book recommendation – The Checklist Manifesto: How to Get Things Right, by Atul Gawande (narrated by John Bedford Lloyd)

a little long, a little overexuberant, but Gawande is always worth reading when he’s writing about medicine

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:

an abstinent Christmas for malaria mosquitos

This, from News Daily [here is the original research article in PLoS Biology]

Interfering in mosquitoes’ sex lives could help halt the spread of malaria, British scientists said on Tuesday.

A study on the species of mosquito mainly responsible for malaria transmission in Africa, Anopheles gambiae, showed that because these mosquitoes mate only once in their lives, meddling with that process could dramatically cut their numbers.

Researchers from Imperial College London found that a “mating plug” used by male mosquitoes to ensure their sperm stays in the right place in the female is essential for her to be able to fertilize eggs during her lifetime. …

“The plug plays an important role in allowing the female to successfully store sperm in the correct way inside her, and as such is vital for successful reproduction,” Flaminia Catteruccia of Imperial’s life sciences department wrote.

“Removing or interfering with the mating plug renders copulation ineffective. This discovery could be used to develop new ways of controlling populations of Anopheles gambiae mosquitoes, to limit the spread of malaria.”

book review: how medicine gets better

I just listened to the audiobook of Better, by surgeon Atul Gawande (capably narrated by John Bedford Lloyd). Gawande explores how behavioral innovation and medical organization improve medicine at least as much as scientific discovery. In his advice on being a positive innovator in the conclusion, one item that impressed me was his counsel to count something. “If you count something you find interesting, you will learn something interesting.”

Here is the summary of my thoughts on the book, posted on Amazon:

fascinating exploration of past and present improvements in medicine from behavioral innovation rather than scientific discovery

Gawanda is a surgeon and a skilled writer. This collection of essays explores the ways in which changes in medical behavior and organization (as opposed to new scientific discoveries) can lead to drastic improvements in health and survival. He explores a broad array of applications, from interminable efforts to eliminate polio in India and elsewhere to impressive innovations in front-line war medicine in Iraq to ways that hospitals have tried to get doctors to … wash their hands. Even though many of the essays were previously published (in the New Yorker), Gawanda has updated them and integrated them into the broader theme of the book.

Some of the essays stray from that theme, such as the one discussing medical malpractice, but each one is engaging. Gawanda is excellent at writing for a lay audience: I have no medical training and found the book completely accessible.

One of the principal messages, introduced early and revisited often, is that of “positive deviance”: the idea that wonderful changes come from identifying (and learning from) individuals who deviate from norms and achieve impressive results. In his conclusion, Gawanda gives some ideas for becoming a positive deviant in medicine and in life. One is to “count something,” building on the book’s examples in which measurement systems led to drastic improvements in performance: one example is the Apgar score for newborns; another is the publication of cystic fibrosis treatment performance across hospitals around the country. Gawanda goes on to give a compelling example of how his own measurement helped him understand how to reduce sponges getting left inside patients.

The audiobook published by Sound Library consists of 6 CDs (about 7 hours and 30 minutes). It has good, engaging narration by John Bedford Lloyd.