigation of this plane.' Instead he kept saying 'it was teamwork and adherence to protocol.' "
Gawande says he experiences a similar displacement of credit when he performs a surgery.
"I come out of my operations and then I go out and talk to the family and they say 'Doctor, thank you for saving my husband!' " Gawande says. "You feel a little bit like a fraud because you know how much you were dependent on everybody getting this right. And when we acknowledge it, that's when we come back to ideas like checklists."
Despite all the evidence, Gawande admits that even he was skeptical that using a checklist in everyday practice would help to save the lives of his patients.
"I didn't expect it," Gawande says with a chuckle. "It's massively improved the kind of results that I'm getting. When we implemented this checklist in eight other hospitals, I started using it because I didn't want to be a hypocrite. But hey, I'm at Harvard, did I need a checklist? No."
Or so he thought.
"I was in that 20 percent. I have not gotten through a week of surgery where the checklist has not caught a problem."
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STEVE INSKEEP, host:
Our next guest wants to tackle what he considers a huge challenge in health care, the effort to get really smart people to remember essential things.
MADELINE BRAND, host:
Atul Gawande is a surgeon and he's a health care writer. His articles sometimes get passed around the White House. He's focusing on the complexity of medical treatment. Gwande says American doctors might save money and lives if they used a checklist.
INSKEEP: It's just a rundown of best practices for treating anything from back pain to cancer. Atul Gwande's book �The Checklist Manifesto� includes the story of a man who came to an emergency room with a stab wound.
Dr. ATUL GAWANDE (Author, �The Checklist Manifesto�): He had perfect blood pressure. It was a single wound about an inch in size in his belly.
INSKEEP: Probably didn't looked that bad?
Dr. GAWANDE: Didn't look that bad. About 10 minutes later, he crashed, lost his blood pressure. And when they got him open they found that the wound had gone � this is a pretty big guy � and had gone straight through more than a foot into him, all the way into his back and sliced open his aorta. And so afterwards they asked a few more questions of the family. How did this happen? Well, it was a Halloween party. Well, what exactly went on? And then they learned that the guy who stabbed him was dressed as a soldier carrying a bayonet. And if they had understood it was a bayonet, they would have thought about it quite differently.
INSKEEP: And so it seemed in retrospect very simple stuff. What was this man stabbed with? It's a stab that was not followed. Somebody made one too many assumptions about this.
Dr. GAWANDE: Yes, and this is why the case was interesting to me. Our great struggle in medicine these days is not just with ignorance and uncertainty. It's also with complexity - how much you have to make sure you have in your head and think about. There are a thousand ways that something can go wrong. We miss stuff. We are inconsistent and unreliable because of the complexity of care. And when I looked at other fields and how they handled complexity, again and again they come back to the simple idea of just using a checklist.
INSKEEP: Well, let's make a comparison here. How does the way the average doctor work compare with the way the average airline pilot works?
Dr. GAWANDE: It was very interesting. I got a chance to visit Boeing and see how they make things work, and over and over again they fall back on checklists, as people know. The pilot's checklist is a crucial component, not just for how you handle takeoff and landing in normal circumstances, but even how you handle a crisis emergency when you only have a couple of minutes to make a critical decision.
In surgery the way we handle this is we say, You need eight, nine, 10 years of training, you get experience under your belt, and then you go with the instinct and expertise that you've developed over time. You go with your knowledge. What we found is that when you have the music checklist, when you have them turn to that reminder, that bedside aid, we get better results, massively better result.
We brought a two minute checklist into operating rooms in eight hospitals. I worked with a team of folks that included Boeing to show us how they do it, and we just made sure that the checklist had some basic things, make sure that blood is available, antibiotics are there, and we caught basic mistakes and some of that stupid stuff. But then the second part of it was we also found that good teamwork required certain things that we missed very frequently. So on the checklist is make sure everybody knows each other's name in the room, and the average reduction in complications and deaths was over 35 percent.
INSKEEP: Just from missing basic things. And another thing about teamwork, knowing the other people's names, just being sure that the doctors are communicating with the nurses who may be in the room at that moment.
Dr. GAWANDE: Making sure everybody knew each other's name produced what they called an activation phenomena. The person having gotten the chance to voice their name, let speak in the room, were much more likely to speak up later.
INSKEEP: If they saw a problem?
Dr. GAWANDE: If they saw a problem.
INSKEEP: Well, being questioned on a mistake is another thing. How do surgeons that you know respond to this notion of being questioned by their colleagues and having to refer to some simple or elaborate checklist to make sure they got everything right?
Dr. GAWANDE: When we first brought in the idea of a checklist into operating rooms, you can imagine the response. The predominant one was, we already do this stuff, we don't need it and this is a pain in my butt. We asked them to give it a try, and when we surveyed people afterwards, there was about 80 percent who were - thought this was something they wanted to continue to use. But 20 percent remained strongly against it. They said this is a waste of my time, I don't think it makes any difference. And then we asked them, if you were to have an operation, would you want the checklist?
(Soundbite of laughter)
Dr. GAWANDE: Ninety-four percent wanted the checklist.
INSKEEP: What, if anything, in society at large makes people resistant to this notion of relying basically on memory aids or reminders when they're doing a complex task?
Dr. GAWANDE: Partly I think we have a hard time admitting weakness, and one of the things that we have to grapple with is that we have to assume we are fallible, even as experts.
INSKEEP: Although that's not the image we see in TVs and movies, is it? I mean you see the heroic pilot flying by the seat of his pants. You see House hobbling through the hospital and coming up with another brilliant diagnosis out of the back of his head somewhere.
Dr. GAWANDE: In my last chapter I grapple with - one of the things that struck me about the miracle on the Hudson when Sully Sullenberger brought the plane down that saved 155 people after it was hit by geese over Manhattan and landed it in the river, over and over again we wanted to say, look at this hero who piloted this plane down, and the striking thing was how much over and over again he said there was nothing that hard about the physical navigation of this plane. Instead he kept saying it was teamwork and adherence to protocol. And when you walk your through - and I did it, I walked through all the things that the team did, what Jeff Skiles did in the jump seat to try to restart the engines and make sure that the flaps were in the proper position for the landing and so on, you realize how much of a team effort it is.
I come out of my operations and then I go out and talk to the family and they say, Doctor, thank you for saving my husband, and you feel a little bit like a fraud, because you know how much you were dependent on everybody getting this right. And when we acknowledge it, that's when we come back to ideas like checklists.
INSKEEP: Have you made yourself a better surgeon?
Dr. GAWANDE: I didn't expect it. It's massively improved the kinds of results I'm getting. When we implemented this checklist in eight other hospitals, I started using it in my operating room because I didn't want to be a hypocrite. But hey, I'm at Harvard, did I need a checklist? No. I didn't - I didn't think...
INSKEEP: You were in that 20 percent...
Dr. GAWANDE: I was in that 20 percent, said no. I have not gotten through a week of surgery where the checklist has not caught a problem.
INSKEEP: Atul Gawande is the author of "The Checklist Manifesto.� Thanks very much.
Dr. GAWANDE: Thank you. Transcript provided by NPR, Copyright National Public Radio.
