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Checklists and Culture in Medicine

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.

Posted in: Science and Medicine, Surgical Procedures

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9 thoughts on “Checklists and Culture in Medicine

  1. kalashnikov says:

    I think one of the more amazing aspects is that this low-tech solution has actually been used by hosue staff for many years, and that only now is the utility of this practice being quantified and disseminated.

    I can remember making 6 boxes to be checked every time someone was admitted with decompensated heart failure – to ensure that appropriate care was given. I had a similar checklists for every patient admitted. I’d bet if you shook down the first intern you saw, their pockets would have a patient census dotted with similar checkboxes.

    Some time ago at my University, a “checklist” system for the emergent treatment of sepsis was instituted, and found dramatic improvement in outcome, presumably just from ensuring that things don’t get missed. Since then, more checklists have appeared – acute MI, stroke, DVT/PE, even admissions for acutel leukemias are in some way governed by these lists. The age of the checklist is already upon us.

  2. Zetetic says:

    I’ve seen “checklists” used to great advantage at a number of hospitals to ensure that that all requirements are met for surgical and other procedures. Nursing quality and performance improvement initiatives have developed these kinds of protocols for at least 15 years. Physician peer review committees have “checklists” as a part of establishing “standard of care” evaluation programs. I am currently nearing the end of a three year project installing an outpatient EMR in a 90+ provider multi-specialty group practice with 22 clinics in 5 physical locations. Many types of checks, balances and “checklists” are built in to our EMR and we can run reports to monitor compliance.

  3. JayHawkDoc says:

    I read this book on my Kindle (!!!!) three weeks ago, and I was pretty impressed. Gawande broached this subject in his last book (Better), but really expanded on his ideas in this one.

    I am a fourth year med student about to (Fingers crossed) match in Family Medicine, and throughout the book all I could think was “How can I do this in my practice/residency”. He did not touch on other specialties besides the surgical/intensivist set, and perhaps I’m just being lazy/uncreative, but I was hoping for more solid recommendations across the board.

    I think Steve’s comment about the younger generation being more accepting of this state is true, it sounds obvious, actually, that this needs to be done. I have brought up the idea of checklists to several physicians I’ve worked with over the last month, and ALL of them seem constitutionally opposed to it, that it degrades medicine.

    I think I’m rambling by this point, but suffice to say, I highly recommend this book to anyone in a complicated field, medicine or otherwise.

  4. Dpeabody says:

    It is rather amazing how much of an impact such a simple idea can have. I think maybe one of the mistakes that is made at med school is the focus that is put on memorisation. I don’t mean to say it’s not important as obviously if every time you saw a doctor they had to dust off the texbooks to write a perscription they would never get through the number of patients they need to see. However I think the emphasis on memorisation for exams leads to the culture of relying on memory for everything.
    I’m a chemical engineer and when I design something I am expected to follow calculation guides(checklists) as to remember all the equations you could be called apon to use or even the methodology behind each design would be near impossible. And even after it has been designed it goes through a checker who also uses a checking checklist : p Then the item will probably go through several revisions before it is ever even thought about being built.
    It is obviouse this process would be to slow for medicine, however I think is illustrates the different mentalities behind the two professions. It makes you wonder what improvements there are out there to be found just by looking at the most basic practices of other industries.

  5. Harriet Hall says:

    JayHawkDoc,

    Checklists are particularly appropriate to Family Medicine. How else can we remember to make sure our patients are getting all the appropriate immunizations, preventive medicine counselling, recommended cancer screening tests, etc.? These checklists can be automated and carried out by support personnel, but the family doctor should take the responsibility.

  6. sandman says:

    I thought Gawande did a good job of building the case for checklists. In pathology, we use checklists for reporting cancer resections – to insure we’ve included all the relevant data. I’ve found that the use of these lists doesn’t make me feel like an automaton – rather, it allows me to spend my time looking and thinking rather than worrying I’ll forget something.

    I like Dr. Novella’s point that medical specialties have their own culture. It probably is easier to get a nerdy neurologist (or pathologist) to use a checklist than to rope a cowboy surgeon into it.

    As checklists and expert systems become more prevalent in medicine, I suspect a different sort of person will be attracted to the profession – those more interested in collaboration. The cowboys can become bankers and fund managers. Maybe it’s already begun…

  7. DTR says:

    As a military helicopter pilot, I found this topic quite interesting. The military began using checklists decades ago as part of a campaign to reduce mishap rates, with much success. It’s good to see their use being incorporated into medicine.

    Military aviation actually borrowed much of its safety philosophy from civilian aviation, which also had it’s problems with cowboy types. The disaster at Tenerife, in which a fully loaded aircraft collided on the ground with another fully loaded aircraft, was caused by this type of mentality. That disaster, and others, caused civilian aviation to completely reexamine the cockpit relationships between captain, co-pilot, and engineer. The relationships that exist now in the cockpit are much more collaborative, and each crew-member has the right to question a decision. Think Captain Sullenberger instead of “Maverick.”

    Another factor that is common in aviation mishaps is fatigue. We are frequently told in safety training that 24 hours awake is roughly equivalent to being legally intoxicated, in terms of performance on tests of mental acuity and task accomplishment. We have strict requirements for minimum rest prior to flying (crew rest), and maximum time spent in the cockpit (crew day). The requirements are even more stringent for night flights. Provisions exist for crew-members to opt out of a flight if they feel they are too fatigued. Since I am not a doctor, I’m curious to hear from anyone if similar provisions exist in medicine.

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