8. Atul Gawande, The Checklist Manifesto

[pauraque]

I used to work at a greeting card store that stood between a coffee shop and a smoothie place. We had a sign asking customers not to bring their drinks inside, because too many people had spilled them all over the cards, but often people didn't see the sign or ignored it.

One day a tall, well-dressed guy walked in with a drink, so I pointed out the rule and asked nicely if he would set the drink down while he looked at the cards. He glared down at me, and in complete seriousness and withering condescension, he said this:

"Do you actually think that *I*, a 40-year-old doctor, am going to spill my smoothie?"

I thought a lot about Dr. Never-Spills-His-Smoothie while I was reading The Checklist Manifesto, which is indeed about checklists, but is also very much about the dangers of arrogance, particularly among medical professionals.

Gawande tells us about the terrifyingly high incidence of preventable mistakes before, during, and after surgery. Things like forgetting to give an antibiotic, or not checking a line for infection often enough. Is it because the doctors and nurses are no good? Of course not. It's because even when you know exactly what to do and have done it hundreds of times, you can get distracted for just a second, or be so lulled by routine that you forget just one thing or think it isn't important. That's where lists come in handy -- they keep you focused and ensure thoroughness. There is no need to rely 100% on human memory, which we all know doesn't always work.

Or don't we? In some professions, they have already adopted written lists and scheduled checking of whether everything has been taken care of. Gawande's two primary examples are construction and commercial aviation. In construction, there used to be a Master Builder who supervised every aspect of building from the top down, but today it's just too much for one person -- any person -- to handle. So there are checklists, and there is communication. Every worker on the site is given regular opportunities to voice their concerns, and every concern is addressed. If they did not do this, buildings would fall down. (The incidence of buildings falling down is actually incredibly low in the US, near zero.)

In aviation, there used to be heroic test pilots who were expected to handle everything themselves and go by instincts and improvisation. A quarter of them died. When a commercial aircraft is flown today, there is a checklist for nearly every contingency; when a new kind of accident occurs, a new list is made and distributed to combat it. Aircraft crashes have become rare. This is part of aviation culture now, and it is not questioned or resented.

By comparison, in Gawande's opinion, medicine is stuck in the dark ages. Doctors, particularly surgeons, are expected to be test-pilot-style "heroes" who know everything, do everything, and are never questioned by their inferiors. But when the lessons of construction and aviation are applied to medicine -- when there are lists reminding everyone what to do, and when nurses and anesthesiologists are specifically asked if they have any concerns -- fewer people die. Gawande and the WHO have done studies showing this, and the results are pretty devastating. Yet even when confronted with the results, doctors haven't exactly fallen over themselves to start using these checklists. Gawande thinks he knows why: just plain arrogance.

The one thing I would have liked to hear more about is the pitfalls of medical specialization, which he touches on a little but not much. I'm a person with multiple medical issues, and many times I've wished all the specialists I've seen could just sit down in a room and talk to each other. For various reasons, that's not how it works in my case, and I don't doubt that I'm getting less ideal care than I could be because of it. Superspecializations are a result of the massive amounts of medical knowledge that we've gained, but I don't think I know anybody who has just one minutely specialized medical concern.

But the book is still a fascinating read. (I'd actually always wondered how buildings get built and don't fall down!) It's not too technical but also doesn't feel dumbed-down or sensationalized. Gawande's voice is thoughtful, compassionate, and convincing. If I needed adrenal gland surgery (his specialization), I'd like it to be done by Dr. Gawande with checklist in hand, and definitely not by the guy who thought he was incapable of spilling a smoothie.

(tags: a: gawande atul, indian-american, medicine)

Comments

[sibilance7.livejournal.com]

This book sounds utterly fascinating - thanks for posting it here! I don't read a lot of nonfiction (other than lit theory for school), but I may have to check this one out.

[pauraque]

There's an art to making popular nonfiction readable while still being accurate, and Gawande has it down.

[tala-tale.livejournal.com]

He really, really does, doesn't he? I love his work.

[holyschist.livejournal.com]

His other two books (Better and Complications) are some of the best medical writing I've read. He's a fantastic writer.

[browngirl.livejournal.com]

You have reinforced my desire to read this book. *bumps it up my list*

[pauraque]

I wasn't planning to read it, but my girlfriend had it out from the library for herself and I ended up reading it too. She has good taste. ;)

[rsadelle]

Ooh, thank you for this. I love Gawande's pieces in The New Yorker, and I keep forgetting to put one of his books on my to-read list. This sounds like a good one for that list!

[pauraque]

I think I started to read one of his books years ago at the bookstore but then had to leave. I wish I'd just bought it then!

[seabookmonger.livejournal.com]

Loved this book and his others too. Note that his OR always sounds pretty multiethnic and that he respects the nurses. Hope we pay attention to what he's saying in the New Yorker about health care reform.

[pauraque]

I rarely read magazines, was this in a recent New Yorker? Or available online perhaps?

[seabookmonger.livejournal.com]

Yes, here it is: AGawande (http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande)

More articles, including one on care at the end of life:
More (http://gawande.com/articles)

I'm going to post on POC but another great, great book is Siddhartha Mukherjee's Emperor of All Maladies. Here's a biography of cancer that's a page turner. A must read for beleaguered grad students also, for what it says about researchers trying to break new ground. It helped me come to terms with the death of a friend who died of a virulent form of breast cancer, but that isn't really why I read it. Can't recommend it more highly. A very different writer than Gawande with a very different project. Love them both.

[pauraque]

Sweet, thank you!

[buria-q.livejournal.com]

thanks for the review and the funny personal anecdote. passing it on to mom, she's an anesthesiologist who's struggled a lot with her workplace culture.

[pauraque]

The book has a lot of discussion about the importance of respect and teamwork among surgeons, nurses, and anesthesiologists. It sounds like some individuals choose to foster it, but the overall culture of medicine discourages it, sadly.

[holyschist.livejournal.com]

I thought this book was fascinating and a little disheartening at the same time--the amount of resistance to checklists in the medical field* is frightening.

And I loved how Gawande wrote about everything in the book--he could seriously make anything interesting (I especially liked the parts about chefs, since a lot of writing about professional chefs focuses on the Genius and Innovation and not on how they turn out consistently good food night after night).

*I originally typed "medieval field," oops. *facepalm*

[pauraque]

Yeah, the chef section was good. I think people know deep down that everything really is 10% inspiration, 90% perspiration, as they say, but the desire persists to romanticize things and make them more glamorous and heroic than they really are.