I loved Atul Gawande’s collection Better. At the end of that collection, he talks about experimenting with checklists to reduce accidents in surgery. This book is entirely dedicated to that concept. When he focuses on the medicine, whether his own practice, that of other doctors, or in public health work, he really elucidates the experience of medical practice and shows how checklists have made a massive difference in patient health. I found the description of his work at the World Health Organization, and the subsequent failures and successes of their work with checklists, to be particularly interesting.
One of the most compelling insights is how checklists can shift the balance of power within a surgery, empowering nurses and other staff to stop surgeons from making mistakes and forcing pre-operative communication and (resultant) team-building. This shift – from the evidence presented here – has massive positive impacts for patient health.
When Gawande strays into construction and financial markets, the examples are less compelling (I started to wish the book had been one of Gawande’s great New Yorker articles). For example, he shows how several successful financial traders have used checklists, but there is no counterfactual in the style of the trials employed in medicine: There also seem to be lots of successful financial traders without checklists! Nevertheless, Gawande has convinced me that it is worth experimenting with checklists to reduce errors in my own life.
Below are excerpts from two professional reviews (both New York Times). Both were very positive, but the excerpts demonstrate the caveats. Finally, I include a link to the Wall Street Journal review, which is more negative. (Incidentally, I believe the WSJ reviewer misreads Gawande’s last case study, of an emergency airplane landing in the Hudson River.)
Note on potentially offensive content: None.
Robin Marantz Henig, "A Hospital How-to Guide That Mother Would Love," New York Times, 23 December 2009. Very positive with caveat.
But in his effort now to apply the checklist to all walks of life — venture capitalists, skyscraper construction workers, restaurant chefs — he occasionally treads uncomfortably close to the territory claimed by his New Yorker colleague Malcolm Gladwell, taking a single idea and trying to make it fit almost every situation. Maybe there’s a case to be made for why checklists help in enterprises as diverse as finance and government, but Dr. Gawande doesn’t really make it convincingly. Nor does he need to.
Sandeep Jauhar, "One Thing After Another," New York Times, 22 January 2010. Very positive with caveat… Overreach!
Gawande’s missionary zeal can give the book a slanted tone. For instance, there is almost no discussion of the unintended consequences of checklists. Today, insurers are rewarding doctors for using checklists to treat such conditions as heart failure and pneumonia. One item on the pneumonia checklist — that antibiotics be administered to patients within six hours of arrival at the hospital — has been especially problematic. Doctors often cannot diagnose pneumonia that quickly. But with money on the line, there is pressure on doctors to treat, even when the diagnosis isn’t firm. So more and more antibiotics are being used in emergency rooms today, despite the dangers of antibiotic-resistant bacteria and antibiotic-associated infections.
Even when doctors know what works, we don’t always know when to apply it. We know that heart failure should be treated with ACE inhibitor drugs, but codifying this recommendation in a checklist risks that these drugs will be prescribed to the wrong patient — a frail older patient with low blood pressure, for example. Checklists may work for managing individual disorders, but it isn’t at all clear what to do when several disorders coexist in the same patient, as is often the case with the elderly. And checklists lack flexibility. They might be useful for simple procedures like central line insertion, but they are hardly a panacea for the myriad ills of modern medicine. Patients are too varied, their physiologies too diverse and our knowledge still too limited.
Less positive – WSJ:http://online.wsj.com/article/SB10001424052748704320104575015294037289412.html